The Cause of Death

Message from the author, Cynric Temple-Camp

ROYALTIES FROM THE SALE OF THIS BOOK

My office overlooks the rescue helicopter landing pad at Palmerston North Hospital. I am lucky to be able to watch the crew lifting off in their awesome machine just metres from the window. I see them scramble on average once a day, on missions to help the distressed and those who are injured. Their missions are literally a matter of life and death. They deliver the living to the waiting medical services. The dead come to us. They have been involved in so many of the cases I have investigated, including several events in this book. We all owe them a debt for the unceasing vigil they keep and the help they bring in times of tragedy. It is fitting that these tales belonging to the dead stand as a tribute to the work of the rescue teams.

I have therefore pledged to give all royalties from the sale of this book to the Palmerston North Rescue Helicopter, an essential emergency service for the Manawatu-Whanganui region.

CONTENTS

Prologue

Chapter 1    The Makings of a Pathologist

Chapter 2    The Exhumation

Chapter 3    The Naked Woman

Chapter 4    A Tale of Two Publicans

Chapter 5    A Touch of Madness

Chapter 6    Drug Mule

Chapter 7    The Devil Comes to Town

Chapter 8    In the Arms of Ecstasy

Chapter 9    The Eggshell Skull

Chapter 10  Trouble with the Babysitter

Chapter 11  The Circumstances of Death

Chapter 12  The Smallest Speck of Evidence

Chapter 13  Accidents, Accidents, Accidents

Chapter 14  Questionable Evidence?

Chapter 15  Victims of a Disaster

Chapter 16  Dangerous Elements

Chapter 17  The Privy Council and Beyond 287

Afterword

Acknowledgements

Copyright

Prologue

The dead baby is gone, returned to her parents, but her presence lingers in the building. Questions have arisen from her death that remain like an unquiet spirit.

She presented as just another ‘cot death’, or SUDI (Sudden Death in Infancy) case. That, on my advice, was the Coroner’s preliminary finding. Her little corpse was flawless, both externally and internally. If it weren’t for the bluish pallor that had replaced the glow of vitality on her alabaster skin, she would have been the very picture of a healthy, well-cared-for little girl, plump and perfectly formed.

I had performed the usual array of tests. I had X-rayed her and examined the films minutely, looking for any evidence of the multiple rib and other fractures, old and new, that are known to indicate abuse, or what was once called ‘Battered Baby Syndrome’. But the films were pristine, as I knew they would be. It’s never quite that easy.

Next, there was an array of more invasive tests: careful and difficult dissections, using small scissors and scalpels specially designed for the task, for the purpose of collecting samples for detailed examination. I took spinal fluid by doing a lumbar puncture. This was negative for meningitis, or indications of any of the other, rarer diseases that can affect the brain and nervous system and cause sudden illness and death. I took swabs from the lungs, the throat, and the spleen, but there was no indication the infant had been carried off by an overwhelming bacterial infection such as by Haemophilus influenzae, which can cause rapid swelling of the larynx and a death by suffocation that is nearly as fast as meningitis.

I collected blood and tissue for the lab to look for a rare condition called QT syndrome. I had encountered this before, but it wasn’t the cause of this little girl’s death. I inserted a needle into the baby’s sightless eyeball to extract fluid so that her electrolyte levels could be measured, but there were no abnormalities in the balance of sodium and potassium. And of course, I had taken tissue biopsies from every organ, fixed them on slides and, later, examined them under the microscope.

There was nothing out of the ordinary whatsoever.

It bothers me that she had died while being looked after by the babysitter. But I have come to the end of the set of investigations that the autopsy comprises, and I am no closer to determining a cause of death. It bothers me, but it won’t be the first unresolved mystery I’ve had in my time and it certainly won’t be the last.

And now like an awful slow-moving dream, two years later it was all happening again to the same family: to her sister. Her paediatrician had visited me to discuss the case. ‘Her sister died of cot death two years ago,’ he said.

‘I remember,’ I said. ‘I did the autopsy then.’

‘So you remember she was with a babysitter the night she died. I told the family they should think carefully before they ever left their little one with that sitter again. The babysitter was a family friend and they supported her. But guess who was looking after her the night the second child died?’

I stared at him.

‘That’s got to be coincidence, doesn’t it?’

‘Well, I’m not so sure. Because over the last few months, they’ve brought her in several times for apnoeic attacks.’

‘Interesting, but . . .’

‘And guess who was looking after her every time she stopped breathing in her sleep.’

‘The babysitter? Really?’

He nodded.

The phone rings. It’s my colleague, Dr Bruce Lockett, who is leading the investigation this time.

‘Cynric, you won’t believe this,’ he says.

I listen as he tells me what has happened, and what he has found.

‘What do you think it means?’ I ask.

He isn’t sure.

‘Who can tell us what this means?’ I think aloud.

‘If anyone can, it would be David Becroft in Auckland,’ says Bruce.

Both of us know that this is a step forward. I already feel a slight tingle of anticipatory excitement. We might get a resolution, after all.

Because, in the end, that’s what the whole science of pathology is based upon: the belief that every death is a question that deserves — that demands — an answer.

* * *

Some of the stories in this collection have been reported elsewhere. Others are untold stories, relating my part in the unexpected deaths and accidents that have befallen others. I believe the stories of the dead should be told, as quite apart from anything else, they are our story, too. For as much as we don’t like to talk about it or even to admit it to ourselves, death is our common destiny.

What’s more, the living can learn much from the deaths of others. That is the whole point of pathology (literally, the study of death). From an analysis I once did on the many autopsies I have performed on people who have died in hospital, I have determined that only 40 per cent of patients die with the benefit of a correct diagnosis. In another 30 per cent, the right organ system is targeted, but the precise diagnosis has been wrong. For the remaining 30 per cent of patients, the diagnosis has failed to identify the correct organ, let alone the nature of the disorder. My findings are consistent with similar studies everywhere, even emanating from such an august body as America’s prestigious Mayo Clinic.

We do not need to be unduly alarmed by this, but nor should we shrug and cease to strive to do better, on the grounds that we are human and humans make mistakes. The science of pathology is dedicated to learning from human error.

There are indeed tales of woe here. Of course there are. For that is death, and that is life: happiness and woe.

CHAPTER 1

The Makings of a Pathologist

I had my first, up-close experience with death when I was growing up in the African nation that used to be known as Rhodesia. Like all white Rhodesian families, we had servants back then. Our cook Robert, his wife Samma, his daughter Tombi and his newborn son Samuel lived in a small brick and mortar outbuilding called a kia. Tombi was the same age as me and we were inseparable companions.

One morning when I was eight years old, my mother stopped me as I made to head over to the kia to play with Tombi as usual.

‘Samuel has died,’ she told me. ‘The police are on their way.’

I wasn’t entirely sure what she meant, and it made me more determined than ever to visit Tombi to find out what was happening. I managed to hold off until my parents retired for their post-lunch siesta, when I ran up the path to the kia to see for myself.

I found Robert outside, feeding blankets and clothing into a fire. I recognised the tiny items belonging to his son.

Robert glanced up at me as I ran up breathlessly and nodded at me solemnly.

‘Robert, why are you burning your blankets?’ I asked.

He looked at me again, and held my eye. I saw all the ancient anguish of Africa in that look, but I was too young to fully understand. A tear welled up in his eye. He dashed it away.

‘It is because of what the witches have done that I must burn everything,’ he replied.

I shivered despite the hot sun.

Later, I secretly went back to the site of the fire. Robert had buried all the burnt embers.

I dug them up, examining ash and fragments of clothes and blankets.

I have no idea why I did this. I was only eight years old. Perhaps I was looking for some traces of the witches. Or perhaps I was just curious and behaving like a nosey boy.

* * *

Years later I came across a different experience of death that had a significant similarity.

A prominent surgeon in the Cape went to play golf one afternoon with a few of his colleagues. He took his 13-yearold son to act as a caddy. Somewhere along the course the lad dropped dead before their eyes.

They did everything to resuscitate the boy, but to no avail.

The initial autopsy showed nothing, but the father could not accept that there could be no reason for his son’s death. He wanted an answer. Day after day he harried the pathologists for progress. The cardiac pathology specialist, Dr Alan Rose, eventually dissected the conducting system of the boy’s heart into hundreds of microscopic slides. Finally an answer: Alan found an abnormal conduction pathway that would have misdirected the electrical current and caused a ventricular fibrillation and sudden death.

Only then was the father prepared to let it go.

How are these stories similar?

All humans react in the same way to the unexpected death of their loved ones. It doesn’t matter whether you are an African tribesman in the 1960s, or an orthopaedic surgeon in the 1980s, you will feel the death of your son similarly and keenly. And you will search until you have an explanation of why this tragedy has occurred.

Whether the answer that satisfies you lies in your certainty that we afflicted by the dark forces of witchcraft, or whether you take comfort from the modern shamans — contemporary pathologists — the power of the explanation is the same. Nothing haunts as tenaciously as questions. Answers are like an exorcism, of sorts.

* * *

I emerged from my medical training with no clear idea about which branch of specialist medicine to pursue. But like most doctors, I began my career imagining I would be looking after the living rather than the dead. I graduated first from the University of Rhodesia and then from the Royal College of Surgeons of Edinburgh, shivering through the winter of my final exams in the Royal Infirmary.

After you had qualified and prior to registration, Rhodesian doctors were required to do a year in a hospital as a house surgeon, working you hard in medicine, general and neurosurgery. No sooner had I finished, I was called up for military service. The prospect was both daunting and exciting. Rhodesia had been in the grip of a brutal civil war since the early 1960s, and it was showing no signs of abating. I was assigned as a an Air Force medical officer, and for 18 months I looked after the wounded from both sides and saw many who were beyond help. There was no sense or logic to the conflict as seen from the inside. There were just spells of intense boredom and sudden bursts of activity and fear. Mostly there was only a short, daily sick parade (soldiers’ clinic) to occupy me; my medical orderly could have done this parade at least as competently as I could. Once the clinic was over, we read and waited and played bridge and waited again. A cup of tea or the next meal was about as exciting as it got.

Every so often, we would receive a call to perform a ‘casevac’, or casualty evacuation. Then, high with adrenaline and excitement, I would clamber into an Alouette III helicopter and we would thunder off to pick up injured soldiers or civilians. The civilians were usually victims of landmines, and the soldiers were generally casualties of bush contact with the insurgents. All too often, civilian or solider, they were dead when we arrived.

It was a hot October month when I was assigned to a Forward Airfield on the banks of the Zambesi River at Kariba. The daily sick parade was over and everything was coagulating into the accustomed boredom. I asked the Squadron Leader, our base commander, whether I could head up the hill to the local public hospital at Kariba to see if I could help out. The hospital was a simple, 25-bed facility with one operating theatre and an ancient X-ray machine. But with a catchment of 300,000 people living in the vicinity of Lake Kariba and the Zambesi valley, the hospital was always busy and the beds full. At least there, there would be something to do, and if I was needed on a casevac, the hospital was only three minutes from the base by helicopter. The Squadron Leader agreed on condition I undertook to be back within 20 minutes if something came up at base.

I took a Land Rover and headed into Kariba township. The District Medical Officer who was running the hospital, Diederik van der Byl, had been a senior surgical registrar when I did my stint as a house surgeon. Diederick was palpably relieved to see me, because as it turned out, there was a lot going on and in the middle of it all, he was facing the prospect of performing a double amputation.

I was quite well accustomed to the procedures for double amputations, as all too many victims of landmines suffered horrific injuries to both legs. This time, it was different. The patient was a German tourist, which was strange enough in this war-torn region. But what made it truly bizarre was that his injuries had been inflicted by a charging elephant. Upon spotting a herd close to the road, the man had stopped his car and got out to take a photograph. Thinking it would be better from a photographic perspective if the animals were flapping their ears, he began throwing stones at them. This had the desired effect, but after flapping its ears as a warning, one of the elephants charged. It was a miracle the animal didn’t kill him outright.

I went up to the ward to see his injuries for myself. He was quite a sight. Two units of blood were running into him and there were tourniquets around his thighs, but he was pale as alabaster. There was a pulpy mush below his knees where his lower legs had been.

‘The wife is hysterical,’ Diederik told me. ‘She’s been on the phone to the German ambassador in Pretoria, telling him to fly in a planeload of specialists to save his legs. She’s refusing to agree to the amputation.’

‘What are you going to do?’ I asked.

‘I’m going ahead,’ he shrugged. ‘He won’t make it otherwise. As soon as we can get him stable, we’ll get him into theatre. Do you think you could give them a hand in maternity?’

In the maternity ward, I found five women in various stages of labour. I examined each of the women, checking their progress. Obstructed labour was common here, as the women of the valley were usually malnourished and had small pelvises. Intervention was required in about one in every four deliveries.

Sure enough, one woman was plainly in trouble. She had been 18 hours in labour, yet the head was still only three-fifths engaged and cervical dilation was dropping towards the minimum allowed. The birth process was in danger of stalling.

I listened through the ancient, tin ear-trumpet and found the foetal heart still okay. That was something.

I put up an oxytocin drip, and as the drug sped the contractions up, the cervix dilated. The head descended, but only as far as the pelvis, where it stuck. Now things started to go wrong. I listened, and found the beat regular at 130 beats per minute but dipping during the contractions. That deceleration of the baby’s heartbeat was the first sign of foetal distress.

Quickly I injected the woman’s perineum with local anaesthetic. I held out my hand and the midwife passed me a pair of scissors. I inserted two fingers between the stretched skin of the perineum and the baby’s head and waited. As the next contraction bore down I slid one blade of the scissors between my fingers and snipped. Blood gushed over my hand as the skin split and the introitus gaped open.

‘Let’s have the ventouse,’ I told the midwife assisting. She handed me the vacuum cup with its two handgrips. This suctions onto the baby’s scalp and gives you purchase, providing you with a simple and relatively safe way to assist a slow second phase of birth.

While I awaited the next contraction, I placed the ear-trumpet to the woman’s belly and listened to the baby’s heart. It was down to 100 beats per minute now.

‘We need this baby out fast,’ I told the others in the room.

At this critical point, the Matron arrived and stood behind me.

‘Doctor, you are wanted at the airfield,’ she said.

My shoulders sagged. That gave me 20 minutes, but I needed 40 minutes at least to finish this delivery and get back.

The surge of the contraction began and I dragged steadily on the handles. The head began its descent, but the contraction was over too soon.

I listened to the baby’s heart again: 96 beats per minute now.

If one more pull with the ventouse failed to bring the baby into the world, the options were diminishing. Normally, a Caesarean section would be performed, but Diederik’s double amputation would have the operating theatre tied up for at least a couple of hours yet.

‘Sister, can you get the Wrigley’s forceps ready, please?’ I asked. I didn’t dare use the Kielland forceps. These are more efficient, but because they can reach higher in the maternal pelvis, you need to be experienced to use them safely.

All the while, I was trying not to imagine what the hell was happening at the airfield.

The next contraction came and I pulled as firmly and steadily as I dared.

‘Push!’ I implored the woman. ‘Please push! This is important!’

She gave it everything, and the baby came!

I guided the head and pulled as the baby emerged, slowly at first, and then rapidly once the shoulders were clear. A boy. He gasped and began to wail. I handed the baby to the midwife and turned to tie off and cut the cord. I began to pull gently on the cord to deliver the placenta.

The baby was crying furiously. That was always the best sign, and I was beginning to allow myself to feel a sense of satisfaction. The placenta was delivered and it was intact and normal. Good. The midwife injected the baby with vitamin K to prevent neonatal bleeding and then prepared to inject the mother with Pitocin to prevent post-partum haemorrhage.

She looked strangely sombre. I looked at her enquiringly. She shook her head slightly, not making eye contact.

She passed me the baby. I looked and saw nothing. I turned the baby over.

A bulbous, membrane-bound nodule of tissue, known as a meningomyelocoele, protruded from the lower spine. My heart sank.

It was a spinal defect exposing the lower cord to the air — effectively a death sentence in tropical Africa, where disease is everywhere. There was nothing to be said or done that could make one shred of difference.

I turned back to my patient, my relief and sense of accomplishment snuffed and replaced by darkness. Methodically, I stitched the layers of her episiotomy closed. She lay still, her lips moving as she whispered something. As I tied the last suture off, I leaned forward to listen.

‘Thank you, Doctor,’ she breathed.

I realised, at that moment, I wasn’t cut out for clinical medicine.

* * *

A helicopter clattered overhead, rattling the frame of the hospital building, and there was a whine as it altered pitch for landing. I pulled off my gloves, picked up my medical pack and ran outside. The machine was squatting on the pad, dust whirling in the wash from its blades. The technician gunner beckoned me and I ran, doubled over, beneath the blades. I pushed my medical kit aboard and clambered up after it, slipping past the twin Browning .303 machine guns. Once seated, I put on a headset and listened to the jumble of voices in the static.

‘… hit a mine,’ I heard. ‘We’re getting that it was a boosted mine. Total wreck and mass casualties. Many dead. We have one confirmed wounded, condition described as critical. Over.’

‘Can you confirm location of LZ [landing zone]?’ our pilot asked.

The reply placed the scene of the tragedy about 150 kilometres to our west towards Kanyemba.

We flew over African bush, brown and sere because the rains had not yet come. No trace of human life was visible, and the landscape looked as it had looked long before human beings first strode the plains of Africa. As I looked down out of the open door of the helicopter, I saw two adult elephants and their calf break away into the clear from where they had been browsing. In a flash we were past. Craning to see behind us, I saw their dark forms lumbering away, ears flapping.

There was a confusion of urgent voices in the earpieces of my headset. I couldn’t quite follow what they were saying, but I thought I heard something about an aeroplane crash. And sure enough, as a pall of smoke became visible rising from the bush ahead of us, I heard an anguished voice reporting that a plane was down at our destination.

When we landed, we learned that a light, single-engined single engined Police Reserve Air Wing Cessna had landed on this bush strip to unload a four-man patrol of Game Park Rangers and had hit a boosted landmine cunningly planted by the insurgents. There were already three dead men and two more,