The COR prefix documents

On 23 January 2012 I contacted the National Archives with a Freedom of Information request regarding any documents they had with a COR prefix ... in other words documents involving the coroner.  They came back to me with a list of 15 items.  This is the request and response:

“This FOI request is for a schedule of all the documents submitted to the Hutton Inquiry to which the Inquiry used the prefix "COR". These to include any that have been returned to the sender. The information required is the COR number of each document, the date of each document together with a brief description of each document.”

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Your request has been handled under the Freedom of Information Act 2000 (FOIA). I can confirm that we hold the information you have asked for and have communicated this to you below.

Since the transfer of the documents to the National Archives I can confirm that no documents have been removed from the COR prefix.

The following documents were transferred to The National Archives using the COR prefix created by the Hutton Inquiry Secretariat:

COR prefix documents

Post Mortem Report COR/1/0001-0014

Letter Hughes / Gardiner 22 July 2003 COR/1/0020-0021

Letter Lord Hutton / Gardiner 28 July 2003 COR/1/0188

Letter Lord Chancellor / Janice Kelly 13 August 2003 COR/2/001-002

Letter Gardiner / Lord Hutton 14 August 2003 COR/2/0236

Letter Gardiner / Lord Hutton 20 August 2003 COR/2/0237

Notes of Evidence from 21 July 2003 COR/2/0238

Letter from Dr Kelly’s Medical Centre/Coroner’s Office 4 August 2003 COR/2/0239

Final Post Mortem Report COR/1/0240-0253

Witness Statement of Toxicologist Dr Allan 21 July 2003 COR/2/0254-0259

Witness Statement Janice Kelly COR/2/0260

Notes of Coroner 14 August 2003 COR/2/0261-0262

Letter Gardiner / Allan 23 January 2004 COR/7/0001

Note of Coroner’s Rules 1984 23 January 2004 COR/7/0002

Letter Gardiner / Lord Hutton 28 January 2004 COR/7/0003

                                                                                                                                    

I have been critical of the coroner Nicholas Gardiner in the past, and will continue in like vein where appropriate.  Here though it appears that he was behaving in a perfectly professional manner in keeping the Hutton Inquiry informed of his activities.

Mr Gardiner briefly reconvened the inquest on 14 August and from the schedule it can be seen that the Inquiry received a letter from him (COR/2/0236) and his notes of that day (COR/2/0261-0262).  This is of particular interest when related to a letter sent by Hutton to Norman Baker in 2007, something to be discussed in my next post.

One other quick point to flag up is the fact that it is only the first of Dr Allan's three reports that is listed here.  In fact reports 2 and 3 weren't written until after 14 August, they aren't listed on the Hutton website and it seems that Hutton was oblivious of their presence.  It wasn't until Mr Grieve made his statement on 9 June 2011 that they were listed anywhere.  The letter from Mr Gardiner to Dr Allan of 23 January 2004 - five days before Hutton published his report is intriguing (COR/7/001), particularly when allied to the fact that on the same date the "Note of Coroner's Rules 1984" (COR//7/0002) was sent.

I imagine that the first document listed COR/1/0001-0014 is Dr Hunt's original report of 19 July 2003 ... Hutton certainly refers to that ealier report when he makes his opening statement on 1 August.

There is some linework at the bottom of the schedule which shouldn't be there, that's my fault.  I don't know how to delete it from blogger unfortunately!

 
 

The co-proxamol (3)

The two substances that make up co-proxamol, paracetamol and dextropropoxyphene, were found in Dr Kelly's body.  Three blister packs of co-proxamol, originally ten in each pack but with just one tablet remaining were found in a pocket of the Barbour jacket Dr Kelly was wearing when the forensic specialists were at the scene.  So originally 30 tablets available, one left, that means Dr Kelly swallowed 29 tablets.  Yes?  No, not necessarily.

That the constituents of co-proxamol were found in the body is clear I believe.  At the end of his testimony at the Inquiry there is this exchange between Dr Allan and Lord Hutton:

LORD HUTTON: Mr Allan, if a third party had wanted paracetamol and dextropropoxyphene to be found in Dr Kelly's blood is there any way that the third party could have brought that about by either persuading or forcing Dr Kelly to take tablets containing those two substances?
A. It is possible, but I think it would be --
LORD HUTTON: That is the only way that those substances could be found in the blood, by taking tablets containing them?
A. Yes, he has to ingest those tablets.
LORD HUTTON: Yes. Thank you very much indeed.


Why did Hutton stop Dr Allan answering his first question?  Then Dr Allan finishes up by telling an untruth:  The components of co-proxamol could have been injected into the body.  Alternatively the tablets could have been crushed and fed by a tube.  Dr Hunt reporting on the mouth writes:  There was a small abrasion consistent with contact against the teeth or biting of the lips on the lower lip on the lipline.  This was approximately 0.6 x 0.3 cms.  There was no significant vital reaction.  Later, at conclusion 16, is this:  The minor injury to the inner aspect of the lip is not associated with bruising nor damage to teeth and does not appear to have any well-developed vital reaction.  This sort of injury may be caused if the tissues of the mouth are bitten.  His deduction may be correct but would this injury to the lip also match the insertion of a tube in his mouth, particularly if Dr Kelly had been incapacitated.

If Dr Allan's last answer in the quoted extract above really had been correct that would have strongly enhanced the suicide hypothesis in my opinion.  Was the "suicide" faked?  If so a lot of trouble was taken over it.  

The co-proxamol (2)

In my last post I reproduced those parts of Dr Hunt's final report relating to the co-proxamol.  I also flagged up the fact that in his initial report of 19 July Dr Hunt hadn't seemingly included co-proxamol ingestion as a factor in the cause of death.  We know from a statement of forensic toxicologist Dr Allan dated 21 July 2003 that certain items from Dr Kelly's body were received at his laboratory on Saturday 19 July http://www.attorneygeneral.gov.uk/Publications/Documents/Dr%20Allan%20statement%201%20%2021%20July%202003.pdf


With the post mortem being completed at 00.15 on the 19th the fact that various items were sent to the laboratory on the same day at least shows a commendable desire to get things done.  Looking at what Dr Allan had to say at the Inquiry he did his testing that Saturday morning.   However the test results given in the 21 July report together with the testimony given by Dr Allan at the Hutton Inquiry gave cause for concern in as much that it seemed that the amount of testing was inadequate.  It wasn't until eight years later, on 9 June 2011, that it was discovered that Dr Allan produced two further reports on 18 August 2003 and 17 September 2003  http://www.attorneygeneral.gov.uk/Publications/Documents/Dr%20Allan%20statement%202%2018%20August%202003.pdf  and http://www.attorneygeneral.gov.uk/Publications/Documents/Dr%20Allan%20statement%203%2017%20September%202003.pdf respectively.  The last mentioned concerned a blood sample NCH/47 sent to the Royal Hallamshire Hospital in Sheffield and I don't know that that document is particularly relevant to possible co-proxamol ingestion.


Dr Allan's report of 18 August (the same day as the Registrar recorded the cause of death of Dr Kelly) details the examination for any contaminants in the liquid in the Evian bottle.  Dr Allan also says: The stomach contents (item NCH/49) was further analysed for dextropropoxyphene, and the vitreous humour (plain - item NCH/53) for this and for paracetamol.  The "missing" results in the 18 August report weren't discussed at the Hutton Inquiry.  There is no evidence that either Hutton or the coroner Nicholas Gardiner saw Dr Allan's second or third reports, certainly they weren't listed in the evidence tab on the Inquiry website.  This may be cock up rather than conspiracy ... perhaps it demonstrates the lack of medical background, or just a lack of concern, on the part of both Lord Hutton and Mr Gardiner.

The apparent failure to test the stomach contents for dextropropoxyphene was an issue raised with the Attorney General.  See number 25 here for the response to this: http://www.attorneygeneral.gov.uk/Publications/Documents/Schedule%20of%20responses%20to%20issues%20raised.pdf  If the 18 August statement was before the Inquiry why wasn't it listed and discussed?


Dr Allan states that he had to estimate the amount of dextrpropoxyphene in the stomach contents.  Why couldn't that have been done for his 21 July report?  Similarly the vitreous humour was among the items received on the 19th July for testing.  The lab didn't receive the decanted liquid from the Evian bottle until 25 July so some delay in that result was inevitable.  It seems ridiculous to me that the stops were pulled out to carry out some initial testing but then there was a delay of almost a month before the second report was produced.  


The question that has to be asked is whether this seemingly haphazard approach to testing and reporting in the forensic industry is widespread.

The co-proxamol (1)

Before examining the evidence relating to the co-proxamol I think it's worth reminding ourselves first of all about Dr Hunt's conclusions on the subject.

Clothing

• A green 'Barbour' waxed jacket, which was undone at the zip and buttons at the front.  A mobile telephone, pair of bi-focal spectacles, a key-fob and a total of 3 blister packs of co-proxamol (10 packs) were found in the bellows pocket on the front right panel of the jacket.  Only one co-proxamol tablet remained in its blister pack.

Toxicology                 
At the time of completing this report, I have been provided with the following verbal information by Dr Alexander Allan, a forensic toxicologist from Forensic Alliance Limited.

• The blood sample contains the drug dextrpropoxyphene at a concentration of 1.0 micrograms per millilitre.
• The blood sample contains the drug paracetamol at a concentration of 97 micrograms per millilitre.
• Paracetamol is present in the stomach contents.
• No alcohol has been detected.

In addition, I have been provided with a copy of the formal statement of Dr Allan dated 21 July 2003 (21/07/2003) and given the laboratory reference FAL-05969-03.

The levels of dextropropoxyphene and paracetamol in the blood were confirmed as above.

Conclusions

12. Given the finding of blister packs of co-proxamol tablets within the coat pocket and the vomitus around the mouth and floor, it is an entirely reasonable supposition that he may have consumed a quantity of these tablets either on the way to or at the scene itself.

13. The toxicology result indicates that prior to his death he had consumed a significant quantity of these tablets.  The active ingredients of co-proxamol are paracetamol and dextropropoxyphene.  The absolute levels of paracetamol and dextropropoxyphene in the blood are not particularly high and may not ordinarily have caused death in their own right.  In this particular case however, even these levels may be relevant as one must consider that dextropropoxyphene may cause death by its actions upon the heart leading to abnormalities of heart rhythm.  Such abnormalities of heart rhythm are made all the more easy to induce if there is hypotension (low blood pressure) as the result of bleeding and underlying narrowing of the coronary arteries.  In this case, both the latter factors would be operant.

14. Dextropropoxyphene is an opioid drug which is relatively rapidly absorbed into the blood following ingestion.  It has an analgesic effect and hence would be expected to deaden the perception of pain due to injury, particularly when taken in the sort of amount seen here which is above the normal therapeutic range.

25. In summary, it is my opinion that the main factor involved in bringing about the death of David Kelly is the bleeding from the incised wounds to his left wrist.  Had this not occurred he may well have not died at this time.  Furthermore, on the balance of probabilities, it is likely that the ingestion of an excess number of co-proxamol tablets coupled with apparently clinically silent coronary artery disease would both have played a part in bringing about death more certainly and more rapidly than would otherwise have been the case.  Therefore I give as the cause of death:

          1a.    Haemorrhage
          1b.    Incised wounds to the left wrist

          2.     Co-proxamol ingestion and coronary artery atherosclerosis  

The extract above is from Dr Hunt's final report of 25 July 2003.  He had made a preliminary report six days earlier on the 19th, in other words two days before Dr Allan's (first) formal statement.  In his opening statement on 1 August Hutton states:

37. A post-mortem examination was carried out by Dr Nicholas Hunt, a Home Office accredited forensic pathologist and his post-mortem report dated 19th July has been sent to me by the coroner. A toxicology report has also been sent to me by the coroner. The post-mortem report will be referred to in greater detail at a later stage in this Inquiry. However, it is relevant to state at this stage that it is the opinion of Dr Hunt that the main factor involved in bringing about the death of Dr Kelly was the bleeding from incised wounds to his left wrist. 
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Dr Hunt also states:  "It is noted that [Dr Kelly] has a significant degree of coronary artery disease and this may have played some small part in the rapidity of death but not the major part in the cause of death."   

Because he removed the three blister packs from the jacket pocket Dr Hunt ought to have considered at that time that co-proxamol might have been a contributor to the death.  Perhaps he did but on the 19th the toxicology results from Dr Allan wouldn't be to hand.  Therefore he, perhaps knowingly, produced a post mortem report that would likely have to be amended.  The subject of the production of more than one post mortem report by a pathologist is one that will have to keep for another day; here though we have the situation of Dr Hunt initially providing a report for the coroner in which he doesn't refer to co-proxamol ingestion in the "cause of death".  

The delay in testing the Evian bottle contents

An argument might be made along the lines of "whenever human beings are making decisions cock ups are likely to occur from time to time".  In the case of an unexplained death, such as that of Dr Kelly, there is a counter argument in my opinion that such an investigation will be carried out by professional people who should know what they are doing.

A nearly empty bottle is found near the body.  Notwithstanding the fact that toxicology tests were being carried out on samples from the body at a very early stage I would have thought that testing the remaining contents of the Evian bottle would have assumed a very high priority.

From Dr Allan's second report dated 18 August 2003 we learn that it isn't until 25 July, that's a week after the body discovery, that Dr Allan receives the decanted water at his lab.  Presumably the analysis of this then receives some priority.  The statement of 18 August does, to be fair, also deal with other toxicological matters.

However we have Dr Allan delivering his conclusion as to the analysis of the bottle contents on the same day as the Oxfordshire registrar is recording the cause of Dr Kelly's death.

As an aside I wonder how the bottle and its contents were transported from the scene to avoid spillage and contamination.  Surely the top would have to be bagged separately and indeed it has a different reference number. 

Forensic evidence relating to the Evian bottle

As noted in a previous post the fingerprint technician had recorded the presence of two marks on the neck of the Evian bottle.  The possible identity of the person who might have left the marks has not been revealed; it may be that the quality of the marks wasn't sufficiently good to come to a conclusion.

Mr Green's tests though do have something more detailed for us.  This is what he said about the bottle in his written statement:

Item RG.1 was a swab taken from the non bloodstained thread area of the Evian bottle (AMH.2).   STR profiling of this swab gave an incomplete STR profile whose components were present in the corresponding positions in the profile of Dr Kelly so this DNA, presumably from saliva, could have come from him.

Item AMH.2 was a 500 ml clear plastic Evian water bottle.  Airborne spots of blood and contact smears of blood were present on this item.  STR profiling of one of the smears and one of the spots of blood gave full profiles, which matched that of Dr David Kelly.  This shows that the bottle had been handled after Dr Kelly's wrist was injured.

The threaded top of the bottle and the inside thread of the Evian bottle top (AMH.3) were swabbed and the swabs combined.  A full STR profile was obtained from the combined swabs, which matched the STR profile of Dr Kelly.  This indicates that it was Dr Kelly that drank from the bottle.

The outside of the bottle top also bore faint smears of blood.  STR profiling of one of these smears and of a separate non-bloodstained area was undertaken but no profiles were detected.  Although it was not possible to determine from whom the blood originated it seems a reasonable assumption that the blood came from the same source as the blood on the bottle.  If this is the case then it indicates that the top was taken off the bottle after Dr Kelly had injured his wrist. 

Earlier in his report Mr Green explains that 'STR profiling is a sensitive DNA analysis technique' 

The toxicologist (Dr Allan) records his analysis of the liquid in the bottle in his second report dated 18 August 2003:

The liquid consisted of 111 millilitres of clear colourless fluid with the appearance of water and having no unusual odour.  The pH (acidity) was normal for water indicating that no corrosive material such as an acid or alkali was present.

Apart from a trace of dextropropoxyphene, nothing of else of significance was detected in the water.

Reading these forensic reports it seems as if the laboratory work has been thorough.  Assuming all necessary care was taken to avoid for instance contamination of samples then I would have little reason not to accept the results.  It is what is then inferred from these results that becomes critical.

For instance a trace of dextropropoxyphene (dp) was found in the bottle contents suggesting that dp was in Dr Kelly's saliva and thus he had swallowed some tablets.  The most obvious conclusion of course but not necessarily true.  A few drops of dp could have been added to the water by a "scene setter".  Unlikely - yes.  Impossible - no.

Again the DNA results from the STR profiling from swabs of the threaded part of the bottle and the threads in the bottle top suggest that Dr Kelly had drunk from the bottle.  But at Harrowdown Hill?  If it was an old Evian bottle with tap water in it then Dr Kelly might have drunk from it before leaving home.  Very unlikely - perhaps.  Impossible - no.

These are examples of instances where a forensic expert has to be incredibly careful about arriving at his conclusions.  Where there is any reason for doubt then that doubt ought to be expressed.

Bowing to the knowledge of the forensic "experts"

This post is a development of the theme outlined on 7 May when I briefly discussed the question of whether the expert witnesses were competent and honest http://drkellysdeath-timeforthetruth.blogspot.co.uk/2012/05/were-expert-witnesses-competent-and.html  I'm not going to consider the point regarding honesty at the moment.

It seems to me that it is far too easy to be overawed by the testimony given by medical specialists, particularly forensic pathologists.  Some coroners come to the profession with a medical background, unfortunately the Oxfordshire coroner at the time, Nicholas Gardiner, didn't.  There is no indication that Lord Hutton had any meaningful medical knowledge to bring to his Inquiry either. 

Mr Gardiner, on 14 August 2003, briefly resumed the inquest in order to to able to complete the death certificate.  I shall explain in another post why he was wrong to do this.  The point here though is that he appears to have accepted the reports provided by the forensic pathologist Dr Hunt and the forensic toxicologist Dr Allan without demur.  Similarly Lord Hutton, in producing his report on the 28th January 2004, fails to critically analyse what the forensic experts had to say.  In other words the experts have spoken, who am I to criticise their procedures and conclusions seems to have been the unspoken refrain.

So why did both Gardiner and Hutton just accept what they had been told?  As a non expert I have deduced just how bad Dr Hunt's work in the Dr Kelly case has been.  In some instances I have admittedly been pointed in the right direction by other concerned individuals.  There are also some aspects of the conclusions reached by the various experts that I have seen as inadequate without assistance from anybody else, it has been simply down to forceful logic.

The forensic pathologist Freddy Patel it now seems got it wrong when he conducted the Ian Tomlinson post mortem.  His professional ability was already suspect.  His case is an example surely of the "expert" being wrong. http://en.wikipedia.org/wiki/Death_of_Ian_Tomlinson#Freddy_Patel  There are other pathologists that haven't been up to the mark.  Did Gardiner and Hutton have some other imperative that stopped them making any critical appraisal of the evidence supplied by the "experts"?  Perhaps they did!

Were the "expert" witnesses competent and honest?

When Lord Hutton conducted his Inquiry he quite reasonably called a number of witnesses who one would expect to be expert in their specialisms.  We imagine these individuals are both competent and honest.  A person who is supposedly a forensic expert can pull the wool over one's eyes because most of us don't have the knowledge to immediately refute the expert's argument nor do we have the time to dissect what they have said or written.  The expert has had his say, and with a number of qualifications and in most cases years of experience who are we to say they are wrong?

I am not an expert but, as with certain other folk, I can pull an argument apart and am prepared to do so where necessary.  The following have all been found wanting: Assistant Chief Constable Michael Page, Forensic Pathologist Nicholas Hunt, Forensic Toxicologist Alexander Allan, Forensic Scientist Roy Green, Consultant Psychiatrist Keith Hawton and we musn't overlook Lord Hutton himself.  An expose of at least some of their failures will be a key feature of this blog.

It's worth noting at this point what Hutton was saying about expert witnesses and his Inquiry on 3 September 2010.  On this date he wrote to the Attorney General with an attached report, what he described as "a note" that he intended giving to the Lord Chancellor.  In response to criticisms he states at 1(b):
The inquiry was as full and thorough as an inquest, and was probably more so because a considerable number of expert witnesses gave detailed evidence including a Home Office pathologist, a forensic biologist and a forensic toxicologist.  The leading expert on suicide in England, Professor Keith Hawton of Oxford University, was also called to give evidence.

This paragraph by Lord Hutton is absolute nonsense!  It would have been open to the coroner to call all of these people including Hawton.  There would have been nothing at all to stop the Oxfordshire coroner doing this, whether he would have done so is a different argument, the point is he could have done.  Moreover, because they would have had to give evidence under oath at an inquest then it would be more likely if anything for the inquest to be better than an inquiry (or at least the casual sort of inquiry that happenned here).

The example just given of Hutton's musings demonstrates how poor his arguments can be.