- Angela Cannings was born in May 1963, the daughter of Stephen Connolly.
After her marriage to Terry Cannings, they had four children, Gemma, born
on 14th August 1989, Jason, born on 25th April 1991, Jade, born on 15th January
1996 and Matthew, born on 5th July 1999. Three of these children, Gemma,
Jason, and Matthew died in infancy.
- On 16th April 2002 in the Crown Court at Winchester, before Mrs Justice
Hallett and a jury, after a conspicuously fair and balanced summing up, the
appellant was convicted of two counts of murder, count one relating to Jason
and count two relating to Matthew. It was elicited
at trial that the appellant had also been charged with Gemma’s murder, but
that allegation did not proceed. Before his death Jason, and the surviving
child, Jade, too, suffered an "Acute" or "Apparent Life Threatening
Event" (ALTE). Before his death, Matthew was thought to have suffered
an ALTE, but the preponderance of specialist evidence suggested that this
was no more than a troublesome and worrying "episode" rather than
a true ALTE.
- The relevant chronology is straightforward. Gemma died on 14th November
1989. She was then aged 13 weeks. Jason suffered an ALTE when aged 6 weeks,
but he died a week or so after discharge from hospital, on 13th June 1991.
Jade suffered an ALTE on 1st April 1996, when aged 11 weeks. She made a full
recovery. On 3rd November 1999 Matthew, aged 17 weeks, suffered his episode.
He was discharged from hospital, but died some nine days later.
- The Crown’s
case was that the appellant had smothered both Jason and Matthew, intending
to kill
or do them really serious bodily harm by obstructing their
upper airways. To support that allegation it was suggested that Gemma’s death,
and each of the ALTEs, were also consequent on smothering by the appellant,
and that the deaths of Jason and Matthew formed part of an overall "pattern".
The appellant, a woman of good character, described as a loving mother, apparently
free of personality disorder or psychiatric condition, consistently denied
harming any of her children. It was not suggested that they had been harmed
by anyone else. Her case was that the deaths were disastrous, but natural,
even if unexplained incidents, to be classified as Sudden Infant Death Syndrome
(SIDS), known colloquially as cot death. In expressing the issue in this
way we do not overlook the comforting ease of applying such a description
to an extremely complicated subject, nor that specialists do not treat SIDS
and cot death as synonymous.
- Without medical
evidence about the appellant’s mental state, a verdict of infanticide was
not open
to the jury. Following conviction of murder,
sentences of life imprisonment on each count were mandatory. Hallett J expressed
her concern at the "kind of injustice that can be caused by mandatory
sentences". Honouring, as she had to, the verdicts of the jury, and
acknowledging the absence of any medical evidence relevant to the appellant’s
state of mind, she observed:
"I
have no doubt that for a woman like you to have committed the terrible
acts of suffocating your own babies there must have
been something seriously wrong with you. All the evidence indicates you wanted
the children, and apart from these terrible incidents you cherished them,
so in my layman’s view, it is no coincidence that these events took place
within weeks of your giving birth. It can, in my view, be the only explanation
for why someone like you could have committed these acts when you have such
a loving and supportive family."
- This is an appeal against both convictions. On 10th December 2003 we quashed
them. We shall now give our reasons.
The issue
- The issue before the jury is easily defined. The deaths of Jason and Matthew
were either natural sudden infant deaths, or unnatural sudden infant deaths.
In the vast majority of cases of murder, there is no doubt that someone has
caused or contributed to the death of the deceased in some way, for example
by gunshot wound, or knife, or repeated blows, or indeed a single blow. In
a few cases issues may arise whether the defendant’s actions caused the death,
or whether some other underlying or intervening cause contributed to or was
responsible for it. Unusually, but not uniquely, the primary and stark question
in the present case was whether either of these children was killed at all,
their deaths resulting from deliberate actions by their mother to deprive
them of breath, and successfully achieved without revealing any obvious physical
manifestation of a killing. We are not blind to the fact that, sadly, these
catastrophes happen: mothers, and fathers also, do sometimes kill their infant
children. Nevertheless the crucial question here remains whether the deaths
of either of these two baby boys were indeed the result of crime.
- The unavoidable
reality is that some infant deaths remain "unexplained" or "unascertained".
Professor Berry, a consultant pathologist called by the Crown, identified
three categories of death which were encompassed within this last word, "unascertained".
It includes deaths which are natural and explained (i.e. a similar mechanism
to sudden infant death syndrome, but not fitting the strict case definition),
natural and explicable (but the cause was not found) or unnatural (accidental
or deliberate). Whatever form of categorisation, and there are several, we
must emphasise what is self-evident, that only proof of a death falling within
the second half of the last of Professor Berry’s categories, an unnatural
death resulting from deliberate action, can justify a conviction for murder.
- The convenient
acronym SIDS requires a little amplification, particularly in relation
to the last "S",
which stands for syndrome. Treating the problem as a syndrome tends to
obscure the fact that sudden unexplained
infant deaths occur in different circumstances, and some may be multi-factorial,
the result of a coincidence of processes which, taken in isolation, would
not necessarily cause death. No underlying condition for every death categorised
as SIDS has been identified. The critical point of each such death is that
it is indeed unexplained, and that its cause or causes, although natural,
is or are as yet unknown. SIDS does not apply to deaths, or if already attributed
to SIDS, ceases to apply to deaths which are clinically explicable or consequent
on demonstrable trauma. In each SIDS case the mechanism of death is the same,
apnoea, loss of breath or cessation of breathing. In the true SIDS case we
do not know why the particular infant’s breathing stopped. All we know is
that for some unexplained reason it did. One obvious reason for loss of breath
is smothering or some deliberate interference with the infant’s normal breathing
process. However the same process, with the same result, also occurs naturally.
In the present context ALTEs are SIDS in which no death has actually resulted.
Again, approaching the issue in layman’s terms, ALTEs may be described with
reasonable accuracy as sudden infant acute or apparent life threatening events.
They represent the consequence of an unexpected and unexplained temporary
loss or cessation of breathing, which has occurred naturally. Whether the
cause is natural or harmful interference, the body of the infant undergoes
great stress. If the event is the result of deliberate interference with
the infant’s breathing it is not a true ALTE: it is attempted murder or attempted
grievous bodily harm.
Two critical problems
- It would probably be helpful at the outset to encapsulate different possible
approaches to cases where three infant deaths have occurred in the same family,
each apparently unexplained, and for each of which there is no evidence extraneous
to the expert evidence that harm was or must have been inflicted (for example,
indications or admissions of violence, or a pattern of ill-treatment). Nowadays
such events in the same family are rare, very rare. One approach is to examine
each death to see whether it is possible to identify one or other of the
known natural causes of infant death. If this cannot be done, the rarity
of such incidents in the same family is thought to raise a very powerful
inference that the deaths must have resulted from deliberate harm. The alternative
approach is to start with the same fact, that three unexplained deaths in
the same family are indeed rare, but thereafter to proceed on the basis that
if there is nothing to explain them, in our current state of knowledge at
any rate, they remain unexplained, and still, despite the known fact that
some parents do smother their infant children, possible natural deaths.
- It will immediately
be apparent that much depends on the starting point which is adopted. The
first approach is, putting it colloquially, that lightning
does not strike three times in the same place. If so, the route to a finding
of guilt is wide open. Almost any other piece of evidence can reasonably
be interpreted to fit this conclusion. For example, if a mother who has lost
three babies behaved or responded oddly, or strangely, or not in accordance
with some theoretically "normal" way of behaving when faced with
such a disaster, her behaviour might be thought to confirm the conclusion
that lightning could not indeed have struck three times. If however the deaths
were natural, virtually anything done by the mother on discovering such shattering
and repeated disasters would be readily understandable as personal manifestations
of profound natural shock and grief. The importance of establishing the correct
starting point is sufficiently demonstrated by this example.
- Before this trial began, this Court, differently constituted, had decided
that the fact of three deaths (that is those of Gemma, Jason and Matthew),
as well as each of the ALTEs, provided admissible evidence relevant to each
count. There could be no denying that the death of three apparently healthy
babies in infancy while in the sole care of their mother was, and remains,
very rare, rightly giving rise to suspicion and concern and requiring the
most exigent investigation. Given the overwhelming consensus of medical evidence,
it would indeed have been an affront to common sense to treat the deaths
of the three children and the ALTEs as isolated incidents, entirely compartmentalised
from each other. All the available relevant evidence had to be examined as
a whole. Nevertheless a degree of caution was necessary to avoid what might
otherwise have been the hidden trap of taking the wrong starting point. If,
for example, at post mortem it was positively established that Matthew’s
death had resulted from natural causes, the situation reverted to precisely
where it stood before he died. The concerns which would have arisen as a
result of his death – as the third in the sequence – would have been dissipated.
There would have been a positive innocent explanation for the death, which
would no longer be a SIDS, and might help to confirm that the earlier deaths
were indeed natural deaths. Equally, if there were unequivocal evidence that
one of these deaths, or even one of the ALTEs, had resulted from deliberate
infliction of harm by the appellant, that would be likely to throw considerable
light on the question whether the other deaths, or ALTEs, resulted from natural
or unnatural causes. If, after full investigation, the deaths, or ALTEs,
continued to be unexplained, and there was nothing to demonstrate that one
or other incident had resulted from the deliberate infliction of harm, so
far as the criminal process was concerned, the deaths continued properly
to be regarded as SIDS, or more accurately, could not properly be treated
as resulting from unlawful violence.
- Reverting to the two possible approaches to the problems posed in a case
like this, in a criminal prosecution, we have no doubt that what we have
described as the second approach is correct. Whether there are one, two or
even three deaths, the exclusion of currently known natural causes of infant
death does not establish that the death or deaths resulted from the deliberate
infliction of harm. That represents not only the legal principle, which must
be applied in any event, but, in addition, as we shall see, at the very least,
it appears to us to coincide with the views of a reputable body of expert
medical opinion.
- As we have
already emphasised, the question in this case was whether there were any
crimes at all, and
whether there were, in the legal sense, any victims
of crime. As we shall see, there was no direct evidence and very little indirect
evidence to suggest that they were, and there was further evidence which
tended to suggest that they were not. Mrs Cannings was not contending, for
example, that someone else had harmed her babies, or that she had caused
their injuries accidentally. If so, the jury might reasonably have thought
that three infant deaths as a result of accident, all at the hands of their
mother, would be highly improbable, or equally, that her presence at home,
on her own, when each of these "accidents" occurred, extinguished
any realistic possibility that someone else was responsible. Mrs Cannings’
defence was simple: she had done nothing to harm any of her children. Although
she was contending that the deaths were natural, notwithstanding specialist
evidence called on her behalf at trial, she could not explain them, and she
was not seeking to offer an explanation of her own. And, unusually, she was
doing so in the very special context that medical specialists, both domestically
and internationally, continue to acknowledge that the death of an infant
or infants at home can simultaneously be natural and unexplained, even by
them.
- In recent cases
which attracted considerable public concern and interest, two mothers were
charged,
and in one case, Sally Clark, convicted, and the
other, Trupti Patel, acquitted of murder, following the deaths of their infants.
The verdict in Trupti Patel decided no point of principle: on the evidence
the jury was not sure of guilt. Lest anyone seek to read anything deeper
into that observation, and imply that we are commenting one way or another
on the verdict, we emphasise that that is all that is ever decided by a "not
guilty" verdict. Nowadays, we read and hear much about a new concept, "found
innocent": that is not a verdict known to the law.
- As is well known, the conviction of Sally Clark has been quashed. Save
superficially, however, this appeal is dissimilar, and raises different issues.
Unlike the Court of Appeal Criminal Division in that case, we have not been
presented with evidence of apparent misconduct and serious non-disclosure
by an expert witness, Dr Williams, called by the Crown, which came to light
after conviction. Of itself, that would have been sufficient for the conviction
to be quashed. In addition, expert evidence describing statistical probabilities
was also severely criticised. That evidence was given by an expert witness
of great distinction, if not pre-eminence in this field, Professor Sir Roy
Meadow, whose evidence would undoubtedly have carried great weight with the
jury which tried Sally Clark. If it were flawed, as it was, the safety of
the jury’s decision was further called into question. Professor Meadow’s
evidence in the present case did not extend to the flawed statistical evidence
presented to the jury during the trial of Sally Clark. The present convictions
therefore cannot be quashed on either or both of the grounds relied on in
her appeal, and the observations on the facts in the CACD in that case were
case-specific, and not otherwise of general application to the present appeal.
- Mr Michael
Mansfield QC submitted that although Professor Meadow did not expressly
give statistical
evidence, he offered it to the jury by implication.
We shall examine the relevant evidence later in this judgment. On any view
however, we must reflect on the likely impact on the verdict in the present
case if Mr Mansfield had been able to cross-examine Professor Meadow, and
undermine the weight the jury would inevitably attach to his evidence, by
exposing that, notwithstanding his pre-eminence, at least part of his evidence
in the Sally Clark case was flawed in an important respect. To some extent
at least, Professor Meadow’s standing as a witness would have been reduced.
Therefore the flawed evidence he gave at Sally Clark’s trial serves to undermine
his high reputation and authority as a witness in the forensic process. It
also, and not unimportantly for present purposes, demonstrates not only that
in this particular field which we summarise as "cot deaths", even
the most distinguished expert can be wrong, but also provides a salutary
warning against the possible dangers of an over-dogmatic expert approach.
- The word "dogma" was used in his evidence by Dr Rushton, a consultant
paediatric and perinatal pathologist, to record his unhappiness, and that
of some of his colleagues at "a set of rules being laid down",
and, because they were felt to be over-restrictive, followed with reluctance.
In evidence, Dr Rushton repeated part of the contents of his report. It included
this passage:
"However,
in a family with a history of this type, current dogma is that an unnatural
cause has been established unless it is
possible to demonstrate an alternative natural explanation for these events."
That dogma encapsulates what in a criminal case we have
described as the first, and we would emphasise, the erroneous approach.
- By way of linking
the word "dogma" with SIDS, Dr Rushton went
on:
"The
definition of SIDS, for instance, .... says usually the definitions include
babies up to one year of age; it used to be two years
of age but it has been decided by experts in the field meeting that one year
is the limitation. I would suggest that biology does not behave like this
and [in] any event, sudden unexplained deaths occur throughout life – they
also occur in adults. So there is not a magical cut-off point at one year
of age."
- Professor Golding, professor of paediatric and perinatal epidemiology,
made the same point in a different way when she said in evidence:
"I
think, to put it in context, there is a fashion nowadays that if you have
more than one sudden infant death the next one
must have been killed deliberately, and that is something that people within
the paediatric profession have taken on board without sufficient evidence.
Certainly, obviously, there are cases where it happens, but (in the vast
majority) there is no evidence of that."
If that is the fashion, it must now cease.
- Professor Golding continued:
"...
there are a few cases where it (smothering) appears to have happened, but
it is by no means clear that the claims that so many
families where more than one sudden infant death has occurred are due to
smothering. The results haven’t been subjected to what I would call an appropriate
statistical analysis. They are mostly a hunch that the paediatrician or whoever
is looking at it might have but it is not based on any scientific foundation."
- These observations serve to highlight the second problem which can arise
in this case, and cases like Sally Clark and Trupti Patel. We have read bundles
of reports from numerous experts of great distinction in this field, together
with transcripts of their evidence. If we have derived an overwhelming and
abiding impression from studying this material, it is that a great deal about
death in infancy, and its causes, remains as yet unknown and undiscovered.
That impression is confirmed by counsel on both sides. Much work by dedicated
men and women is devoted to this problem. No doubt one urgent objective is
to reduce to an irreducible minimum the tragic waste of life and consequent
life-scarring grief suffered by parents. In the process however much will
also be learned about those deaths which are not natural, and are indeed
the consequence of harmful parental activity. We cannot avoid the thought
that some of the honest views expressed with reasonable confidence in the
present case (on both sides of the argument) will have to be revised in years
to come, when the fruits of continuing medical research, both here and internationally,
become available. What may be unexplained today may be perfectly well understood
tomorrow. Until then, any tendency to dogmatise should be met with an answering
challenge.
- This
troublesome aspect of cases such as this is well illustrated by post-trial
material which we have received in evidence.
Each paper is awaiting publication. The first, the Sudden Unexplained Infant
Death (Europe): findings of the Europe Concerted Action on SIDS (ECAS),
has been accepted for publication in The Lancet. It is anticipated that
the second, entitled Repeat Sudden Unexpected And Unexplained Infant Deaths:
Natural or Unnatural, based on analysis of the Care Of Next Infant Program
(CONI) research to determine the probability that a second infant death
in the same family may be natural or unnatural, will, subject to minor
corrections, shortly be published. Professor Berry described this paper
as a "long-awaited" study. Although not yet formally "accepted" we
received the study in evidence. One passage, at 9.5.2, provides a clear
illustration of the speed with which knowledge in this particular field
is developing.
"In
the CONI study there were two families in which both deaths were attributed
to the same condition (one … VLCAD, and one prolonged
QT syndrome). In both families, diagnosis was assisted or confirmed by the
birth of a third child identified with the same condition. Rib fractures,
attributed to resuscitation, were found in the VLCAD CONI infant. A few years
ago these deaths would have been totally unexplained. Both families would
probably have had a third unexplained death had the underlying cause not
been identified and treated, and at least one of the parents might have been
suspected of murder."
- In this context we should perhaps also note the concerns expressed by Dr
Paul Johnson, consultant clinical physiologist and Director of Maternal Infant
Healthcare and Tele-monitoring Research Centre at the Women’s Centre at John
Radcliffe Hospital, Oxford. He has for many years held appointments both
in the United States and here which have involved him in research into perinatal
pathology, paediatric neonatology, cardiovascular medicine and physiology,
as well as developmental neurophysiological disorder, including respiratory
and cardiac disorders. The extent of his current work is well-illustrated
by the fact that he has developed a unique computerised tele-monitoring system
and service for infants, with one of the largest databases for cardio-respiratory
function during sleep in infants aged under one year.
- Dr Johnson
accepts without hesitation that parents who appear to be affectionate and
caring towards
their infants sometimes kill them. He described the impact
on him personally of experiencing infanticide "first hand" when
he was training in California. He regarded three infant deaths in apparently
healthy infants in the same family as "extraordinarily unusual".
He did however lay emphasis on the apparent good health of such infants.
He examined the information about the deaths and ALTEs in the Cannings family.
He was extremely concerned at the paucity of information about these children,
without, as far as we can see, criticising those responsible for the post
mortems carried out on Gemma, Jason and Matthew.
- Dr Johnson
believed that there was "a wealth of information on development,
both before birth and after birth" which would have provided valuable
insight into what happened to these three children. He would say, "categorically
that once there has been sudden (unexplained) infant death ... you are obliged,
when that mother produces a second child or foetus" to do much more
than was done with this family. The purpose was to discover whether the child
or children may or may not deviate in their normal "developmental processes",
some of which were "extraordinarily subtle". He pointed out that
unless these investigations took place before and after birth and in the
first months of life, they could not be replicated. It was now known that
SIDS infants may have been affected by events before birth, although the
mechanism remained unknown. These include well-known factors such as maternal
malnutrition, and stress, and smoking. Without going further into the details
of Dr Johnson’s evidence, on the broad issues currently under consideration
his position was summarised in a few words, "We know a lot, we don’t
know enough."
- Dr Johnson linked this level of ignorance with a concern that what was
already known in the United Kingdom was less well applied here than elsewhere.
In Belgium, Scandinavia, and some parts of the United States, Dr Johnson
believed that the investigation into the development of Jason, Jade, and
Matthew, both when their mother was carrying them, and after they were born,
would have been much more precise and extensive. We see no reason to assume
that these concerns, and criticisms, are misplaced. Again, when monitoring
arrangements have improved, we should expect not only a greater degree of
insight into the natural causes of infant death, but hopefully and more important
a reduction in their number.
- This is too tragic a case to trivialise any aspect of it. We can however
illustrate this problem in a layman’s context. Not so long ago, experts were
suggesting that new born babies should lie on their tummies. That was advice
based on the best-informed analysis. Nowadays, the advice and exhortation
is that babies should sleep on their backs – Back to Sleep. This advice is
equally drawn from the best possible known sources. It is obvious that these
two views cannot both, simultaneously, be right. Towards the end of the hearing,
we became aware of research in Australia which suggested that the advice
that babies should sleep on their backs had not achieved the improvement
in the rate of cot deaths attributed to the modern practice. We do not for
one moment comment whether this research is valuable. Paediatricians and
other experts will certainly take serious issue with it. Our point however
is to highlight the fact that even now contrasting views on what might be
thought to have been settled once and for all are current.
- At a later
stage in the judgment, we shall examine the results of further research
of immediate
importance to the particular problems posed in this
case, and the evidence of Professor Meadow and Dr Ward Platt on the rarity
of three unexplained infant deaths in the same family, and the "pattern" which
was said to have emerged in the Cannings family. For the moment we shall
confine ourselves to observing that this research powerfully reinforces the
need for caution against the dangers of dogmatism at a time when our knowledge
is limited and incomplete.
- Before turning to the facts of this case in more detail, we shall begin
by considering Mrs Cannings’ extended family.
The Family Context
- The parents
of Mrs Cannings’ father, Stephen Connolly, were Stephen and Harriet. Harriet’s
sister, Babs,
had a number of grandchildren of which her
son, Patrick McDermott, was the father. Patrick, who lives in Ireland, had
seven children. Two died in infancy, one at 9 weeks, and one at 3 weeks.
Both deaths were properly categorised as SIDS. The next two children suffered
what appeared to have been genuine ALTEs in their early months, again both
natural but unexplained incidents. Patrick McDermott is Mrs Cannings’ second
cousin. Professor Patton, a consultant clinical geneticist described "a
very striking family tree ... with the rare condition occurring in two parts
of the extended family". This view was contradicted at trial on the
basis of the large number of apparently unaffected members of the common
family between the two branches which had suffered infant deaths or near
deaths, that is, the McDermott and the Cannings families. An important aspect
of the investigation of these issues was whether the pattern of inheritance
was autosomal recessive or autosomal dominant. Elucidation of this point
was complicated by the information that Mrs Cannings’ uncle, her father’s
brother Johnny, had a child who died suddenly at 8 months, whose death may
or may not have been regarded as a SIDS, but which was subsequently attributed
to established natural causes.
- Since the trial
further investigation has been carried out into the extended family. Further
infant
deaths have been identified. However on close examination
it is not obvious that they were all relevant. Professor Patton himself did
not suggest that any sufficient link had been made between the problem presently
under consideration and one male infant, born in Ireland in 1896, who died
on the day he was born, of "debility". Mrs Cannings’ grandparents,
Stephen and Harriet, had two further children who appear to have died in
infancy. We say "appear" to have died because although there is
a birth certificate showing the birth of Anastasia on 20th January 1926,
there is no corresponding death certificate. It seems to us however a reasonable
inference to be drawn from the fact that none of the surviving members of
the family remember her, and that a younger sibling was given her name, that
she must have died young. However, how young, and from what cause, is impossible
to say. Anastasia had a brother, Michael. In his case, both his birth and
death certificates have been found. Michael died in April 1931, aged 10 months.
The cause of death was described as "debility since birth". This
description would not now be used, and it is impossible to say what the certifying
doctor would have meant by it in 1931.
- Professor Patton
was tentatively inclined to include these two children in the category
of SIDS.
He may, of course, be right, but we know nothing
of the circumstances of Anastasia’s death, and the expression "debility
since birth", applied to Michael’s death, suggests a chronic condition
rather than a sudden occurrence. It is therefore far from clear to us that
either of these deaths should be regarded as an earlier SIDS in Mrs Cannings’
family.
- There is a
more compelling candidate for inclusion. Unbeknown to her at trial, Mrs
Cannings has a
half-sister, who following these convictions, made
herself known to her solicitors. For quite understandable reasons, she wishes
not to be identified by name. We shall respect her wishes and refer to her
as JM. Stephen Connolly is the father of both these women. They share a quarter
of their genes. JM has three children, two of whom suffered what appear from
her description to have been possible ALTEs. The first has been excluded
from consideration by Professor Patton, following a close examination of
the medical records. JM also has identical twin daughters. In March 1997,
when four weeks old, one of them, AM, was admitted to hospital following
what was described at the time as an "apnoeic episode". This was
a true life threatening event, and AM required resuscitation. At the time
when it occurred, it is common ground between Professor Patton and Dr Ward
Platt that the incident was rightly treated as an ALTE. Professor Patton
continues to think that it was. Dr Ward Platt refers to AM’s subsequent admission
to hospital in May 1997 for what appeared to be a seizure, or febrile convulsions.
He suggests that this provides a very plausible explanation for the earlier
incident. Although we understand the argument, we are unconvinced that the
diagnosis for the second incident necessarily provides the correct diagnosis
for the first. In any event, in our current state of knowledge, it would
be unwise not to recognise the distinct possibility that, in addition to
the McDermott family, Mrs Cannings’ niece, therefore the cousin of her children,
who had never met, let alone lived with her, suffered an ALTE when she was
4 weeks old. This is important fresh evidence. Taken on its own, it strengthens
the view expressed by Professor Patton at trial that this is indeed an unusual
family tree, and that the incidence of infant death and ALTEs in this particular
family are unlikely to be explained by chance alone. There may well be a
genetic cause, as yet unidentified, for the deaths of the Cannings children,
manifesting itself in some, but not all of the extended family, through autosomal
dominant inheritance with variable penetrance. That would mean that the child
in question needed only to inherit the gene from one parent to be liable
to develop whatever the genetic mechanism may be.
- We cannot avoid recording that we have been left
with the strong impression that some of the mystery surrounding SIDS is
likely to be dissipated when our knowledge of the impact of genes and genetics
is greater than it is now. By way of example, Professor Golding described
human genetics as a very complicated story, with much research yet to be
done. Speaking broadly, she observed:
"Genetics
at the moment is such that there are new discoveries all the time. Things
that we have no idea about are being revealed
every day ... There is a lot of work to be done, and once we have looked
at 30,000 genes we should have a clearer idea of what we should be looking
at."
In any event, for the purposes of this appeal, we are quite
unable to reject the realistic possibility that in the absence of some compelling
piece of evidence, whether specialist or extraneous, suggestive of the deliberate
infliction of harm, there may have been a genetic cause, as yet unidentified,
for the deaths and ALTEs experienced by the Cannings children.
Mrs Cannings’ Children
- We must therefore narrate the circumstances surrounding the deaths and
ALTEs in Mrs Cannings’ family. The expert evidence runs to several thousand
pages of typescript. A mass of expert evidence from witnesses of great distinction
in their respective fields was presented to the jury and to us. Listing these
witnesses, their many professional qualifications, their practical expertise,
and the contributions they have made to areas of research in and connected
with this field would itself occupy several pages of this judgment. We shall
not repeat everything contributed by each expert. Rather, we shall seek to
encapsulate the critical issues in brief summary, so far as possible avoiding
technical language.
Gemma
- In evidence
at trial the appellant described feeling "fantastic" when
Gemma was born by Caesarean section. She was a good baby, and her development
appeared normal. As was then routine, she was laid on her tummy. On 13th
November she was given her triple vaccine immunisation. Current research
suggests that nothing in that process provides any basis for anticipating
what happened to her next day.
- On 14th November 1989, the history of events leading up to her death, based
on the appellant’s account, appeared straightforward. The record shows:
"On
the night of 13th the baby was restless but then seemed to return to normal
and slept through the night. On 14th the mother
fed the baby at 9.00 am and went into town. Came home at 10.30 am and the
baby was fine. She checked her at 1.00 pm to give her a feed and found her
to be lifeless."
- The cause of
death was recorded as "natural, being Sudden Infant Death
Syndrome (cot death)". The pathologist, Dr Scott, could find nothing
which may have caused or contributed to Gemma’s sudden death, no causes which
might explain it. In the course of microbiological examination she found
the organism, staphylococcus aureus, in Gemma’s nose and mouth.
- The defendant was first interviewed on 16th November 1999, almost exactly
ten years after Gemma’s death, and a few days after Matthew’s death. She
said that she had found Gemma lying on her back, looking very, very white.
She tried, unsuccessfully, to revive her. She called an ambulance. In a later
interview on 8th March 2000, she described events during the day of 14th
November 1989. She found Gemma looking white, and not moving. At trial she
said that after Gemma’s death the shock and trauma meant that she could not
remember everything that had happened. In view of the passage of time that
was not unreasonable.
- The Crown’s opening at trial was unequivocal.
"Nothing
was found on post mortem examination that was suggestive of an unnatural
death and there was nothing in the history
of Gemma’s life or in the circumstances of her death that showed her death
to have been unnatural. However, no cause for her death was ever identified.
The fact of Gemma’s death is a background against which you will have to
consider what happened to the two children you are principally concerned
with, Jason and Matthew."
- Gemma’s death
did indeed provide a good deal of background relevant to subsequent events.
For example,
as we shall see, when Jason’s ALTE occurred,
Mrs Cannings greeted the health visitor, "It’s happened again".
Without knowledge of what had happened to Gemma, that evidence would have
been incomprehensible to the jury. In reality, at trial, Gemma’s death assumed
much greater importance than mere background to Jason’s and Matthew’s deaths,
and Jason’s and Jade’s ALTEs, and whether they resulted from the deliberate
infliction of harm. As we shall see, Professor Meadow attached huge importance
to the fact of three infant deaths in the same family. With hesitation, Dr
Ward Platt would have been content to accept that, taken on its own, Gemma’s
death fell within the description SIDS. He did however say:
"Question
marks have to hang over Gemma. Again we do not have in clinical terms the
evidence to suggest hers was anything other
than a natural death but when one steps back from the situation it has been
repeatedly found that when everything comes out, in fact the first death
turns out not to have been natural."
- We can illustrate the development of the Crown’s case by this passage from
the cross-examination of Professor Golding.
"Q.
Are you saying then that we should regard these three deaths as possibly
being entirely random?
A. I can’t see any evidence that they shouldn’t be ... by
random doesn’t mean, you know, a bolt from the blue; it means that this is
a normal sort of pattern for repeated cot deaths, or, if you had a cot death
and took somebody else’s cot death and somebody else’s cot death and put
them together you would get that sort of pattern.
Q. Well, taking three cot deaths from three different families
and putting them together is surely quite a different thing to taking three
deaths within one family?
A. It is different only that it is from one family.
Q. Are you saying, therefore, that these deaths may not
be linked in some way by some common cause?
A. No. What I am saying is that the fact that they are from
one family does suggest that there is something else happening that would
be responsible for putting that family at higher risk. ...
Q. It is not just the three deaths that have to be looked
at when considering the history of the four Cannings children, is it?
A. No, everybody has put acute life-threatening events together
with them.
Q. Yes. Do you?
A. I see them as part of the pattern certainly, and definitely
knowing that there is good evidence that children who have apparent life-threatening
events are at greater risk of sudden infant death syndrome. ...
Q. In this family we have a total of six events: three deaths,
three non-fatal events?
A. Yes.
Q. Affecting all four children. If it is right that no cause
has been found for any of them, they are six unexplained events?
A.
I don’t want to comment on whether it is right or not that no cause has
been
found ... but these children seem particularly susceptible."
- This cross-examination
was perfectly legitimate. If we may say so in passing, the responses were
equally robust. The passage we have quoted, and others
to be found in the transcript, do however illustrate that Gemma’s death was
no longer being viewed simply as "background": it encapsulated
the fundamental basis of the Crown’s case against Mrs Cannings, dependent
on the "pattern" of events in this family, and the extreme rarity
of three infant SIDS in the same family. Our earlier warnings about the danger
of taking the wrong starting point or making inappropriate assumptions of
guilt do not mean that the sequence of events was irrelevant. As we have
said, the deaths and ALTEs were not and could not be treated as "isolated
incidents, entirely compartmentalised" from each other. Defence as well
as prosecution experts were troubled by the sequence. That is why each case
had to be investigated with great care. Gemma’s death formed part of this
troublesome sequence, and so far as practicable, was properly investigated
at trial. We can perceive no ground for complaint.
- In the event, we must record that there was not a scintilla of direct objective
evidence that Gemma’s death was anything other than SIDS. The Crown’s opening
was correct.
- Mrs Cannings and her husband did not think about the possibility of another
baby for some little while because of her sense of shock at Gemma’s death.
Jason
- When she became pregnant with Jason, the appellant was given instructions
in resuscitation techniques and provided with an apnoea alarm. This is a
well known device, which detects the motion of a baby’s breathing. When none
is detected, after a pre-set period, the alarm sounds. Without diminishing
its potential value, it is not, as some think, a machine which prevents an
infant death.
- On 25th April 1991 Jason was born by Caesarean section. At birth his hips
were dislocated. The Aberdeen splint required to manage this condition meant
that, as was in any event customary at the time, he was laid on his tummy
rather than his back.
- In her evidence,
the appellant described Jason as a "beautiful" baby.
She cared for him, following her mother’s example, among other things making
sure that windows were appropriately opened to air the home.
- The appellant
was expecting a visit from the health visitor, Mrs Peacock, during the
morning of 4th
June 1991. When Mrs Peacock arrived, the appellant
answered the door, saying, "It’s happened again". Mrs Peacock followed
her into the flat. Apart from the appellant herself, no-one else was present,
and Jason was lying on the double bed "white and apparently lifeless".
The health visitor resuscitated him, telling the appellant to telephone for
an ambulance and for her husband. Before resuscitating him, she had checked
that the baby’s mouth was clear. She found no fluid or vomit in it. After
a while, Jason gasped and seemed to respond. She picked him up, and patted
his back, and stimulated his breathing. Thereafter, she had to keep breathing
air into him whenever he seemed to be drifting off. She did so successfully.
- She took the baby to his mother who seemed very shocked, and was sobbing.
At one stage she heard the appellant in the bathroom, retching or vomiting.
- In due course, Mr Cannings returned home. The ambulance arrived, and the
baby was taken to hospital, followed by his mother and father. On arrival
at the accident and emergency department this account of the incident was
recorded:
"10.15
am. Apnoea alarm – mother finds baby pale and limp. Health visitor … arrived
coincidentally at the same time. Resuscitated
the baby."
- Jason’s condition
on arrival was noted as "crying healthily – good
movement and tone. Breathing spontaneously – no stridor/wheeze. Pale. Shut
down. Mottled. Cool peripherally." His breathing was irregular, and
described as "grunting", suggesting but not conclusive of a respiratory
problem. Part of the base of the right lung was collapsed. His fingers and
toes, legs and arms were very cold, and there was poor blood flow to the
baby’s skin. His temperature was 35o; significantly lower than
normal. His temperature dropped a little further, but then started to recover.
- Investigation revealed a raised white cell blood count, raised platelet
count, and raised blood glucose. It was common ground that these findings
in Jason were consistent with a baby who had been under stress, or unwell,
but they were non-specific or unspecific on the question whether or not the
stress was the result of the deliberate infliction of harm. The first urine
test showed the presence of blood and protein, again suggestive of kidney
stress, but again unspecific as to cause. Some glucose was also found, but
the subsequent urine sample was normal for glucose. In the umbilical swab
staphylococcus aureus was discovered, and an antibiotic prescribed. Bio-chemical
changes in Jason, potentially important to the possible involvement of the
vagus nerve, were also noted.
- Full infection screening was carried out. Nothing untoward was found. The
baby’s treatment at hospital followed conventional lines. By 4.00 pm, his
condition had stabilised. A physical examination by the consultant paediatrician,
Dr Marshall, revealed nothing significant. To stabilise circulation, a drip
was used. When it was noted that Jason had passed some rather loose motions,
his feeding was withheld for a short time until he was settled. By 6th June,
Jason was well, and he was discharged.
- Hospital staff who observed Mr and Mrs Cannings described them as loving
and caring towards Jason, and handling him well. When Jason was discharged,
the consultant paediatrician spoke to them, explaining how to give mouth
to mouth resuscitation, and cardiac massage. He thought that Mr Cannings
understood these instructions, but was unsure whether the appellant was fully
taking in everything he said. A care plan was drawn up. A note was made that
Mr and Mrs Cannings were very upset and anxious about Jason because of a
previous cot death.
- When interviewed on 16th November 1999, the appellant explained that she
was in a state when the health visitor arrived because she had discovered
Jason:
"I
think on one of the occasions I had gone downstairs because we had a garden
out the back … I had been putting some washing out
and when I came back upstairs the alarm was going off and I didn’t have the
walkie-talkie thing, and I just went in, the alarm was going off."
The
health visitor was "literally arriving as I’d found
him." She had run to the door to open it to her. On 8th March, in her
further interview, she said that she was in the room with Jason when she
heard the car. She had not heard the apnoea alarm start up, but heard the
alarm sound.
- In evidence
at trial she described hearing the sound of the alarm when she was in the
garden.
She had run to Jason. When she arrived he did not
look very good, and he was only moving slightly. She turned the alarm off.
She put him on the bed. She panicked. She was distressed and shocked. She
tried to remember what she had been told about resuscitation but did not
try it. She saw the health visitor arriving and thought "Thank God".
She thought it was a pretty serious situation, and Jason in need of urgent
help. She said to the health visitor, when she opened the door, "It’s
happened again".
- These accounts
of events immediately before Jason’s ALTE were closely analysed by Mr Paul
Dunkels
QC, before the jury, and again before us. The Crown’s
contention was that the appellant smothered Jason, and that the smothering
began once the appellant knew that Mrs Peacock was arriving at her home,
in an attempt to evoke sympathy. We had difficulty following this suggestion.
We cannot understand why the appellant should have done so, unless to draw
attention to herself, a manifestation of factitious disorder by proxy, a
condition which, in her case, was excluded. If however she had no intention
of being caught, or indeed intended to kill Jason, she did not have to wait
until the moment when the health visitor was about to come into the house
and interrupt her, or carry out the attempted smothering process in such
a way that no sign of it would be apparent. The process of airways obstruction
could have been started earlier, or later, after Mrs Peacock had left. Furthermore,
if this suggestion were correct, this particular ALTE (in which, on the Crown’s
case, Mrs Cannings was apparently hoping to be caught, rather than in each
of the other cases, seeking to evade detection) was quite inconsistent with
the establishment of the "pattern" which represented such an important
strand in the Crown’s case.
- The appellant stayed with Jason for a couple of days in hospital. When
he was discharged she thought that he was not as alert as he had been before,
but she was reassured by the midwife. She had therefore felt no need to take
Jason to the doctor.
- On 13th June 1991 Jason died. He was due to be taken to hospital that morning
for a consultant paediatrician to check the progress of his dislocated hips.
Mr Cannings went to work. He telephoned home, to be told that Jason had stopped
breathing again, and he called the emergency services. The appellant’s account
of what had happened was recorded in reported speech, as follows:
"Jason
stopped breathing on 4th June but was resuscitated by a health visitor.
Since that time he had been fine, feeding well and no
chest or breathing problems. At 3.30 am on 13th June he had feed (bottle)
no problems, and was put back into his cot with baby alarm turned on, mum
went back to bed herself in the same room. At 7.45 am mother checked baby,
he was ok, she went to get her own breakfast and the baby alarm went off
at 9.00 am. She went back to the room and found him still and white, resuscitation
tried with no success."
- Before Jason arrived at hospital, in response to a 999 call, the emergency
services arrived at the appellant’s home. A paramedic said that as he arrived,
the appellant was coming up from a kneeling position on the floor where Jason
was lying. Although attempts were made at resuscitation, Jason was probably
already dead. One paramedic, using specialist instruments, thought she had
found some vomit in Jason’s lower airway, but it was agreed at trial, that
if there was any vomit it was entirely consistent with the baby’s stomach
contents having been released after he died.
- In interview on 16th November 1999, eight years after Jason’s death, the
appellant explained that she had felt that Jason had not been quite right,
or quite the same, after he was discharged from hospital. She thought she
had heard the apnoea alarm after it had started. She went in to the baby.
She found that Jason was white. She had tried to revive him. In her interviews
on 8th March 2000, she repeated that she did not think that the baby had
been himself on his return from hospital. She thought she had not heard the
alarm starting, but became aware of its sound. She went straight to Jason,
but found that he was very pale, fairly cold and lifeless. She was asked
how it was that she had not heard the sound of the alarm earlier. The basis
for that question was that if Jason felt cold by the time the appellant reached
him, then he must have stopped breathing for some time before she went to
him. The appellant said that the bedroom door was shut or nearly shut because
of the family dog.
- In evidence
at trial the appellant described how Jason seemed "alright" at
7.45 am. Then at 9.00 she realised that the alarm was sounding. She found
him still and white. He was not breathing. She tried to resuscitate him,
without success. She thought her husband may have phoned at the time when
she was trying to resuscitate Jason, and she told him that there was a crisis.
An ambulance was called. When she realised Jason had died, neither she nor
her husband could believe that it was happening again. She said that she
blamed herself and felt that she "had failed".
- The paramedics
all described Mrs Cannings as upset, sobbing and distressed, and they tried
to comfort
her. The post mortem examination on Jason was carried
out by Dr Scott who had performed the post mortem on Gemma. As with Gemma,
she found nothing that could have caused or contributed to Jason’s death.
She carried out precisely the same tests as she had before, and also an x-ray,
which was negative. She looked for any "feature of abnormality" and
found none. The child’s brain was looked at by a paediatric pathologist.
It, too, was normal. Dr Scott was also aware of Jason’s ALTE nine days earlier.
She appreciated that she should bear in mind the possibility of smothering,
or something similar. These concerns led her to check her findings with a
consultant neuropathologist, Dr Isabelle Moore. At the end of her investigation
Dr Scott’s opinion of the cause of Jason’s death was "Sudden Infant
Death Syndrome (cot death)".
- When the health visitor returned from her holiday, she visited Mr and Mrs
Cannings. She gave evidence that throughout her dealings with the appellant
and Gemma and Jason, she thought they were properly cared for by their parents.
She introduced them to Professor Emery, the distinguished paediatric pathologist,
to some of whose research into cot death we shall draw attention later, and
Dr Scott herself later had contact with Professor Emery, who has now died.
She showed him all her reports. He conducted a microscopic examination of
the lungs. She understood that he agreed with her conclusions that both these
deaths were natural, but that the causes were not yet defined. Dr Barnes
confirmed that in Professor Emery’s mind there was nothing suspicious about
these two deaths. When Dr Scott carried out this post mortem, in accordance
with practice at the time, she did not look for intra-alveolar haemorrhaging
and iron-laden macrophages. The possible relevance of such material only
became apparent in 1997, another mark of the constant development of knowledge.
- After Matthew’s death these findings were reviewed by Professor Berry,
a consultant paediatric pathologist at the Bristol Royal Infirmary. He read
all the records for Mrs Cannings and all the children, reviewed Dr Scott’s
post mortems on Gemma and Jason (speaking favourably of the quality of Dr
Scott’s work) and conducted the post mortem on Matthew. On examining the
slides of Jason’s lung tissue he found evidence of intra-alveolar macrophages,
consistent with bleeding into Jason’s lungs, which had taken place on an
occasion earlier than his death. In view of the quantity, this evidence was
consistent with an indication of obstruction of his airways at the time of
the ALTE. However, on any view, there was no copious recent bleeding into
the lungs. So there was no evidence of fresh bleeding, and as we shall see,
a critical dispute developed whether and if so to what extent, there was
evidence of old bleeding.
- Professor Berry explained macrophages as scavenger cells found in the lungs.
When blood is present in the intra-alveolar cells, the macrophages are unable
to consume its iron content. Perl's (stain) test is used to detect siderophages,
cells which themselves scavenge haemosiderin, the iron left behind in the
lungs from a prior bleed, and which are well described as iron-laden macrophages.
Pathologists can be confident that there has been prior bleeding, but the
existence of siderophages, even if significant, is not diagnostic of smothering.
Professor Berry expected that haemosiderin would develop within 36 to 48
hours and that the siderophages would be cleared, by absorption into the
blood stream, coughing or swallowing within weeks.
- Dr Rushton
took a different view from Professor Berry about the quantity of haemosiderin
visible on
the slides. Using a microscope in court, he explained
what he was seeing on them, and his view that it was possible to describe
haemosiderin as present in only two of the seven pieces of lung which were
examined, and then only in parts of those two pieces. He explained that the
cells were not "all through the lung with a wide distribution; they
are in quite small areas of the lung, in fact very small, microscopic areas
of the lung". He disputed Professor Berry’s observations that macrophages
were present in exceptional numbers, "because in fact most of the lung
doesn’t contain any of these cells. They are localised in the sections to
two of the small pieces of tissue and only in parts of those tissues." In
his opinion the amount of haemosiderin to be seen was not exceptional, and
based on his experience he concluded that, at the highest, it was only marginally
in excess of the amount occasionally seen in cot death.
- Dr Rushton
postulated various ways in which bleeding in the lungs such as that suffered
by Jason
might occur, including blood inhaled at birth (which
was excluded by Professor Berry), and damage to the lung from foreign bodies
such as vomit or stomach juices, or from the inhalation of toxic gas, or
infection, or from bleeding or circulatory disorders, or even from resuscitation
procedures. He was not in the slightest degree critical of the health visitor,
or her efforts at resuscitation on 4th June, which were described as gentle.
It was suggested that if so, attempts at gentle resuscitation would not be
likely to have caused any bleeding. His response, in effect, was that there
was no way of knowing "because obviously most babies that are resuscitated
don’t die, and therefore we can only judge from the ones that die. It may
be that in fact lung haemorrhages are very common in resuscitation. Unfortunately,
that’s evidence that you can’t acquire." He also noted that resuscitation
was carried out in the ambulance on the way to hospital. Again, although
he implied no criticism whatever of the paramedics, the same point remained.
If the effort were too gentle, the lung would not expand and resuscitation
would not take place: if the resuscitation were too hard, then some of the
thin membranes with blood vessels in them might be torn and produce local
bleeds. Dr Rushton agreed that the blood could have resulted from the ALTE
which had taken place nine days earlier, but felt it was difficult to estimate
the time taken for the blood to leave the lungs. This affected the question
whether the appearance of the macrophages was more consistent with an incident
at the time of the ALTE rather than on delivery at birth. Dr Rushton’s concern
was that the length of time taken for blood to disappear from the lungs was
not known. He pointed out that "Some people believe it can disappear
extremely rapidly while other people believe it may hang around for some
considerable time."
- Although we
have explained the areas of dispute between these experts, the real question
dividing
them was whether there was a sufficiently reliable
way of assessing the amount of haemosiderin to enable them to offer assistance
to the jury on whether the quantity found in Jason was sufficient to be indicative
of, or consistent with smothering, or SIDS. Despite the disputed problem
of haemosiderin in Jason’s lung tissue, Professor Berry made clear at the
outset that he was not "for a moment" suggesting that what he found
was "diagnostic of imposed upper airway obstruction". He did however
regard it as a "warning" and "extremely worrying", and
although he thought that the blood found in Jason’s lungs had not resulted
from efforts at resuscitation, he could not "absolutely rule this out".
As a consultant paediatric pathologist, Professor Berry believed and even
now remains of the view that the cause of Jason’s death, and Matthew’s, too,
remains "unascertained". Dr Rushton did not suggest that his overall
analysis of the pathological data provided any positive alternative explanation
to that advanced by the Crown that there was an unnatural cause for the deaths
and ALTEs. He also recognised that any assessment of the amount of haemosiderin
had a subjective element, namely the experience and judgment of the individual
examining the relevant slides. That said, he did not resile from his fundamental
view that the amount of haemosiderin to be seen was not inconsistent with
a natural event, or efforts at resuscitation after it. In our judgment, the
presence of haemosiderin on Jason’s lung slides was an ascertained fact.
It was not however possible to conclude that it represented the result of
smothering.
- We shall reflect on the vaso-vagal issue, as it may relate to Jason’s ALTE,
when dealing with the ALTE subsequently suffered by Jade. We also note in
passing that an issue canvassed at trial related to the proximity of the
house to Porton Down, and to the deaths of two other babies living in the
same vicinity in 1990 and 1991. This issue was not pursued before us, and
it plays no part in our decision.
- We must now
return to the narrative: after meeting Professor Emery, Mr and Mrs Cannings
were
willing to help him in his research into cot deaths.
They changed their lifestyle. They gave up smoking. They moved house. Mr
Cannings returned to work. After a while the appellant felt "empty".
She wanted another child.
Jade
- After an unremarkable pregnancy, Jade was born by Caesarean section on
15th January 1996. Before her birth Mr and Mrs Cannings had accepted Mrs
Kenny’s suggestion that they should join the CONI scheme to which reference
has already been made. Mrs Kenny was a new health visitor covering the area
of their new home, and like Mrs Peacock, she was very experienced. With advice
from Dr Barnes, a consultant paediatrician with a special interest in these
problems, they did so in December 1995.
- A neo-natal
check shortly after Jade’s birth revealed no problems. Mr Cannings himself
was off work,
sick, for some six weeks. Mrs Kenny made her first
visit to the appellant’s home some two and a half weeks after Jade’s birth.
Jade was very well. Mrs Kenny continued to visit on a regular basis, a total
of fifteen times before 1st April. Nothing was noticed by Mrs Kenny during
her visits to raise any cause for anxiety. Jade was also seen during the
post-natal check and a six-week check, which revealed "a perfectly normal
healthy baby". The General Practitioner also recorded that Mr and Mrs
Cannings seemed to be very well. The appellant herself had no concerns about
the little girl.
- On 1st April
1996, in response to a call by the appellant, her general practitioner,
Dr Meader,
called at the appellant’s home. She found the appellant
distressed, because Jade had woken that morning with breathing difficulties
and her condition was similar to that of the two babies that had died previously.
On examination, the doctor found that Jade was not in fact "desperately
ill", but she was "floppy, heavy breathing, vomiting ++".
Her chest was clear. She nevertheless took the appellant, together with Jade,
to hospital where Jade was admitted at 8.45 am. The appellant’s account of
events in reported speech was:
"Baby
fed at 6.00 am – floppy, laid back down as thought baby tired. Turned apnoea
alarm off as thought baby would wake. Mother fell
asleep again. Woke at 7.30 am went into her bedroom and noticed white colour,
eyes closed, breathing gasping and laboured. Shook baby, called GP, baby
began crying, breathing still laboured. Apnoea alarm went off two weeks ago
when disconnected."
The evidence also showed that Jade had vomited twice at
home and again in the ambulance on the way to hospital. The appellant added
that until this incident Jade had been well, but she reported that the baby
had been lethargic during the previous day, and had suffered two bouts of
diarrhoea. There was a dispute at trial between experts, which summarising
it simply, was whether this was a true ALTE, or simply a consequence of a
bout of gastro-enteritis. If the latter, of course, it ceased to be relevant
to the issue before the jury: the baby was suffering a normal unremarkable
illness.
- When interviewed
on 16th November 1999, the appellant told interviewing officers that after
her husband had gone to work, and Jade had woken and
finished her feed, she had put Jade back down to let her sleep. She forgot
to put the apnoea alarm on, and went back to bed herself. She woke with a
start, and went to Jade, who was very pale and white. She rang for the doctor.
Jade started vomiting when the doctor arrived. In interviews on 8th March,
she repeated this explanation, saying that she had forgotten to put Jade’s
apnoea alarm back on when she put her down after feeding her, saying, "Maybe
I was still tired myself from getting up and giving her a feed."
- In evidence at trial, the appellant described the incident in very similar
terms. She said that she had forgotten to put the apnoea alarm back on because
she was tired, adding that this was the only time she had forgotten, and
she did not forgive herself for a long time afterwards. She had telephoned
the doctor because Jade was very pale, gasping for breath, with her eyes
closed. She denied having shaken Jade, but added that it seemed that what
had happened to Jade was similar to what had happened to Jason nine days
before he died. She described an overwhelming sense of panic. She went on
to describe events at the hospital, and then her own increasing confidence
as Jade flourished.
- On examination
at hospital Jade was found to be very pale and her hands and feet were
cold and mottled.
Her fontanelle appeared sunken, and it was
noted that there was "slight wheezing" in her chest. Treatment
by an intravenous drip, containing albumin and salt solution, and later intravenous
antibiotics was arranged. A broad range of tests was carried out. Her glucose
level, white blood cell count and platelet count were moderately but not
significantly raised. Analysis of organic acids in a urine sample taken four
hours after admission suggested that her kidneys had become "unhappy".
It also showed increased levels of lactate, or lactic acid, pyruvate, alanine
and hydroxybutyrate. This would be consistent with a stress response to a
severe incident of acute deprivation of oxygen. Cerebral ultrasound of the
brain was normal, and a disorder of the body chemistry was ruled out, although
an increase in IgM was noted. At the time gastro-enteritis was not diagnosed.
At trial the defence case was that the non-diagnosis was wrong.
- Jade remained
in hospital until 13th April. While there she continued to have episodes
of vomiting
and diarrhoea. There were no problems with her
breathing. Taking this in a little more detail, by 3rd April, the problem
of diarrhoea and vomiting appeared to have been alleviated. The next day,
it was felt that Jade was well enough to go home, but her parents decided
that she should remain as an in-patient. There were further episodes of vomiting,
which continued into 5th April. A substitute baby milk was introduced and
then reduced. On 6th April there was a single episode of loose stools, but
no vomiting, and a spike of temperature. It was noted that she "has
passed urine now with some diarrhoea". Progestamol was discontinued
lest it was causing the vomiting. She was given some water to drink, and
that afternoon was "more alert." On 7th April Jade was tolerating
her food, and said to be clinically well. On 8th April observations continued.
The baby was feeding well and was more comfortable. Her temperature was normal.
On 9th April the progress had continued. The baby had a very good morning,
and was again tolerating all food and her temperature was normal.
- Jade was due to have second stage immunisations, and so the appellant wanted
her to be observed in hospital. She therefore remained for another 3 days.
The immunisations had no side effects. Tests were carried out which excluded
any possible metabolic problems. A twenty-four hour heart recording excluded
cardiac problems. Special immunological tests were carried out. These proved
negative. As with Jason, bio-chemical changes in Jade, of potential relevance
to this particular ALTE as a vaso-vagal incident, were noted.
- Jade left hospital with her mother on 13th April.
- As already
noted, there was a dispute at trial about the correct diagnosis. Professor
Meadow and
Dr Ward Platt disagreed with the contention that Jade
had suffered an episode of acute gastro-enteritis. She was not displaying
sufficient symptoms to enable that diagnosis to be made. Professor Meadow,
while conceding that paediatric gastroenterology was not his speciality,
nevertheless believed that this was a topic well within his sphere of expertise,
and noted that Jade had taken a feed normally at 6 am on the morning of her
admission, which was inconsistent with severe gastro-enteritis, and it was "inconceivable" that
gastro-enteritis could explain the state in which she was found shortly afterwards.
Dr Ward Platt believed that Jade’s reduced temperature, as noted on admission,
would have been unusual, and the episode of loose stools and vomiting prior
to admission was insufficient to justify this diagnosis. He suggested that
this would require some days of loose stools or vomiting, together with an
inability to take fluid, and that a severe attack of gastro-enteritis would
have resulted in a significant reduction in the baby’s body weight as measured
on admission and set against her weight on discharge. He did not accept that
the baby was dehydrated. The sunken anterior fontanelle which, he agreed,
would have been a sign of dehydration, was, he believed, misleading, and
one which was often misinterpreted by junior doctors. The term had not been
used by the more senior clinician who saw the baby later. The use of the
intravenous drip had been unnecessary. With Professor Meadow he also believed
that the good urine output noted while Jade was in hospital militated against
the diagnosis of dehydration, and thus of severe gastro-enteritis. He could
accept mild, but would reject severe gastro-enteritis. His final position
was that Jade had an illness consistent with gastro-enteritis, but that after
an incident of smothering, a "knock-on" effect upon the gut can
occur.
- Dr Ward Platt found no evidence of an active infection in Jade’s chest
x-rays, and ruled out any chemical disorder, believing her to be a normal
child developmentally, who had endured a striking and severe stress response.
He believed that the episode was respiratory in nature, characteristic of
oxygen deprivation, and having eliminated the other possibilities, he concluded
that this ALTE had resulted from smothering.
- Professor Milla, a professor of and specialist in paediatric gastroenterology
and nutrition, with twenty years’ clinical experience, gave evidence for
the defence. His belief was that Jade had suffered a circulatory collapse
(rather than a respiratory condition) the cause of which was not clear, but
which, taken together with her pre-admission symptoms, suggested gastro-enteritis.
On analysis of the case records he believed that:
"She
had a circulatory collapse which resulted in her being admitted to hospital.
The cause of that circulatory collapse is not
entirely clear but she had symptoms both prior to the collapse and following
the collapse suggestive of gastro-enteritis."
- He rejected the idea that diarrhoea was the sort of thing to be expected
in a young baby, commenting:
"Neither
you nor I nor infants have diarrhoea for no reason. Diarrhoea is caused
by malfunction of the gastro-intestinal tract
and that may be caused by a whole host of different disorders but most commonly
it will be an acute infection of the gastro-intestinal tract, and in this
country viral infections are the commonest cause of them."
- He addressed
the continuing history of diarrhoea and vomit, as described in the notes,
observing that
the history suggested that this was not a simple "one
off" situation. He agreed that the elevation in the levels of lactic
acid, pyruvate, and hydroxybutyrate were indicators of non-specific episodes
of stress, but suggested that they were equally consistent with gastro-enteritis.
As Jade had a diarrhoeal illness, her body fluids may have shifted from one
part of her body to another, causing a drop in the sodium level. This was
consistent with her notes which showed a low salt level. Her low temperature,
sunken fontanelle, mottled skin, and the description of her as "floppy" suggested
a circulatory shut-down. It was a factor consistent with dehydration that
Jade had not passed urine until the afternoon after her admission. He was
fortified in this view by the estimation of her fluid loss by the clinicians
who treated her, assessed as between 6 and 10%. He viewed the figures for
weight on admission and discharge as without relevance, since her normal
daily growth would have been about 30g. Taking into account that she had
been given fluid during her period of admission, he deduced that Jade had
not grown at all while in hospital.
- Professor Milla
cautioned that the level of diarrhoea endured by a baby can be masked by
the efficacy
of modern nappies. Toxins can be fast acting,
and the physical signs suggested a peripheral shut-down in the circulatory
system, consistent with the passing of a lot of watery diarrhoea. The history
given was neither uncommon nor inconsistent with gastro-enteritis, and though
her hospital notes were insufficiently informative on the subject, he felt
that a number of causes considered by the treating clinicians plainly included
gastro-enteritis. He pointed out that Jade’s history would not have been "that
uncommon" in a child who had gone on to have a severe problem, and that "Something
clearly was carrying on for quite a while after her admission into hospital." He
ended his evidence by repeating that Jade had signs and symptoms consistent
with gastro-entero infection, and that the history of her time in hospital
was consistent with that diagnosis, and nothing inconsistent with it had
happened.
- In summary, if Jade’s admission to hospital on 1st April resulted from
circulatory rather than respiratory problems, nothing unnatural had occurred.
We take note of the fact that a leading expert in this field was unshaken
in his belief that Jade’s problems were consistent with gastro-enteritis,
and that they may have been circulatory in nature. If so, this was not or
may not have been an ALTE.
- Whether Jade
suffered severe gastro-enteritis or not, fairly mild gastro-enteritis or
mild dehydration
might have provided a trigger for an inappropriate vaso-vagal
response. As we have already noted, the same possibility was said to apply
to Jason’s ALTE, and it is convenient to deal with the point in relation
to both infants together. This phenomenon was described by Dr Barnes as a
safety response against reflux, and the possibility of inhaling vomit or
regurgitated substances. Professor Berry acknowledged that as a pathologist
he knew, "Babies can die very suddenly by another mechanism we don’t
quite understand, so I think it is also possible the baby could die almost
instantaneously – almost a kind of shock effect." He agreed that it
would be something like a vagal response, or kind of nervous response. Professor
Meadow rejected the idea that a vaso-vagal attack was a significant factor
in a sudden infant death. Dr Ward Platt rejected it both generally, and with
particular reference to this case. He accepted the possible existence of
an abnormal vaso-vagal response in an infant, but held the view that a baby
would recover very quickly from such an incident.
- Dr Johnson,
a consultant clinical physiologist, whose concerns about the lack of detailed
investigation
and monitoring of the children born to Mrs
Cannings after Gemma’s death have already been narrated, drew attention to
the way in which the vagus nerve operates. The nerve serves many of the organs
of the body, and not only carries information to the brain, but also controls
the heart rate and the opening of the airways. It is "a major controlling
nervous pathway". He described difficulties which babies have in the
first few months of life in breathing through their mouths, and the way in
which chemo-receptors will react to foreign agents by going into spasm, causing
a temporary cessation of breath.
- Dr Johnson is researching the question why some babies over-react by way
of vaso-vagal response, and shut down inappropriately. He described obstruction
of the airways and how it could occur, and yet remain undetected at autopsy.
He believes that existing research shows that a vaso-vagal response may be
one of the causes of ALTEs, and his concern that in these two cases there
had not been the investigation which could, and in his professional opinion
should, have been undertaken. He was not asserting that a vaso-vagal response
definitely caused either of the two ALTEs, nor was he ruling out smothering
or unnatural causes, which, like a vaso-vagal response, were high on his
list of possibilities. He referred to research from Brussels, based on an
investigation between 1983 and 1990 of 3,799 young children. This, he said,
suggested that a significant problem with gastro-oesophageal reflux and an
exaggerated vaso-vagal response might bring about changes to defend the baby’s
airway. The lack of proper investigation led him to conclude that an alternative
explanation to smothering had not been excluded. We cannot resolve this important
and developing issue. Once again, however, we record a responsible opinion
suggesting uncertainty about the true causes of these two incidents.
- What is certain
is that Jade survived. The appellant described her as "the
light of our lives". She and her husband wanted her to have a brother
or sister, and when the appellant became pregnant, Jade was very excited.
After her ALTE, Jade was seen regularly by Mrs Kenny. She made good progress.
In July she was admitted to hospital suffering from what was believed to
be some form of gastro-enteritis, as well as upper respiratory tract infection
and urinary tract infection. She attended at clinic, and the health visitor
returned to see her at home on a regular basis until she was one year old.
There were seventy-seven such contacts during this period. It was pointed
out by the Crown that the family and extended family made considerable efforts
to ensure that during this period the appellant was not left alone. The inference
to be drawn was presumably that this reduced the opportunity for the appellant
to take any further steps likely to harm Jade. If so, we reject the suggestion
that she would have lacked any appropriate opportunity to have caused harm
to her baby if she had wished to do so. In truth, Jade’s subsequent survival
and healthy development after the single ALTE is inconsistent with the pattern
sought to be established by the Crown: putting it simply, both Jason’s ALTE,
and Matthew’s "episode", as we shall see, were followed shortly
afterwards by sudden death.
- Mrs Kenny expressed
the belief that "Mrs Cannings had bonded very
well with Jade, she seemed to be a well cared for and loved baby. Nothing
at any time gave me any cause for any kind of concern in the way in which
either parent treated Jade."
- Before long, Mr and Mrs Cannings moved house again, and Mrs Peacock resumed
her responsibilities for Jade. Happily she has continued to grow and develop
uneventfully. Apart from normal childhood illnesses, there have been no further
problems, and no further ALTE.
Matthew
- Matthew was born by Caesarean section on 5th July 1999. Thereafter the
appellant was sterilised. The birth was uncomplicated, but unfortunately
the appellant suffered from Bell’s palsy. At birth Matthew’s Apgar score
was 9 out of 10, very healthy. Because of the two previous deaths extensive
investigations were carried out. MCAD deficiency was excluded. Blood plasma
was checked and no abnormality found. No cardiac abnormality was detected
by electrocardiogram (ECG), but the measurement of the QT interval (which
we shall describe later) was drawn to the attention of the paediatric cardiologist.
A further ECG was carried out in early August. The information revealed in
these tests was re-examined after Matthew’s death, and questions were subsequently
raised whether Matthew and his family were susceptible to Long QT syndrome.
In that context ECG tests were also performed on Jade and Mr and Mrs Cannings.
In the meantime, the appellant was taken through a paediatric life support
course to teach her advanced resuscitation techniques.
- On their return home, Matthew seemed well, but the appellant was concerned
because her treatment for Bell’s palsy involved taking steroids, and in due
course this meant she had to give up breast feeding him. The appellant apprehended
that the apnoea alarm meant that it was not unsafe for Matthew to sleep on
his tummy, which was his natural preference anyway. Matthew’s progress was
continually monitored. No concerns were expressed about him. Indeed all the
checks, both at clinic, and at home, were normal, and the appellant herself
did not report any problems to the health visitor. Everything therefore seemed
to be going well. His MMR vaccination was given on 1st November. The appellant’s
confidence grew, and she said she felt able to leave him in the house, with
the front door open, or, later, in the car, while she chatted to one of her
neighbours.
- On the morning
of 3rd November, the appellant made a 999 call to the ambulance service.
The transcript
is available. She said that Matthew was "breathing,
I think, but he has been sick everywhere" and after being urged to calm
herself down, said that he was definitely breathing, but he had been sick
and "his hands are pale". She told the ambulance control of the
two prior cot deaths. She said "he looks like he’s trying to, trying
to get his breath … he just looks as if he’s not with us you know, he, his
eyes are open. He is breathing but he is sucking in everything, it is horrible".
She was asked whether he was breathing and said, "yes, but he is very
laboured, he is on his front at the moment".
- The paramedics
responded to the call. The problem was differently described as an ALTE,
or simply
as an "episode", not life threatening, indeed
not of great gravity, which appears to have been the conclusion of Professor
Meadow and Dr Ward Platt. When the paramedics arrived, the baby was found
in a cot. The appellant told them that his apnoea alarmed had worked. One
of them tried to assess the child, who seemed conscious and appeared normal
and alert. Indeed although his limbs were slightly pale, the baby felt quite
warm and there appeared to be no major problems. The appellant was standing
on the opposite side of the room.
- Given the previous history, it was thought sensible to take the baby to
hospital. The report of the appellant’s account reads:
"Mum fed him his breakfast this morning and dad put
him to bed – 9.00 am. Apnoea mattress was on. About 20 minutes later the
mattress was alarm so mum went to investigate. Matthew had been sick – breakfast
and some clear fluid. Fighting for breath. Pale, not blue. Mum describes
him as being distant. Phoned 999 for ambulance."
- When first
examined, Matthew was pale, but conscious and alert, breathing was satisfactory
and
temperature normal. He was said to be bright and alert.
The paediatric registrar noticed some crusted milk around his nose, and a "slightly
inflamed looking throat". Otherwise the examination was unremarkable,
and the record on file suggested that this was not a true apnoeic event.
Arrangements were made for Matthew to be kept in hospital overnight, for
observation. He seemed very well, feeding properly, alert and smiling. Neither
the oxygen monitor nor the heart monitor, gave any cause for alarm. By next
morning Matthew was happy and well. He was discharged.
- At hospital it was noted that the appellant was distressed and had been
crying and her husband was in a similar condition. Her worries for Matthew
appeared genuine.
- In her interview on 16th November 1999 the appellant told the police that
Matthew was put down on his front to sleep because he never settled on his
back. She understood that because an apnoea monitor was available, it was
acceptable not to sleep him on his back. She described hearing the alarm
when she was downstairs. She ran upstairs to the bedroom and turned the alarm
off. She turned Matthew over. He was being sick. His condition was such that
she ran downstairs and telephoned 999. In the interviews on 8th March 2000
she gave a similar account. She said she had not heard the start of the alarm,
but she heard it sounding. The noise of the alarm was relayed downstairs
through a walkie-talkie system. When she went upstairs Matthew was breathing
but gasping for breath.
- Two features
attracted particular interest at trial. First, on the basis of the answers
in interview,
there was said to have been a lengthy gap between
the moment when the appellant found Matthew, and the 999 call, precisely
the opposite situation to that relied on by the Crown in relation to Jason’s
ALTE. Second, if the apnoea alarm was working correctly, and this was no
more than an "episode", then it should have cut out once Matthew
started to breathe again, unless the baby was having some sort of fit and
breathing very rapidly indeed. That of course begged the question whether
this was "any more than an episode". If it was no more than that,
it was inconsistent with a pattern of events relied on by the Crown.
- A few days later the appellant spoke to her neighbour, Mrs Aldous, about
the incident. On this occasion, after they had had a chat about the circumstances
in which the ambulance had come to her home on 3rd November, the appellant
produced Matthew from her car, rather proudly showing him off. Mrs Aldous
thought he looked fine and well, but estimated that on a very cold day Matthew
had been alone in the car for at least ten minutes. The Crown seemed to attach
some importance to evidence of this kind, the suggestion being that it was
inappropriate for the appellant to have left Matthew alone in the car without
the safeguard of his apnoea alarm. We do not see the basis for criticism:
the appellant was nearby, and this behaviour seems unremarkable.
- At 11.04 am
on 12th November, the ambulance service responded to a 999 call from the
appellant’s
address. This call was made by Mr Cannings, who
had himself received a call from his wife while he was at work telling him
that "It’s happened again". The appellant was upstairs, on the
floor with Matthew, performing mouth-to-mouth resuscitation. The baby was
very limp, and cyanosed. There were no obvious signs of breathing or cardiac
output. He appeared to be in cardiac arrest. The paramedic believed that
the baby’s airway was clear, without vomit or any other residue, either in
the mouth or the airways themselves.
- Matthew was taken straight to hospital. On the way resuscitation continued
in the ambulance. In fact, it was too late. He was in cardiac arrest, not
breathing, cool and unresponsive, and centrally cyanosed. There was no evidence
of any blood or trauma to the baby’s face or his head. There was a little,
unremarkable, vomit around the mouth area, and traces of fluid that smelt
like partly digested milk, again in the context, unremarkable. The condition
of his immune system became a subject for discussion, and disagreement between
experts. The baby was pronounced dead at 11.05 am.
- At hospital, the appellant was tearful, and her husband extremely distressed.
A staff nurse heard from the appellant that the baby had been in bed when
she heard the alarm. She had turned it off and ran upstairs. She turned the
baby over and saw that he was purple and blotchy. Her husband asked her in
the presence of the staff nurse why she had called him before she had called
an ambulance, as indeed she had. She was quiet for a few minutes, and then
told her husband that she had panicked. He asked her again why she had not
called the ambulance first and she repeated that she had panicked. She also
spoke to Dr Barnes, the consultant paediatrician who it will be remembered,
had taken a particular interest in this family, and arranged for its inclusion
in the CONI project.
- In interview on 16th November 1999, the appellant described how Matthew
was in bed upstairs, with the apnoea alarm on and the walkie-talkie in use.
She went into the kitchen, and put on the dishwasher. She was working in
the kitchen with the television on. When she left the kitchen she heard the
alarm. She ran upstairs and turned it off. She turned Matthew over and saw
that he was purple, with his face in blotches. She ran to the telephone in
the other bedroom and called her husband asking him to come home because
she thought that they had lost Matthew. She said that initially she had spoken
to a receptionist at her husband’s place of work, but when there was no answer
she had rung the bakery there, asking the person who answered the phone to
get her husband, urgently. She ran back to Matthew’s room, grabbed him and
put him on a bed and tried resuscitation. On her husband’s return he asked
if an ambulance had been called. She said not.
- In interview
on 8th March 2000 she was again asked why she had telephoned her husband
rather
than an ambulance and said "because I wanted Terry
to be there". She was asked why she had done so and she said that she
wanted his help, so that he could see Matthew and see what he was like. This
issue was pursued by the Crown on the basis that, given Matthew’s condition,
it was odd that the appellant had not herself directly and immediately sought
help either from the emergency services or indeed from neighbours, at least
one of whom was a nurse who had offered to help.
- The apnoea alarm was working properly. Its audibility, through the walkie-talkie
system, was tested by sound engineers. Assuming the alarm and transceiver
were operating correctly (which they were) they concluded that the signal
would have been audible in the kitchen, if both the dishwasher and television
were in use in the way described by the appellant.
- In her evidence
the appellant said that as soon as she had heard the alarm sounding, she
turned
it off and went upstairs to Matthew, doing what she
could to resuscitate him. She telephoned for her husband, needing his help.
She "couldn’t believe the way he was". She wanted "Terry to
be there to support me. I had always been on my own". She added that
after Matthew’s death "she was still trying to take in what happened." She
was "numb and in shock". When she was asked about some of the answers
she had given in interview, she said that she had not really felt up to being
questioned.
- Dr Barnes,
the consultant paediatrician, who knew this family, considered whether
in all the circumstances
the fact that there had been three deaths
led him to conclude that the cause was filicide. On 2nd December 1999 he
wrote "although the number of deaths in this case must arouse suspicion
I can say that I did not have suspicions of that nature from observing Mr
and Mrs Cannings’ behaviour during the time that I have known them".
Dr Ward Platt agreed that taking both the episode and Matthew’s death together,
and looked at in isolation from the other events, there was nothing to suggest
the deliberate infliction of harm on him.
- Three days after his death, the post mortem examination of Matthew was
carried out by Professor Berry. Focal pulmonary haemorrhage and oedema in
the baby’s lungs were found, both unremarkable and not diagnostic of unnatural
death. Matthew had inhaled a small amount of stomach content, and a small
quantity of aspirated gastric contents was found in his airways. No relevant
haemosiderin was observed. The post mortem examination showed a very mild
tracheo-bronchitis, but no natural cause for his death, and no unnatural
cause for it either. Professor Berry expressed the opinion that,
"In
view of the extreme rarity of three deaths without explanation occurring
in the same family I have given the cause of death
as unascertained pending further investigations."
- No viruses were detected, but a blood culture showed two types of coliform
bacilli and enterococcus. The former was detected in the cerebro-spinal fluid
sample, and in a culture. This information was not known at the time of trial.
In our pre-reading of the papers it seemed that there might be serious dispute
about the impact of such evidence, if it had been before the jury. In the
result, neither side addressed this issue in any depth, and we did not believe
we should derive any benefit from analysing it for ourselves.
- We must return to Matthew’s ECGs, and the complex problem of the prolonged
QT interval syndrome, the hereditary form of which is usually known as Congenital
Long QT Syndrome. Taking it as untechnically as we may, the interval between
the Q wave and the end of the T wave is a measure of time in milli-seconds
(ms) taken for the pumping mechanism of the heart, to contract and relax.
This, the QT interval, varies with the heart rate, so that a formula is used
which expresses the interval as if the heart rate were 60. Bazett’s formula
is the QT divided by the square root of the RR interval (the time between
two heart beats). The formula gives the corrected QT interval expressed as
QTc. Good practice suggests that the QT is measured in the ECG leads which
show the longest interval, often leads 2 and V5, also called C5. A long QTc
indicates that the relaxation time of the pumping chambers is lengthened
and this can be an indicator for sudden death. The QTc can vary from day
to day and on the same tracing, but Long QT can be diagnosed when the QTc
is over 440 ms and with some certainty when it is over 480 ms. Problems in
measuring the QT interval include difficulty in telling where the T wave
ends, and in particular it can be difficult in infants in part due to their
fast heart rate.
- Long QT syndrome
is an inherited disorder. A number of genes may be responsible for this
genetic
defect, usually autosomal dominant, occasionally autosomal
recessive, and some of the genes are as yet unascertained. As we understand
it, this may be of relevance to Professor Patton’s evidence about events
in Mrs Cannings’ extended family, and the pattern of possible inheritance.
Its importance can be readily explained: there is research which suggests
that some cases described as SIDS may be due to an "abnormal arrhythmia
related to the abnormalities" inherent in the Long QT syndrome. Accordingly,
the QTs of Jade, Matthew and Mr and Mrs Cannings were all considered. Each
expert who measured them achieved different results. In summary, Dr Morgan,
a consultant cardiologist who was involved in the care for Jade, felt unable
to exclude Long QT as a factor in the infant deaths suffered within the Cannings
family, but the Crown’s expert, Dr Wren, was able to do so. A fair summary
of his opinion was that although he acknowledged that the concerns raised
by Dr Morgan were legitimate, the readings did not cross the divide which
suggested that Long QT may have provided a reasonable explanation for Matthew’s
death.
- The weight of the expert evidence was that in the first week of life, the
QT reading, quite apart from all the other difficulties, is in any event
very variable. The first ECG for Matthew, taken when he was three days old
was measured by Dr Stratton, the first of the paediatricians involved in
this work, who measured the readings in such a way that the readings exceeded
the expected, that is between 350 and 430 milli-seconds. Both he and Dr Kinnaird,
another paediatrician, felt that the reading was towards the upper limit
of and perhaps outside the normal range. So the cardiology team at Southampton
was consulted. The team measured the reading at 440/450, a little lower than
the reading made by Dr Stratton at 480, but not so as to exclude Long QT.
So a paediatric cardiologist, Dr Keaton, assessed it. He was unconvinced
that the reading was abnormal, but was not prepared to disregard the findings,
so a second ECG was arranged for Matthew in August. Dr Gnanapragasam, a consultant
paediatric cardiologist, read Matthew’s July ECG as borderline, at the upper
limit of normal, and the August ECG as normal, at 370 ms. Dr Wren agreed
that Matthew’s July ECG was borderline normal, and that in August most definitely
normal or lower than normal.
- Dr Wren reviewed
the ECGs for Matthew, Jade, and for Mr and Mrs Cannings. He found no evidence
to support a diagnosis of Long QT in any of these family
members. He did however explain the difficulties of identifying with confidence
what can be described as "normal", and what is not, because in
practical terms, at present at any rate, it is not possible definitively
to establish where the upper limit rests. He attributed this problem to the
development of the Schwartz criteria, which required the assessment of a
number of aspects of the health of the patients to be assessed on a points
basis. This was a reference to research conducted between 1976 and 1994 by
Dr Schwartz in which he used records of more than 34,000 infants aged between
3 and 4 days, following them up a year later, in an investigation whether
there was any link between Long QT and SIDS. His conclusion (Schwartz et
al, Prolongation of the QT interval and the SIDS, New England Journal of
Medicine 1998 Vol 338 1709-1714) was that the presence of a QTc longer than
440 in the first week of life increased by a factor of 41 the risk of SIDS.
An examining clinician using the Schwartz criteria would look first for a
Long QT interval, and score it between 1 and 3. A female would not score
at all unless there were a reading of at least 450. If the appearance of
the T wave were odd, or if there were any change of rhythm, or a history
of deafness, or a collapse upon exercise, or a relevant family history, points
under the scheme might be credited. Dr Wren felt that one major criticism
of the Schwartz research was that it was not "blind", but Dr Morgan
corrected what seems to have been a misunderstanding. Dr Wren acknowledged
that notwithstanding controversy about the Schwartz research, the condition
of a congenital Long QT was an established phenomenon, and where it existed,
it caused sudden infant death. Professor Golding described the Schwartz paper,
and its results, as "exciting" and her opinion was that, so far
as epidemiology was concerned, this risk factor identified by Schwartz was
striking.
- Dr Wren described children with Long QT who had collapsed suddenly and
unexpectedly, and who had eventually made an almost complete recovery. He
also emphasised that there were different ways in which individual clinicians
may read the same ECG trace, and he warned against the dangers of adopting
too dogmatic an approach to assessing whether a patient was or was not outside
the normal range. He himself considered that Matthew’s July ECG was outside
the Schwartz criteria, there being a temporary difference in his QT level,
and observed that the doctors involved regarded Matthew’s August ECG as normal.
Applying the Schwartz criteria, he was unable to find evidence that any family
member came even close to Long QT syndrome.
- Dr Morgan examined
all the ECGs available for Jade, Jason and Matthew. He was less confident
than
others about the accuracy of the machines, and
less inclined to pay attention to the results from them. Jason’s measurements,
which he was able to extract from the ECG machine only with difficulty, suggested
that he did not have Long QT. He felt that Jade’s ECG in the first twenty-four
hours of life was not relevant, and he devoted some three and a half hours
to reading the eleven ECGs taken when she was six years old, in January 2002.
He did not feel able to exclude the reasonable possibility that Jade suffered
from Long QT. He agreed that Matthew’s ECG for July, almost immediately after
his birth, showed a QT interval at or beyond the normal range, but was not
prepared to make a diagnosis of Long QT on that single reading, made so close
after birth. As we read pages 2048 and 2049 of the evidence, he remained
concerned because, in relation to the research by Schwartz, Matthew’s early
ECG was "clearly abnormal on the third day of his life". He accepted
that the August ECG reading for Matthew was normal, but he was not prepared
to exclude any underlying condition. He had concerns about the readings for
Mrs Cannings herself, agreeing with Dr Wren that those were at the upper
limit of normal.