"CALLS TO “THINK DIRTY” HAVE BEEN PART OF THE PROBLEM IN THE INVESTIGATION OF SUDDEN UNEXPECTED DEATHS OF INFANTS, LEADING TO INSENSITIVE TREATMENT OF BEREAVED PARENTS, INADEQUATE INVESTIGATIONS, INCORRECT DIAGNOSES, AND LOSS OF INFORMATION ABOUT THE CAUSES OF THE MAJORITY OF SUDDEN UNEXPECTED DEATHS OF INFANTS THAT ARE NATURAL."
JOYCE EPSTEIN: FOUNDATION FOR THE STUDY OF ENGLISH DEATHS:
In earlier postings in the series we saw how Ontario's "think dirty" policy - originally aimed at detecting "femicides" - had an apparent link to serial rapists and killers Paul Bernardo and Karla Homolka in the early 1990's.
In that case, there was a public outcry after police and the pathologists had failed to detect the fact that Tammy Homolka had been drugged with Halcion, a hypnotic, and raped before dying a short time later.
It is therefore interesting to learn that a "think dirty" policy was advocated in England in the late 1990's in the aftermath of the convictions of Dr. Harold Shipman - who some regard as the world's most prolific serial killer.
In that case as well there was a public outcry after police and pathologists had failed to detect to detect the administration of a drug - overdoses of morphine - in some of his victims.
Wikipdedia tells us that:
"Harold Frederick "Fred" Shipman (January 14, 1946 – January 13, 2004) was an English general practitioner and serial killer.
On 31 January 2000, Shipman was found guilty of 15 murders and sentenced to life imprisonment with a recommendation from the trial judge that he should never be released.
Two years later, Home Secretary David Blunkett agreed with this recommendation.
After his trial, a public inquest chaired by Dame Janet Smith, decided that there was enough evidence to suggest that Shipman had killed a total of over 215 people, about 80 percent of them female.
His youngest victim was Peter Lewis, a 41-year-old man.
The official inquiry into his career concluded that there existed "real suspicion" that he had murdered a total of over 215 people.
Some reports have claimed that Shipman may have killed more than 215 people.
Much of Britain's legislation concerning health care and medicine was reviewed and modified as a direct and indirect result of Shipman's crimes, especially after the findings of the Shipman Inquiry, which began on September 1, 2000 and lasted almost two years.
Shipman is the only British doctor to have been found guilty of murdering his patients......
Six doctors who had signed cremation forms for Shipman's victims were charged with misconduct by the General Medical Council, which claimed that they should have noticed the pattern between Shipman's home visits and his patients' deaths.
All of these doctors were found not guilty.
Shipman's widow, Primrose Shipman, was called to give evidence about two of the deaths during the inquiry.
She maintained her husband's innocence both before and after the prosecution.
In October 2005, a similar hearing was held against two doctors who worked at Tameside General Hospital in 1994, and had failed to detect that Shipman had deliberately administered a "grossly excessive" dose of morphine.
Here is where "think dirty" comes in;
Dame Janet Smith's many recommendations including the creation of a team of coroners' investigators trained to “think dirty” about the causes of death.
Dame Janet had received testimony about Ontario's system from then Chief Coroner Dr. James Young, who travelled to England to testify.
This portion of her report, based on Dr. Young's evidence, indicates that in Ontario:
"Following a report of a death, investigating coroners are instructed to attend the scene of death, unless there's good reason for not doing so. Investigating coroners should complete a certificate confirming that he/she has legally seized the body. Investigating coroners are instructed considered -- to consider the worst possibility or 'think dirty' and to liaise with the family in investigating the death."
After the Shipman report was released - with its "think dirty" recommendation - a British organization called "the Foundation for the Study of Infant Deaths" was quick to point out that this particular recommendation could have serious adverse consequences in the case of investigations of infant deaths.
This was pointed out by Joyce Epstein, the Association's director, in a letter to a medical publication.
"Your legal correspondent reports that the Shipman inquiry calls for coroners’ investigators to “think dirty” about the causes of death (19 July)," the letter began.
"It is important to point out that Dame Janet Smith, who heads the inquiry, made clear in her Discussion Paper of October 2002 that the investigation of Sudden Unexpected Deaths of Infants (referred to by the British as SUDI) has to be handled differently," it continued;
"Calls to “think dirty” have been part of the problem in the investigation of Sudden Unexpected Deaths of Infants, leading to insensitive treatment of bereaved parents, inadequate investigations, incorrect diagnoses, and loss of information about the causes of the majority of Sudden Unexpected Deaths of Infants that are natural."
In Sudden Unexpected Deaths of Infants, suspicion should be the end point, not the starting point, of any coronial investigation.
The Foundation for the Study of Infant Deaths has been encouraging medical and forensic professionals to cooperate in undertaking comprehensive, standardised and thorough investigations of sudden unexpected deaths of infants.
The Foundation gave evidence to the Shipman inquiry to try to ensure that any changes recommended in the coronial investigation process in response to Shipman do not adversely affect handling of Sudden Unexpected Deaths of Infants and requesting the inquiry to take advantage of the opportunity to improve investigation of infant as well as adult deaths.
The Shipman Report’s overall recommendations are welcome, in particular the provision for medical expertise in coronial investigations.
Dame Janet said in the October 2002 paper that a new coroners’ service should develop protocols for special handling of Sudden Unexpected Deaths of Infants and we concur.
It would be extremely unfortunate if general reporting of the Shipman inquiry gave renewed life to the “think dirty” catchphrase which has caused so much harm in the investigation of infant deaths."
It appears from Ms. Epstein's comments that Dame Janet was aware that the investigation of the sudden unexpected deaths of infants had to be handled differently than those of adults.
I do not see any indication from the evidence called at the Goudge Inquiry that Ontario's Chief Coroner's Office directed its mind to the difference - and to potential consequences - before circulating its "think dirty" policy in 1995;