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You are here: BAILII >> Databases >> Scottish High Court of Justiciary Decisons >> McCreight v. Her Majesty's Advocate [2009] ScotHC HCJAC_69 (01 April 2009) URL: http://www.bailii.org/scot/cases/ScotHC/2009/2009HCJAC69.html Cite as: 2010 SCL 17, [2009] HCJAC 69, [2009] ScotHC HCJAC_69, 2009 SCCR 743, 2009 GWD 31-502 |
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APPEAL COURT, HIGH COURT OF JUSTICIARY
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Lord Nimmo SmithLord ClarkeLord Hardie
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[2009] HCJAC 69Appeal No: NO.
OPINION OF THE COURT
delivered by LORD NIMMO SMITH
in
NOTE OF APPEAL AGAINST CONVICTION
by
CRAIG McCREIGHT Appellant;
against
HER MAJESTY'S ADVOCATE Respondent:
_______
|
Act: Keegan, Solicitor Advocate; Adams Whyte
Alt: Stewart, A.D., Crown Agent
1 April 2009
Introduction
[1] On 18 April 2002, at a sitting of the High
Court in Edinburgh, the appellant was
convicted after trial of a charge in the following terms:
"[O]n 7 or 8 February 1999 at 5 Fairnsfell, Broxburn, West Lothian, you did assault Yvonne Bessant also known as Davidson, residing there, and did place chloroform at her mouth and nose and cause her to inhale same, render her unconscious, fail to obtain medical assistance for her and place her in the garden at 9 Fairnsfell aforesaid and did murder her and you did previously evince malice and ill-will towards her."
The appellant has now appealed against this conviction. Various grounds of appeal are before this Court. At our invitation, the parties led evidence and addressed us on those grounds which relate to fresh evidence.
The death of the deceased
The background
[2] The deceased Yvonne Bessant was usually
known as Davidson, that being the surname of a man with whom she previously had
a relationship and by whom she had two children aged 8 and 6 at the time
of her death. In 1996 the appellant met the deceased and moved in to live with
her at her house at 5 Fairnsfell, Broxburn, about a month after they met. A
child was born to them on 13 June 1997. The appellant was generally employed as a fencer but was
out of work in February 1999. At that time the deceased had been the tenant of
a public house in Broxburn for about two years.
[3] The appellant fathered a child by another
woman. The child was born on 11 June 1998. The mother declared to the relevant agencies that
the appellant was the father of the child. There then ensued correspondence
between the Child Support Agency and the appellant, in the course of which he
denied that he was the father of the child. On about 29 January 1999 the
mother of the child wrote an unpleasant letter to the deceased setting out the
relationship which she had had with the appellant. These events led to
difficulties between the appellant and the deceased.
The finding of the deceased's body
[4] The house at 5 Fairnsfell in which the
appellant, the deceased and the three children lived was situated in a
terrace of four houses. At about 8.00am on Monday 8 February 1999 the
occupant of 9 Fairnsfell, the house at the end of the terrace, went out of his
house and discovered the clothed body of the deceased lying mainly on garden
ground at the side of the house with her right leg extending on to the path.
He alerted his neighbour at 7 Fairnsfell. She immediately went to the scene.
She recognised the deceased. She formed the impression that the body had been
placed there. She telephoned the emergency services. She and her husband then
went to tell the appellant what had happened. When he opened the door and was
told, he just said, "Oh". Later, after the police had arrived, she noticed a
bruise on his left eye.
Pathological and scientific investigations before and during the trial
The locus report
[5] Police officers attended at the locus and,
among other things, took photographs of the body of the deceased where it lay.
Dr Paul Fineron, a consultant forensic pathologist and senior lecturer at the
Forensic Medicine Unit at the University of Edinburgh attended the scene at 11.20am. He prepared a locus report, which
included the following passage:
"Rigor mortis is only just beginning to form in the muscles of the fingers. Rigor mortis is not present in the jaws. Hypostasis is present on the back of the body but blanches easily on digital pressure. There is slight warmth on the under surface of the body adjacent to the ground. Professional limited examination reveals no obvious injury. A small amount of tomato stained vomitus is present around the nostrils and the right side of the mouth.
The body is clothed in a long sleeved black denim jacket with four buttons at the front, the lower three of which are buttoned up. Under this is a long sleeved blue cotton top. On the lower part of the body is a pair of black denim jeans, these are fully buttoned up though the zip is located three-quarters of the way up. There is obvious soil scuffing of the clothes.
The temperature adjacent to the body at ground level is 0˚C."
On more detailed examination at the mortuary at St John's Hospital, Livingston at about 1.15pm Dr Fineron noted that the cuff buttons of the jacket were undone, the deceased was wearing a pair of ankle length leather boots, a pair of ankle length white sports socks and underpants. She was not wearing a bra.
The post mortem examination
[6] On the instructions of the Procurator
Fiscal at Linlithgow, Dr Fineron then carried out a full post mortem
examination and dissection on the body of the deceased, commencing at 1.35pm on 8 February 1999. He prepared a report on
the same day. It had not been thought necessary that the examination be
carried out by two pathologists. In the course of his external
examination he noted that dried vomit was present around both nostrils and on
the lower right side of the cheek. There were trivial external injuries,
consisting of six bruises on the different parts of the body, and a very
faint orange-based abrasion on the point of the chin. Reflection of the scalp
revealed a small area of subgaleal bruising in the frontal region in the
midline. Otherwise there were no internal injuries. Examination of the
stomach led to the following observation:
"[T]he lesser curve shows evidence of acute haemorrhagic gastritis. There are, however, no ulcers or erosions."
The stomach contents were described as "50ml of partially digested food, apparently pizza. No intact tablets or capsules identified." Dr Fineron found no evidence of natural disease to account for the death. In his commentary, he stated:
"Autopsy examination has revealed no evidence of natural disease which can account for death.
Autopsy examination has revealed trivial external injuries and a slight degree of bruising underneath the scalp. There are no internal injuries.
Given the situation in which the deceased was found, namely outdoors following a very cold night with temperatures reported down to -4˚C, it is highly possible that hypothermia has played at least some role in death. There are, however, no specific autopsy signs of hypothermia and hence it is impossible to prove its role in death."
Venous blood, vitreous humour, stomach contents, the liver (weighing 1,590 g) and bile were retained for toxicological analysis. Dr Fineron's opinion at that time as to the cause of the deceased's death was: "1(a) Undetermined (pending toxicology)".
The samples
[7] This is a convenient point at which to set
out the conditions in which the samples mentioned above were stored after
receipt in the laboratory, and the analyses to which they were subjected:
(1) Blood sample label 1, of venous blood, was stored at 2˚C to 8˚C from 8 to 18 February 1999, and thereafter frozen at -20˚C (or -15˚C). The container was a glass vial. This sample was only used for alcohol analysis.
(2) Blood sample label 3, of venous blood, was stored at 2˚C to 8˚C from 8 to 18 February 1999, and thereafter frozen at -20˚C (or -15˚C). The container was a 25ml Steralin screw capped tube. This sample was used for all analytical investigations other than those for alcohol and chloroform.
(3) Blood sample label 4, of venous blood, was stored at 2˚C to 8˚C from 8 to 18 February 1999 and thereafter frozen at -20˚C (or -15˚C). The container was a 25ml Steralin screw capped tube. This sample was only used for chloroform determination.
(4) Bile sample, which was not used at all for analysis and about which no further information was available from the documents.
(5) Vitreous humour sample for alcohol determination.
(6) The stomach contents, as already noted, consisted of 50ml of partially digested food, apparently pizza. They were stored in a polypropylene tube and frozen until analysis for chloroform.
(7) The liver was placed in a plastic container, which Dr Fineron described as a "yogurt pot", and was kept frozen at -15˚C or -20˚C from receipt. It was sent to the Scottish Agricultural Science Agency for a pesticide determination on 7 December 2000. On receipt there the container was recorded as "leaking", suggesting a thawing of the contents. It was presumably unfrozen to allow samples to be taken for analysis for pesticides, which yielded a negative result. It remained there, presumably re-frozen, until March 2002, when it was returned to the laboratory for analysis for chloroform.
[8] By report dated 18 February 1999 Dr Alan Langford and Dr
Howard Okely of the Lothian and Borders Police Forensic Science Laboratory
reported that analysis of blood sample label 1 and the vitreous humour sample for
alcohol yielded a negative result. Analysis of blood sample label 3 revealed
the presence of amphetamine within the blood at a level of 0.05 milligrams per
litre ("mg/l"). The blood also yielded a positive preliminary test for
cannabinoids, and a negative result for other basic drugs. In a supplementary
report dated 11
March 1999 Dr Fineron
stated that histological examination of the brain and tissues did not yield any
further significant information. The report included the statement that
sections from the right ventricle of the heart showed "fairly numerous
scattered hyper-oesinophilic fibres and occasional fibres showing contraction
band necrosis". Dr Fineron concluded, after considering all the information
available to him, that "it seems highly likely that hypothermia has been the
final mode of death". He suggested that the entry in the Register of Deaths
should be modified to read: "1(a) Presumed hypothermia, (b) Acute amphetamine
intoxication. 2 Chronic drug misuse."
[9] Subsequently, the police received
information to the effect that the appellant had killed the deceased by
administering chloroform to her. This led to further analysis of blood samples
labels 1 and 4 and the vitreous humour sample, and re-examination of previous
results, by Dr Okely and his colleague Sylvain Denieul. Blood sample label 1
was re-analysed for chloroform, and by report dated 2 August 2000 they reported that
"Chloroform was found in the blood (unquantified)". The technique which had
been used for the initial examination of that blood sample and the vitreous
humour sample for the presence of alcohol was headspace gas chromatography.
Although it was not observed at the time, on subsequent re-examination of the
chromatogram a small extra peak was detected, which was consistent with the
presence of chloroform in the blood sample. By report dated 11 September 2000 they reported that a
re-examination of the data obtained from the initial analysis for alcohol
"suggests the presence of chloroform". An analysis of blood sample label 4 was
thereafter carried out, and by report dated 18 January 2001 they reported that
chloroform was present in the sample at a concentration of 31mg/l.
[10] On receipt of this information, Dr Fineron
reconsidered his post-mortem findings. In a further supplementary report dated
7 September
2000 he
summarised the toxic effects of chloroform on the human body. He went on to
write that if a cloth soaked in chloroform were forcibly applied to a victim's
nose and mouth, this might result in a degree of suffocation, reducing the
amount of oxygen reaching the tissues and allowing carbon dioxide to build up
within the body. Both these effects - hypoxia and carbon dioxide retention -
were known to predispose to the development of cardiac arrhythmias.
Additionally, if the victim were to struggle or panic, this would cause the
release of adrenaline in the body and would further increase the risk of cardiac
arrhythmias. The presence of amphetamine would further exacerbate the effects
of chloroform and these other factors on the heart. He continued:
"However, it must be stressed that death could have occurred due to chloroform administration, even in the absence of Amphetamine."
Referring to his post mortem findings, he wrote that "the dried red mark on the lower lip on the left side could represent the effects of direct contact of chloroform onto the lip". The superficial bruise on the front of the left shoulder "could have been produced by the application of pressure through clothing during forcible gripping". The bruise on the inner aspect of the right upper arm "could have been produced by forceful digital pressure". He stressed, however, that neither of these injuries was entirely specific. He concluded:
"In summary, in the light of information that has now become available to me, it is my opinion that the cause of death given in my initial supplementary report should be recorded as: 1(a) Chloroform intoxication."
[11] It was only in March 2002 that the liver was
analysed for chloroform, having been returned for that purpose from the
Scottish Agricultural Science Agency. In a report dated 14 March 2002 Dr Okely and Sylvain
Denieul reported "Chloroform was found in the liver (unquantified)". On
28 March 2002 (following a suggestion by the defence expert,
Dr Flanagan, and during the course of the trial) samples of liver were
tested for the presence of chloroform at a temperature of 35˚C. The tests
were carried out by Sylvain Denieul, and were verified by Dr Okely. They
reported on 2
April 2002:
"In the first quantitation ... the amount of chloroform found was below the level of our lowest standard in the calibration curve, therefore the quantitation was repeated ... using a calibration curve with a mid-point associated with the level found in quantitation 1. This gave the concentration of chloroform in the liver as 1064mg/kg."
The prosecution of the appellant
[12] The reports referred to above, along with
the other evidence set out below, provided the Crown with a sufficient basis
for prosecuting the appellant for murder. An indictment was served on him. In
due course, a trial took place from 26 March to 18 April 2002.
Summary of the Crown case at the trial
[13] In his speech to the jury the Advocate
depute summarised the Crown case against the appellant as follows:
"The Crown say that he went to Yvonne Davidson's room where she was lying in bed, he took a rag which [he] had soaked in chloroform, he put it against her mouth and nose, he rendered her unconscious, he took her downstairs, he dressed her and he placed her body outside number 9 Fairnsfell. She may have been dead before she was placed outside. She may, on the other hand, only have been unconscious and the cold air outside caused her to die."
Evidence of a "special knowledge" confession by the appellant
[14] To prove their case, the Crown founded in
the first place on evidence from two friends of the appellant,
David Stewart and Gary Espie. Stewart gave evidence that sometime
between May and August 1998 the appellant referred to trouble he was having
with the deceased over his relationship with the other woman, who was then
pregnant with his child. According to Stewart, the appellant said that the
deceased was "daeing his head in and he'd have to do away with her". He said
more than once that he needed to get rid of her. Some time before Christmas
1998 the appellant showed Stewart a small medicine bottle, took the lid off and
invited him to smell it. The appellant said that a friend had obtained it for
him, that it was chloroform, and "that would do it and they couldn't trace
it". The day after the death of the deceased the appellant came to Stewart's
house, and said to him, "What a buzz. I had to kick the cup over because she
peed the carpet." Stewart noticed that the appellant had a black left eye.
[15] Gary Espie gave evidence that on 10 February 1999 the appellant and another
man came to see him. The appellant said that it was he who had killed the
deceased. After she had gone to bed he waited for a time and then went
upstairs to the bedroom where she was sleeping. He had a rag and chloroform,
which he put onto the rag. He then held the rag over the face of the deceased
and took it off when she had stopped moving. He picked her up off the bed and
carried her down the stairs. He laid her out on the living room floor. She
urinated. He went upstairs and got her clothes, then dressed her. He tipped a
glass of orange juice over the floor to cover the urine stain. Then he picked
the deceased up, took her out into the back garden, carried her to the end of
the building and just placed her down there.
[16] The Crown case was that the evidence of
Stewart and Espie, taken together, proved that the appellant had made
incriminating statements amounting to a special knowledge confession that he
had killed the deceased in the manner set out above. The trial Judge gave
appropriate directions to the jury in this regard.
Corroboration of a "special knowledge" or "circumstantial" confession
[17] A so-called "special knowledge" confession
requires to be proved by two witnesses: Low v HM Advocate
1993 SCCR 493. These witnesses need not accord on each and every element
of the confession: Mitchell v HM Advocate 1996 SCCR 97.
The Crown relied on the evidence of Stewart and Espie as proving such a
confession by the appellant. If the jury accepted that he had made such a
confession to Stewart and Espie, they then had to decide whether the only
reasonable explanation for the knowledge of the details of the crime disclosed
in the confession was that the appellant was the perpetrator: Wilson v HM Advocate 1987
SCCR 217, per Lord Justice-General Emslie at p. 222. It was
therefore necessary for the Crown to lead separate evidence about each of the
details relied on as showing special knowledge on the part of the appellant.
The evidence of corroboration relied on by the Crown
[18] For corroboration, the Crown relied on the
finding of chloroform in the blood and liver of the deceased, and the finding
of urine on the carpet. The Crown also founded on a number of adminicles of circumstantial
evidence: (1) the position of the body, which according to one witness "just
looked as though someone had placed her down"; (2) marks on the face and body
of the deceased, particularly the mark on the lower lip, which on the evidence
could have been a chemical burn caused by a rag containing chloroform being placed
against her mouth; (3) the state of the appellant's clothing, which could be
regarded as consistent with the appellant's having dressed the deceased; (4)
the place where the deceased's body was found, which according to
one witness was not where she would normally have gone; (5) evidence
that lights were on in the deceased's house in the early hours of the night
during which she died; (6) evidence about the finding of vomit on the
deceased's clothing in a position consistent with her having vomited before the
clothing was pulled onto her; and (7) the bruising to the appellant's eye.
[19] It is clear, however, that by far the most
important aspect of the Crown's case related to the finding of chloroform in
the deceased's blood and liver and the other findings at the autopsy, from
which the jury were invited to conclude that it had been proved that the
deceased died as the result of the inhalation of chloroform, that is to say, by
breathing it in in vapour form. The defence sought to counter this by raising
the possibility of ingestion of the chloroform, that is to say, by swallowing
it in liquid form. As to this, the Advocate depute said in his speech to the
jury:
"There is no evidence that Yvonne Davidson ingested chloroform. ... I suggest to you, ladies and gentlemen, that the whole theory of ingestion of chloroform involves speculating from the word go. Now, we begin to depart from what we know for a fact. I suggest to you that if you use your common sense then you will see how unlikely this scenario is. ... I suggest that we can discount ingestion because it involves speculation. There is no evidence that she ingested it and there's no signs at post mortem. That leaves us with inhalation. ... You have heard evidence that the accused confessed to using a rag soaked in chloroform and you know that the medical and the forensic evidence is consistent with that. Does the fact that the accused said that he used chloroform and the finding of chloroform in the blood not make it difficult to escape the conclusion that he put it there? Don't separate the engine from the carriages. Don't separate the confession from the medical and the scientific evidence. Put the two together and I suggest that you have a very powerful case against Mr McCreight."
[20] The solicitor advocate for the appellant
addressed the jury at length on the possibility of ingestion. In the course of
his submissions he said:
"But things came to a sudden halt when it appeared from the liver reading that indeed this death occurred not as the drug-infested Mr Stewart would have it or the fugitive Espie would have it by smothering with a chloroform rag, but by another means of ingestion. So that the theory that emanates from Stewart in the beginning and Espie later on, is debunked."
[21] In the course of his charge to the jury, the
trial Judge said:
"The defence have raised the question of possible ingestion of chloroform .... Obviously, if you accept that what occurred here was ingestion, in other words the consuming or drinking of chloroform by the deceased, whether it was accidental or otherwise, then you could not convict of the charge. The reason for that is that the Crown case is as set out in the charge, and appears to be based on the evidence principally of Gary Espie - was that the chloroform was placed at her nose and mouth and that the deceased was caused to inhale it; so the Crown case is of inhalation based on the evidence of David Stewart and also on the absence of internal damage to the body of the deceased at post mortem, which the Crown say shows that there was no drinking or swallowing."
It might be added that, as was made clear elsewhere in his charge, the trial Judge may be taken to have directed the jury that if, after considering the evidence bearing on the ingestion hypothesis, they entertained a reasonable doubt whether the Crown had proved its case of inhalation, the jury were also bound to acquit.
Chloroform
[22] To assist in understanding the remainder
of this opinion, we propose at this stage to set out what appears to us to be
uncontroversial material relating to chloroform, principally derived from
evidence led before us.
[23] The definition of chloroform given in the Oxford
English Dictionary (2nd edition) is:
"The common name of a thin colourless liquid (sp. gr. 1.5), having a pleasant ethereal odour, and pungent sweetish taste, the vapour of which when inhaled produces insensibility; hence it is much used as an anaesthetic in surgical and obstetrical operations. Chemically, it is a triatomic haloid ether of the methyl series = trichloromethane, or methenyl trichloride, Cl3CH."
[24] The eminent toxicologist Professor Dr
Fritz Pragst, who gave evidence at the appeal (see paragraphs [51] to [56]),
provided the following information. Chloroform was first used as an inhalation
narcotic in 1847. Later, it was replaced by ether and other substances because
of the relatively high risk of fatal complications. The anaesthetic effect of chloroform
is based on its interaction with the membranes of nervous cells of the central
nervous system and occurs in four recognised stages, the third of which is
divided into four planes. There is a clear difference between drop-wise
application for anaesthesia and the application of a cloth pad soaked in chloroform
over the mouth and nose. In most cases of homicide, suicide or other
intentional abuse resulting in death, the method of application has been
inhalation, though there have also been cases of oral intake. The standard
textbook, Baselt, Disposition of Toxic Drugs and Chemicals in Man (8th
ed., 2008) ("Baselt") reports on concentrations of chloroform in blood and
tissues as well as its toxicity. Post mortem blood concentrations ranged from
10 to 834 mg/l in these cases.
[25] Generally, there are two ways in which the
action of chloroform by inhalation may be lethal. In the first, which is
similar to narcosis (anaesthesia), the vapour is inhaled for a longer time at
moderate concentration. The substance is absorbed by the lungs and slowly
distributed in the body including the nervous system. No severe effect on the
heart action occurs during this time. If there are no other complications, for
example, asphyxiation or aspiration of vomit, the concentration in blood and
tissues may increase to very high levels until death occurs by paralysis of
respiration. Since there is sufficient time, chloroform can equilibrate
between blood and tissues, and the concentrations in the tissues, such as the
liver, may be considerably higher than in blood because of the high affinity of
chloroform to lipids contained in the tissues. If in addition to the effect of
chloroform there is a deficiency of oxygen, caused for example by a cloth
wetted with chloroform being firmly held over the mouth and nose, death may
occur earlier and at lower blood concentrations, and the tissue concentrations
are lower in comparison to blood since there has been insufficient for
equilibration.
[26] The second possibility is that, by breathing
through a cloth wetted with chloroform, air with a very high chloroform concentration
is inhaled. This leads to a sudden stream of blood with very high
concentration of the substance from the lung to the left heart ventricle. In
this case, the effect on the autonomic nervous system of the heart dominates,
leading to cardiac arrhythmia and sudden cardiac arrest. In this case, the post
mortem blood concentrations in venous blood and in tissues remain low and would
not be interpreted as being lethal according to the anaesthetic narcosis
scheme.
[27] The following information was provided by
Professor Alexander Forrest, who gave evidence at the appeal (see paragraphs [57]
to [62]). Chloroform is not a corrosive. It is an irritant and, if rubbed on
the skin, it can produce an irritant effect with a reddening of the skin. It
also tends to remove grease from the skin. If applied to the skin, it can
certainly cause reddening and a rough appearance of the skin which would
persist into the post mortem period. It is not uncommonly the case that when a
person has been inhaling non-irritant solvents, such as toluene, and has died
in consequence, there may be reddish discolouration around the mouth. Chloroform
can be regarded as being a solvent.
[28] With respect to the effect of ingestion of chloroform
on the stomach, Professor Forrest quoted from Taylor's Principles and
Practice of Medical Jurisprudence (9th ed., 1934), edited by
Professor Sydney Smith, which contains the following statement at
Vol. 2, pp. 620-1:
"On opening of the cadaver there is very likely to be a smell of Chloroform, and when the drug is swallowed, the stomach may show signs of irritation in patches; beyond these two signs, which, it must be noted, are neither of them constant, and both may be absent, nothing is to be noticed and only a critical analysis will reveal the cause of death. ... As Chloroform is much less volatile than Ether, and its odour is not so pungent, it is not so easily detected in the dead body by the smell. The body should be inspected as soon as possible, and any solids or liquids intended for examination should be kept in well closed glass vessels."
The presence of chloroform in the deceased's blood and liver
[29] It is now necessary to examine in more
detail the evidence which was led at the trial relating to the presence of chloroform
in the deceased's blood and liver, and the competing hypotheses of inhalation
and ingestion. As the trial Judge reports, Dr Fineron gave his evidence
on 4 and 5 April 2002. He was immediately followed by
Professor Busuttil, who completed his evidence on the latter date.
Because he was not available at a later date, the evidence of the defence
expert, Dr Flanagan, was interposed in the Crown case. He gave evidence
on 9 and 10 April
2002. He
was immediately followed by Dr Okely, who completed his evidence on the
latter date. The trial Judge reports that the suggestion of ingestion of chloroform
as accounting for the large concentration of it in the liver was not known to
the Crown until Dr Flanagan gave his opinion to that effect in the witness
box. He therefore granted an unopposed motion by the Advocate depute to recall
Dr Fineron to give further evidence on that point. He did so on 12 April 2002. Professor Busuttil
was recalled by the defence on 16 April 2002. When Dr Fineron and Professor Busuttil were
recalled they commented on the possibility of ingestion raised by Dr Flanagan in
the course of his evidence. We shall now set out the features of the evidence
of these witnesses.
Dr Paul Fineron
[30] At the time of the trial Dr Fineron had
recently ceased to be consultant forensic pathologist at the University of Edinburgh and had become consultant
pathologist at the Western General Hospital in Edinburgh. He gave evidence on 4
and 5 April
2002. He
spoke to his locus and post mortem reports. He confirmed that he had found
evidence of haemorrhagic gastritis, and said that this was a very common
condition, could be caused by a variety of agents and was essentially of no
significance. He also referred to his histological examination of various
samples, including sections from the heart. He said that there were features
of contraction band necrosis, which he described as a non-specific finding
often found in a variety of causes of death, but thought to be associated with
high adrenalin levels within the body (right ventricle). Following receipt of
the results of the toxicological analysis of a blood sample, which showed the
presence of amphetamine, his hypothesis for the sequence of events leading to
the deceased's death "was amphetamine intoxication possibly leading to
disturbed behaviour ... in the heart rhythm precipitating a collapse and then
possibly hypothermia had played a role".
[31] Dr Fineron said that once he had received
information that chloroform was present in the samples obtained at post mortem,
he regarded this as highly significant. It totally altered his opinion as to
the cause of death. Once he had received information from the forensic
scientists that the concentration of chloroform in the blood sample was 31mg/l,
he re-examined his findings on post mortem examination. Among other signs, he
decided that the red mark on the left side of the lower lip could be a "contact
burn due to chloroform". Other signs could have been the result of force used
in applying a chloroform-soaked cloth to the deceased's face. If the deceased
had taken amphetamine, and if through fear adrenalin was released within her
body, these could have exacerbated the effects of the chloroform on her heart.
He then gave the opinion that the cause of death should be recorded as
chloroform intoxication. He said in evidence:
"I consider the presence of finding a significant quantity of chloroform - and certainly the concentrations as detailed in the toxicology report - indicates that it has been administered from outwith. ... It is an abnormal finding and in line with the subtle signs round the mouth would indicate or suggest that the deceased has had chloroform administered to her by being in contact with the face. Given that inhalation of chloroform by this mechanism in my opinion is a totally adequate cause of death, I felt it was entirely appropriate that I should modify my opinion as to the cause of death".
[32] The Advocate depute asked him to comment on the
information which had become available from the forensic scientists, in their
report dated 2 April 2002, that chloroform had been found in the liver at a
concentration of 1064mg/kg. Dr Fineron said that he was not aware of any
reliable scientific literature which allowed him to place an accurate
interpretation on the quantity of chloroform found in the liver. Comparing it
with the concentration found in the blood, he said he was not sure how one
could interpret that. He rejected the possibility of chronic abuse of chloroform:
"It certainly indicates that the deceased has died relatively rapidly, or having consumed in some way chloroform, and I think that is possibly the only interpretation one could place on it."
[33] In cross-examination he said that the
concentration of chloroform in the liver was high, and this indicated acute
intoxication, but that was all he could say. He was referred to the then
current edition of Baselt, and accepted that the figure of 1064mg/kg which had
been given for the concentration of chloroform in the liver was greatly in
excess of the range given in the textbook in cases of deaths from acute
chloroform intoxication. The cross-examiner used this as a basis for
suggesting that the concentration in the liver was attributable to chronic abuse
of chloroform, rather than an acute intoxication. Dr Fineron rejected this
possibility. He said:
"The fact - again I think one has to be very cautious in interpreting these levels - but the fact that it was such a high level may suggest that death followed a very brief but massive exposure to chloroform".
His opinion therefore remained that death was directly due to chloroform intoxication.
Professor Anthony Busuttil
[34] At the time of the trial Professor
Anthony Busuttil was Regius Professor of Forensic Medicine at the University of Edinburgh. He was a highly
experienced consultant pathologist. He had no direct involvement in the
investigations following the death of the deceased, but he had discussed the
case with Dr Fineron, the police and the procurator fiscal. He first became
involved when evidence of toxicological analysis came to light.
[35] When he gave evidence on 5 April 2002, he was taken through Dr
Fineron's reports. He gave general evidence about the effects of chloroform.
He was asked about Dr Fineron's final conclusion, that in the light of
information that had become available to him, in his opinion the cause of death
given in his initial supplementary report was incorrect and it was now his
opinion that the cause of death should be recorded as chloroform intoxication.
Professor Busuttil said that he thought that chloroform was a major
component in relation to the death of the deceased. It was present in the
blood in quantities consistent with toxicity, and in quantities which were
fully consistent with its having been related to the mechanism of death. He
postulated that the chloroform and the amphetamine which had been found in the
deceased's body and the hypothermia at least interacted. If he were certifying
the death, he would have stated that death was caused by the combined effects
of chloroform intoxication, amphetamine intoxication and hypothermia. Even
without the amphetamine intoxication and the hypothermia as causative factors,
the amount of chloroform which had been found in the deceased's blood could
have killed her. The Advocate Depute asked him questions based on the figure
given in the forensic scientists' report dated 2 April 2002. In the course of these
questions the Advocate Depute said:
"We know that 106[4]mg[/kg] is found in the liver; do you have anything to say about that, what does that suggest?"
Professor Busuttil replied that this was a very large amount going by standards which toxicologists refer to. "It suggests an acute inhalation of chloroform." When asked again about his opinion as to the cause of death, he said that he believed that chloroform had "a major if not the most important impact in terms of causing this lady's death". But there were also the presence of amphetamine, and the very cold temperatures. He concluded:
"So my view would be that chloroform had a very major part to play in her death, which may have been attributable to the presence of amphetamine and the exposure to a low temperature; and the three together certainly caused her death with chloroform perhaps being the more important of the (inaudible) of things that caused her death."
[36] In cross-examination,
Professor Busuttil said that the amount of chloroform which had reportedly
been found in the liver was much too high to suggest chronic exposure. The
liver was otherwise normal, and the reported concentration of chloroform in it
was high. These two findings made it more than likely that there had been "an
acute massive exposure", though he could not rule out the possibility of
chronic exposure.
Dr Robert Flanagan
[37] Dr (as he then was)
Robert Flanagan was a consultant clinical toxicologist at Guy's Hospital
in London. His evidence, which was
given on 9 and 10 April 2002, was interposed during the Crown case. He had previously
seen the reports prepared by Dr Okely and colleagues. Additional material
had been provided following a consultation with Crown counsel about
one week previously. He had expressed caution about the interpretation of
their findings because of the possibility of contamination after samples had
been collected, the possibility that another substance had been metabolised in
the body of the deceased, and the possibility that that metabolite had been
converted into chloroform if the analysis was performed at the normal
temperature of 60ºC. To avoid this conversion, the analysis required to be
carried out at 30 to 35ºC. Following his expressions of concern, the forensic
scientists had carried out an analysis of a liver sample at the lower
temperature, and had reported on 2 April 2002 that chloroform had been found at a concentration of
1064mg/kg. He himself had received this information in the morning of the day
when he first gave evidence. He described that as "a massive amount". It proved
chloroform exposure. Under reference to the then current edition of Baselt, he
said:
"Well, the only thing I can think of to try and reconcile not only the blood, the blood of 31 and the liver of 1064, is if exposure has been by ingestion as opposed to inhalation. That is the only way I can think that these figures can be reconciled, unless I am missing something, because the amount in the liver is so large of 1064mg/kg. ... Having at least got the liver to analyse, we now have this massive exposure documented in the liver and a relatively small amount in the blood. All I can think of, it has gone by mouth into the stomach and then into the liver. ... That is all I can think of to try to reconcile the results relating to the bodies of concentration in blood and the massive amount in the liver. ... I think this has come through the mouth, in my opinion."
He went on to say that that concentration in the liver could not have been produced by inhalation. Explaining what he meant by ingestion, he said:
"I was trying to not say that it was deliberately the person that drank it themselves. It could have been somebody else giving them something to drink. It could even have been somebody else making them drink it, but I think exposure was by the oral route as opposed to the inhalation route, is all I am saying."
The concentrations of chloroform reported to have been found on analysis of the blood and liver samples meant that it must have been a major contributory factor in the death of the deceased. The analyses which had been carried out did not, however, give the full picture. If the gastric contents had been analysed for chloroform that might have provided more information as to whether the exposure had been by the oral route.
[38] In cross-examination by the Advocate depute he
repeated his opinion that the most likely explanation for the results was an
acute ingestion by mouth, and not by inhalation. "I would suggest that we
could look at the stomach contents even now during the trial because that might
give some more information." Later he said:
"Toxicologists are paranoid about not over-interpreting. In this case with the chloroform being so high in the liver it is I think dramatic - it is 0.1 of liver weight. Exposure must have been massive and I cannot see how that can be achieved by inhalation .... I think it has got to be ingestion in my opinion."
Dr Flanagan said repeatedly that he was not a pathologist, and he could not give evidence about the signs which would be found on post mortem examination if chloroform had been ingested. The Advocate depute put it to him, in a series of questions, that the information from the pathologists was that they would expect to have seen discolouring or burning in the gullet and in the stomach, and that none had been found. According to the pathologists therefore, "they have had no evidence that chloroform was drunk". In the course of his replies Dr Flanagan said:
"I suggest to look at the stomach contents because that might give us more information, and put it to the pathologist and see how he answers your questions. ... I am just saying that I think it has gone by the oral route, the stomach, intestines and the liver. That is the only way I can think of explaining this massive amount in the liver and the relatively small amount in the blood. When we met before I did explain that I thought that the blood concentration on its own was equivocal. ... I suggested that we need to get more information to complement this solitary result. Having got this liver result that points me to the oral route. How it got in by the oral route I cannot tell you."
Shortly after this, the following exchange took place:
"Q. If there is no pathological evidence to suggest that somebody drank chloroform, are you still maintaining that this lady ingested chloroform?
A. Unless you can give me any other evidence, yes."
[39] The Advocate Depute also cross-examined Dr Flanagan
on the possibility that the results obtained by analysis of the blood and the
liver could be explained by post mortem redistribution "from other parts of the
body into the liver". Dr Flanagan explained that post mortem redistribution
normally occurred from major organs into blood. He therefore thought it
unlikely that that was the explanation for the results in the present case.
Dr Howard Okely
[40] Dr Okely gave evidence on 10 April 2002 about various
investigations which he and his colleagues had undertaken before and during the
trial, as set out above at paragraphs [8] to [11]. He said that the
concentration of chloroform in the blood of 31mg/l lay within the range which
had been found in fatal poisonings, but was also associated with anaesthesia.
He described it as a potentially fatal concentration. He said that the
concentration of chloroform in the liver of 1064mg/kg appeared to be high,
indeed higher than any of the concentrations in cases of fatal chloroform
poisoning which had, to his knowledge, been published. This was only the
second case of alleged fatal chloroform poisoning that he had encountered in 27
years of toxicology. Under reference to the then current edition of Baselt he
said that the range for concentrations of chloroform in the liver given there
was much less than in the present case. The concentration he had found must
have arisen from acute poisoning. He said that the concentration in the liver
seemed to be quite high in relation to the concentration in the blood, and that
this could be for a number of reasons.
[41] He referred in particular to the possibility
that this was attributable to post mortem redistribution:
"That is to say that after death the drugs which are stored in tissues are released to a greater or lesser extent, and this is one of the reasons why we do not generally examine drug levels in the liver, because they tend to be rather unreliable. ... We generally rely on the concentration in the blood."
He went on to say that rapid death would ensue from the application of a cloth soaked in chloroform to the mouth and nose and consequent inhalation. He continued:
"In this case [as just described] I would have expected a relatively high concentration of chloroform in the blood but a relatively low concentration in the liver, whereas if death had ensued after some hours of unconsciousness, then I would expect the reverse scenario whereby there would be a low concentration in the blood and a higher concentration in the liver."
[42] In support of the hypothesis of post mortem
distribution he said that a number of papers had been published about it.
Although it had not been lodged as a production, he referred to one published
by Professor Pounder as being particularly significant. (The reference
appears to have been to Pounder DJ, The nightmare of postmortem drug changes,
Legal Medicine 1993 (ed. Wecht CH), 163-191; Salem, Butterworths, 1993.)
Dr Fineron (recalled)
[43] Dr Fineron was recalled to give evidence on 12 April 2002. The Advocate Depute
informed him that Dr Flanagan had expressed the view in the course of his
evidence that the chloroform entered the deceased's body by way of ingestion.
He was asked what he would have expected to find at post mortem, if chloroform
was ingested. He said:
"Chloroform is - as we know - an organic solvent like carbon tetrachloride which is used for dry cleaning. While the skin is quite resistant to these compounds because it has this layer of dead cells on the surface, the oesophagus or gullet does not, so it is more susceptible to injury. So, if somebody actually swallowed a quantity of chloroform into their mouth and it went down the oesophagus or gullet, we may well see that the lining has been stripped off and it would appear either congested or possibly with a dry whiteish appearance. Once the chloroform reaches the stomach, the cells lining the stomach are different and they are very vulnerable. Now, normally the stomach cells secrete a protective layer of mucus that protects the cells from acid and other compounds within the stomach. However, chloroform will very rapidly dissolve this away and expose the underlying cells and these would be very rapidly damaged. So, we would expect to see a blackened stomach where there was bleeding into the stomach wall and these black areas, not the speckled appearance I saw on initial autopsy due to gastritis but large areas of black discolouration of the skin. Also, if somebody had ingested chloroform and subsequently died, I would be able to smell it. I would expect to smell the chloroform or similar compound actually within the stomach contents and in this case, I saw none of these changes nor did I detect the smell of chloroform at all".
[44] Asked whether if chloroform had been drunk,
one would see anything on the lips, he said:
"Yes, one certainly may see lesions on the lips area drying [sic]. In the initial autopsy, we did see the sort of appearance one would see on the outside of the lip but no lesions, no drying on the inside of the lip or in the inside of the mouth itself which I would expect to see if somebody had swallowed chloroform and had been in contact with the lining of the mouth for a period of time".
The acute haemorrhagic gastritis which he had found was a very common acute reaction to a whole host of insults. If chloroform had been drunk neat, he would expect to see more florid changes, as described. He went on to say:
"I would be quite confident I would detect the smell of chloroform had it been within the stomach contents".
Asked whether he thought that the chloroform entered the deceased's body by way of inhalation or ingestion, he said that in his opinion it was inhalation. This was "because there was absolutely no evidence in autopsy to support the hypothesis that the chloroform was ingested, for the reasons I have already stated".
[45] In cross-examination, Dr Fineron was asked
about the reported concentration of chloroform in the liver. He agreed that
this was a "massive amount". He said:
"I do not think we have enough knowledge to interpret the levels and as I have already indicated in my evidence in past, levels of drugs within blood certainly changes after death and will change another organ [sic]. ... So, I do not know how to interpret this and I am not prepared to interpret the levels found in an attempt to make an assessment of how the chloroform was taken or how much".
He was asked what he thought of Dr Flanagan's recommendation that the stomach contents be examined by a toxicologist for the presence of chloroform. He replied:
"If chloroform was present - was in the stomach contents - that would imply it was ingested but that it is all it would tell. ... Simply, one cannot make any conclusions about concentrations of drugs within stomach contents because the drug is in the stomach, it is not actively in the body. If a drug is present within the stomach contents, the implication is it has been swallowed rather than reached the body by another route".
He was asked about the possibility that the reported concentration of chloroform in the liver was attributable to post mortem redistribution by leakage from the stomach to the surrounding organs. In the course of his reply he said:
"Well, obviously if the drug is not present within the stomach, it cannot leak out of the stomach after death which is what that statement is saying".
He accepted that if chloroform had been inhaled, there could not be post mortem redistribution of it from the stomach. The following exchange then took place:
"Q. Because you see, your colleague - Dr Okely - seemed to suggest ... that that was one possible explanation for a higher concentration in the liver - post mortem distribution?
A. Yes, but as I indicated earlier, determined post mortem redistribution does not just refer to leakage from the stomach. There are a lot of other causes of redistribution."
Professor Busuttil (recalled)
[46] On 16 April 2002 Professor Busuttil
was recalled and further cross-examined (1) on the question whether
Dr Fineron's findings during the post mortem examination were consistent
with ingestion of chloroform by the deceased; and (2) the issue of post mortem
redistribution of chloroform. He explained that chloroform is irritant, not
corrosive. If ingested, it might produce irritant effects, and its smell might
be detected (or might be missed) on post mortem examination. The finding of
haemorrhagic gastritis was consistent with the presence of an irritant in the
stomach. He disagreed with Dr Fineron's evidence that if chloroform had been
ingested he would have expected to see blackening: this was usually a feature
of corrosive effect and in Professor Busuttil's opinion chloroform was not
sufficiently irritant to cause this. On the topic of post mortem
redistribution, Professor Busuttil explained that, where there was a gradient
of concentrations, the drug or chemical would diffuse from an organ where there
was a high concentration to other parts of the body which had a lower
concentration of that particular substance. He was not aware of any
experimental data relating to the diffusion of chloroform. In general, if
there was a high concentration of a substance in blood, this might diffuse from
the blood into the adjacent tissues, such as the liver, but it was not possible
for post mortem redistribution of a substance from blood into adjacent tissues
to result in a higher concentration of the substance in the latter.
Scientific investigations after the
trial
[47] Extensive
efforts were made after the conviction of the appellant to secure fresh
evidence which might lead to the quashing of the conviction. The evidence
itself which was thus secured is set out below. At this stage, there are only
two matters which require mention, both of them arising from investigations
carried out at the prompting of those advising the appellant.
[48] First, by report dated 30 March 2006 Sunella Brahma and Jane
Officer, of the Lothian and Borders Police Forensic Science Laboratory reported
that the stomach contents taken at autopsy had been examined, and that
chloroform had been found in them at a concentration of approximately 162mg/kg.
[49] Secondly, by letter dated 9 October 2006 Dr Okely reported that he
had reviewed the quantitation of chloroform carried out on the liver. He had
re-calculated the concentration of chloroform from the original data and had
found there was an error in the reported result. He wrote:
"The reported result should in fact be approximately 1.0 milligram of chloroform per kilogram of liver [precisely 1.064 mg/kg], not 1064 milligram of chloroform per kilogram of liver as stated in the document produced by myself and Sylvain Emile Denieul during the trial. ...
The error in the calculation occurred while extrapolating from the concentration of chloroform in the liver samples used in the quantitation to obtain a final result expressed in milligram per kilogram (usual units of concentration measurement for liver). This resulted in an incorrect translation of units giving rise to a 1000 fold magnification of the true result." (Emphasis added)
Evidence at the appeal
[50] We
now turn to consider the evidence led at the appeal, so far as salient. For
clarity of presentation, we shall set the evidence out in a different order to
that in which it was led before us. We shall set out the evidence led from
witnesses who did not give evidence at the trial. We shall then set out the
evidence led from witnesses who did give evidence at the trial. We should
emphasise that the witnesses in both categories gave evidence before us on the
basis of (1) the concentration of chloroform in the blood of 31mg/l reported on
18 January 2001 (see paragraph [9] above); (2) the concentration of chloroform
in the stomach contents of approximately 162mg/kg reported on 30 March 2006
(see paragraph [48] above) ); and (3) the concentration of chloroform in the
liver of approximately 1.0mg/kg reported on 9 October 2006 (see paragraph [49] above.
Of these, (2) and (3) were not available at the trial, and the then reported
concentration of chloroform in the liver was 1064mg/kg (see paragraph [11] above).
Witnesses in the latter category gave evidence, moreover, in knowledge of the
evidence which had been or would be led from those in the former during the
course of the appeal.
Professor Dr Fritz Pragst
[51] Professor Dr Fritz Pragst is a
highly experienced forensic toxicologist. From 1989 to 2006 he was head of the
Department of Toxicological Chemistry of the Institut für Rechtsmedizin (Institute of Legal Medicine) of Charité-Universitätsmedizin Berlin. Since retirement in 2006 he has
continued working at the Institute of Legal Medicine as a Guest Scientist. Among the numerous deaths and
acute intoxications he has been involved in investigating is one case of
homicide by forced inhalation of chloroform, which became the subject of a
paper published in 1996, of which he was one of the authors.
[52] From his review of the papers in the present
case Professor Pragst compiled a useful summary of information about the
collection and storage of materials used for toxicological analysis in the
present case, which we have adapted and set out in paragraph [7] above. He provided
the following commentary about the collection and storage of the samples. The
Steralin containers used for collection and storage of the samples consisted of
polypropylene. This substance absorbs chloroform, leading to noticeable
swelling of the polymer material. With a melting temperature of -63˚C, chloroform
is able to diffuse even within frozen sample material slowly to the surface and
can be absorbed directly by the polypropylene walls of the container. If the
container is not completely filled with the sample, so that some air remains in
the headspace between the sample and the lid, chloroform, which has a
remarkable vapour pressure at -20˚C, can evaporate from the sample surface
and be absorbed from the air by the polypropylene of the container. It can
penetrate the polypropylene and can finally evaporate to the surrounding air.
This would not be possible with glass vessels, although the usual plastic cover
can also lead to losses. Over a long time of storage, contraction and
expansion of the gas volume within the container caused by temperature
variations of the refrigerator can lead to leakage of chloroform after
evaporation, since the container is not usually absolutely tightly closed.
Such loss is even more pronounced if the container is warmed up to room temperature
and opened for taking out parts of the sample. The rates of loss have been the
subject of reports in two papers referred to by Professor Pragst. In his
opinion, taking into account the long storage time of between 18 and 86 months
before the analyses, it was very probable that a considerable part of any chloroform
which was present had been lost, this loss increasing with increasing storage
time. Given that the liver was sent to another institution between the autopsy
and analysis for chloroform, it could be assumed that it was at room
temperature for some time and that the container was opened and the material
intermediately removed in order to separate some liver tissue for pesticide
analysis. Professor Pragst expected that this would have led to a further
loss of chloroform in addition to the foregoing reasons.
[53] Professor Pragst examined in some detail the
analytical methods which had been used in the course of the various
investigations which were documented in the papers before him. This led him to
express the following opinions. Chloroform was unambiguously identified in
blood sample label 4 and the quantification was accurately performed. No
essential analytical errors could be found. A concentration close to 31mg/l at
the date of analysis must be accepted. It was very probable from the results,
though not entirely proved, that the small peaks found in the chromatograms of
the alcohol assay carried out on 9 February 1999 originated from chloroform, taking into account the
unambiguous identification in blood at a later time and the presence in liver
and gastric content.
[54] Professor Pragst found no errors in the
preparation of the standards, the performance of the measurement and the
calibration in respect of the liver sample. Chloroform was unambiguously
identified by the mass spectrum in six portions of the liver sample. He
did, however, criticise the calibration, which in his opinion should have been
performed with spiked liver tissue samples, and the same sample amount should
always have been used in order to obtain correct results. It could not, in his
opinion, be concluded without experiments whether this error led to a positive
or negative deviation of the results from the real value. A second error was
that in the calculation the higher specific weight of liver as compared to the
aqueous standard solutions was not taken into account. Since the specific
weight of liver tissue is higher than 1.00 the result in mg/l corresponds to a
lower concentration in mg/kg. These two errors were, however, with a high
probability, small in comparison to that caused by the loss of chloroform during
the time between sampling and measurement. It could be accepted that a
concentration of around 1mg/kg chloroform was contained in the liver at the time
of investigation. An error of e.g. - 50% or + 100% would not essentially
change the interpretation.
[55] Of the analysis for gastric content,
reported on 30
March 2006
as yielding a chloroform concentration of 162mg/kg, Professor Pragst was
prepared to assume that chloroform was unambiguously identified, although the
method of analysis was not described in the documents before him.
[56] After considering the interpretation of the
chloroform concentrations in blood, liver and gastric content in the present
case, and under relevance to the relevant literature, Professor Pragst
concluded, in part 7 of his report, as subsequently amended by him:
"7.1 Chloroform was unambiguously detected in blood, liver tissue and gastric content.
7.2 The concentration in venous blood of 31 mg/l can be regarded as a minimum concentration at the time of death. Probably the concentration was considerably higher but this cannot be proved.
7.3 The chloroform concentration of about 1 mg/kg in liver measured 38 months after sampling is not compatible with the venous blood concentration. The value is by far too low. Losses, occurred probably mainly during using the sample for other analytical investigations. No profound interpretation from this value is possible.
7.4 In the same way, the chloroform concentration in the gastric content of 162 mg/kg proves only its presence.
7.5 The concentration of 31 mg/l in venous blood is not necessarily lethal. Death at this concentration can have occurred:
- by cardiac arrest after inhalation of a high concentration with a very short survival time
- by combination of narcotic effect and suffocation, also with short survival time. However there was no evidence for suffocation found in the documents which came to my attention.
- by combination of the narcotic effect with hypothermia with longer survival time. In this case ingestion, alone or in combination with inhalation, would also be possible.
It cannot be distinguished between these possibilities from the analytical data available. Additional evidence, particularly an estimation of the time of death and of the survival time after chloroform application, which would be helpful, is missing. Furthermore, it cannot be distinguished from the analytical data between self-application and forced application from second hand.
7.6 The detection of the relatively low concentration of chloroform in gastric content neither proves nor completely exclude[s] the possibility [of] oral ingestion.
7.7 From the whole of the evidence which was contained in the papers and disposed to my attention ..., a fast death after inhalation of chloroform (e.g. from a cloth wetted by chloroform over mouth and nose) by cardiac arrest and in combination with suffocation seems to me most probable. However, there was no evidence for suffocation found in the documents which came to my attention.
7.8 A volatile screening should be involved in the routine of the every general unknown toxicological analysis. At latest after specific suspicion to chloroform, not only blood but all other samples should have been analysed for this substance. This would have avoided much uncertainty and speculation in the present case."
Professor Alexander Forrest
[57] Professor Alexander Forrest, a registered
medical practitioner and chartered chemist, with numerous qualifications and
memberships of learned bodies, was Honorary Professor of Forensic Chemistry at Sheffield University and Visiting Professor in the
Faculty of Health and Welfare at Sheffield Hallam
University. He also held
appointments as Assistant Deputy Coroner in two jurisdictions in Yorkshire. He stated that he had
never himself investigated a case of ingestion or inhalation of chloroform
himself, such cases being very rare in the United Kingdom. The expertise he
brought to assist the Court was derived from his general knowledge of
toxicology, reading widely in the relevant literature, including nineteenth
century literature, and sharing experience with colleagues, in particular in
the United States, at scientific meetings.
[58] Chloroform is volatile and will be lost by
evaporation from blood samples, particularly blood samples contained in plastic
containers, and particularly if the containers were not full to the brim. Professor Forrest
believed that there was a significant probability that the chloroform
concentration, as measured in a blood sample which had been collected in a 25ml
Steralin container, had been affected by evaporation. Volatile substances had
a tendency to disappear more rapidly from plastic containers, such as the
plastic "universal" type of container in which the quantitative analysis of
blood obtained by Dr Fineron from the deceased's body at post mortem was
collected. This would be even more so if, as might have been the case, the
Steralin container was made from polystyrene rather than polypropylene.
Consequently, the concentration of chloroform in the blood sample when it was
first obtained from the deceased could have been considerably higher than when
it was measured.
[59] Professor Forrest was not aware of data
relating to the loss of chloroform from frozen liver or stomach content, though
from first principles he expected that a frozen liver sample might be less
likely to lose chloroform rapidly than would be the case from a frozen blood
sample. He thought that the only certain conclusion one could draw from the
finding of chloroform, at a concentration of 162mg/kg of stomach content, was
simply that there was chloroform present in the stomach at the time of death.
It was probable that the concentration found in 2006 when a sample was analysed
was lower, possibly much lower, than that which would have been present at the
time of death. If the chloroform was ingested, it was not possible to estimate
from the levels of chloroform detected in the liver and the blood the quantity
which had been ingested. Any such calculations were likely to produce results
so imprecise as to potentially be misleading. It was very likely that there
had been considerable changes, which it was not possible to quantify, in the
concentration of chloroform in stomach content, liver and tissue between the
time of the death and the time at which the analyses were carried out.
[60] Chloroform was formerly used as a general
anaesthetic. The inhalation of chloroform would first of all have produced
drowsiness and then unconsciousness. Vomiting could occur and, in the presence
of depressed consciousness, this could lead to obstruction of the upper part of
the airway. One cause of death could simply be depression of consciousness to
the level that the individual concerned could no longer breathe. When chloroform
by inhalation was used for homicidal purposes, by the placing of a chloroform-soaked
cloth over the victim's mouth and nose, it might be combined with firm pressure,
which itself could obstruct the airways. The combination of intoxication with chloroform
and obstruction of the airways was likely to be rapidly fatal. Once
unconsciousness had supervened, which would occur rapidly, there would not be
much of a struggle. In the absence of a struggle, when a person already
unconscious had their airway obstructed, characteristic changes of asphyxia, in
particular petechial haemorrhages, might not be seen. There was frequently a
cardiac component involved when a person died as a result of the inhalation of chloroform.
Chloroform could cause increased irritability of the heart muscle and of the
electrical conducting system of the heart. Particularly under conditions of
stress, when adrenaline was released from the adrenal glands, this could
precipitate fatal disorders of the heart beat. The finding reported by
Dr Fineron of contraction band necrosis in the muscle on the right side of
the heart suggested that the deceased might have died rapidly rather than with
a slow decline into unconsciousness over a period of many minutes or hours;
although it might simply indicate a rapid terminal event after an extended
period of unconsciousness. The concentration of amphetamine found in the
deceased's blood was a relatively low one, but it was sufficient to cause
pharmacological activity and, as such, would be expected to potentiate the
potential adverse effects of chloroform on the heart. Amphetamine was a
stimulant and would stimulate and potentiate the effects of natural adrenaline
in the body. Taking all of these findings together, Professor Forrest felt
that on balance the deceased was more rather than less likely to have died
rapidly, that is to say, within a very few minutes, or less, of the initiation
of the process that led to her death rather than over an extended period of
many minutes or even hours.
[61] Professor Forrest said that ingestion
and inhalation of chloroform were not mutually exclusive. Much depended
on the method of administration. It was entirely possible that with pure
inhalation chloroform could enter the stomach. It would be present in the
upper part of the airway in high concentrations. It would tend to dissolve in
saliva and be swallowed. In addition the swallowing of some chloroform-laden
air would occur. The concentration in stomach content in the present case could
reflect either ingestion or inhalation, or a combination of both. On balance,
he favoured its primarily reflecting ingestion, or a combination of inhalation
and ingestion, but he could not be certain. He did not think that the orange
material in and around the opening of the deceased's nostrils could be
attributed specifically to the effects of chloroform. Ingestion or inhalation
of chloroform could result in vomiting, so the colouration could be
attributable to the deceased's having vomited following her last meal. Taking
the information overall, it was his opinion that the available information was
compatible with, and in no way excluded, the hypothesis that the deceased might
have ingested chloroform shortly before her death. The data were also
compatible with the hypothesis that she both inhaled and ingested chloroform
shortly before her death. The data were less compatible with the hypothesis
that death was a result of the inhalation of chloroform alone with or without
asphyxia associated with obstruction of the airway. There was nothing in the
data he had seen which made him believe that her death was due to any factor
other than the toxic effects of chloroform. At the very least, chloroform had
made a more than minimal contribution to her death.
[62] In a statement dated 19 October 2006, prepared once the
revised result for the concentration of chloroform in the liver had been
communicated, Professor Forrest wrote:
"Having reviewed this result together with all of the other information available to me, I would agree that the analytical results obtained ... are entirely typical of the results that one would expect to be found were the deceased to have inhaled chloroform shortly before her death. Further, the results are typical, taking into account the delay between the time of death and the various analyses that have been carried out, of the results one would expect following the lethal inhalation of chloroform."
In a report dated 12 January 2009 Professor Pounder (whose evidence is set out next) commented that Professor Forrest had in this passage not commented on the possibility of ingestion. In the course of his evidence Professor Forrest accepted that this was a valid criticism. He did not exclude ingestion alone, or a combination of ingestion and inhalation. It was possible to formulate a hypothesis of ingestion alone, but unfortunately this was not testable, as toxicology data could only be interpreted in knowledge of all the circumstances.
Professor Derrick Pounder
[63] Professor Derrick Pounder, Professor of
Forensic Medicine at the University of Dundee, had many years of experience in forensic pathology. He had
a special interest and expertise in drug and poison related deaths and had
conducted original research and published extensively on a phenomenon known as
post mortem drug redistribution. Professor Pounder prepared
two reports, the first dated 31 March 2008 and the second,
incorporating all relevant matters contained in the first report, dated 12 January 2009.
[64] Having reviewed the information available at
the latter date, Professor Pounder stated that the concentration of chloroform
in the blood of the deceased was within the range found in chloroform-related
fatalities. He agreed with the witnesses who gave evidence at the trial that
the death was, with reasonable medical certainty, attributable to chloroform.
This view was not dependent upon the chloroform concentration in liver and
consequently was unaffected by the disclosure of the error in calculation of
the chloroform concentration in liver. This view was based on a number of
facts: (a) there was no trauma sufficient to account for death; (b) there
was no natural disease to account for death; (c) the presence of chloroform
and specifically its concentration in the blood was sufficient to account for
death; (d) hypothermia as a cause of death could not stand alone and must
necessarily be secondary to some other incapacitating condition; and (e)
amphetamine intoxication was only a remote possibility as a cause of death and
was entertained originally because of the absence of any more likely
alternative. The mechanism by which chloroform caused the death could only be
a matter of speculation. The same was true of the contribution, if any, of
amphetamine and hypothermia. Although the precise mechanism of death might be
unclear, there was reasonable certainty on the issue of cause of death, namely
that it was the result of the effects of chloroform.
[65] Professor Pounder commented on the
evidence given by Dr Fineron at the trial, in particular the statements
that there was absolutely no evidence at autopsy to support the hypothesis that
the chloroform was ingested, and that if chloroform had been ingested he would
expect to find damage to the gullet, a blackened stomach, and would expect to
smell the chloroform on opening the stomach. Professor Pounder stated
that the medical literature did not support these statements. While they
reflected one extreme end of the spectrum of possible findings following a
fatal ingestion of chloroform, they did not fairly reflect the usual or the
full range of possible findings following fatal chloroform ingestion. Dr
Fineron failed to advise the Court that the absence of any noteworthy changes
to the inside of the mouth and gullet of the deceased, and the presence of a
haemorrhagic gastritis in the stomach, were consistent with the ingestion of a fatal
dose of chloroform. He failed to advise the Court that the presence of
gastritis, although an entirely non-specific irritant effect, could be viewed
as corroborative of ingestion of chloroform, an irritant. He further failed to
advise the Court that ingestion as a route of administration could not be
excluded on the basis of the anatomical findings at autopsy. The literature
did not support the view that Dr Fineron would have expected to smell the chloroform
on opening the stomach. In the single case of which Professor Pounder had
personal experience, he detected only an extremely fleeting unusual odour of a
volatile compound. Had he not been alerted to the possibility that the
compound was present he would certainly not have smelt it. In any event, the
issue was now definitively settled by the analysis of the stomach contents.
Thus the opinion of Dr Fineron on this issue was proved to be wrong.
[66] Professor Pounder proceeded to consider the
evidence relating to the marks found upon the deceased's face. He described as
"balanced" Dr Fineron's view at the trial that although non-specific these
findings "could be due to a chloroform-soaked pad, for example, being placed on
the face". Professor Pounder said that the fair presentation of non-specific
findings to the face being consistent with the prosecution proposition of the
placement of a chloroform-soaked rag over the nose and mouth was not matched with
an equally fair acceptance that the non-specific finding of an acute
haemorrhagic gastritis could be due to the ingestion of chloroform. His report
contained this statement:
"In my opinion the presentation at trial of the scientific evidence with respect to the possibility of ingestion was erroneous as a matter of science, carried the flavour of bias when seen in the context of the totality of the scientific evidence, and was seriously misleading on a critical matter for consideration by the jury."
[67] Professor Pounder went on to consider
the evidence given at trial about the possibility that post mortem
redistribution could account for the remarkable and unexpectedly high (and in
fact erroneous) reported concentration of chloroform in the liver relative to
that of the blood. He stated that, in general, the interpretation of post
mortem blood and tissues levels of drugs and poisons presented considerable
difficulties, not least of all because the concentration of drugs and poisons
in blood and tissues changed with time after death. These temporal changes in
drug and poison levels in the body post mortem were commonly encompassed within
the term "post mortem drug redistribution". The proposition of the Crown
pathologists and toxicologist that the unexpectedly high chloroform
concentration in the liver might be explained not by ingestion but by
inhalation followed by post mortem redistribution from the blood to the liver
had no scientific foundation, to the best of his knowledge and belief. The
discounting of the significance of the finding of the high chloroform level in
the liver, on the basis that there had been post mortem redistribution from
blood to liver, had
"the flavour of an ill-considered, on-the-hoof reaction to a new evidential fact, potentially devastating to the prosecution position, in what was already a scientifically challenging case in which the experts had made errors during the investigation".
[68] Professor Pounder went on to say that there
was no need to consider this matter further, given that the concentration of chloroform
in the liver as discussed at trial was erroneous. The true concentration of chloroform
found in the liver was itself problematic to interpret since it was
significantly less than the lowest reported concentration of chloroform in the
liver in a series of deaths attributed to chloroform inhalation, where the
range was from 6mg/kg to 201mg/kg. Such a very low concentration of chloroform
in liver when contrasted with blood possibly reflected substantial loss of chloroform
from the liver sample sometime between autopsy and analysis. Whatever the cause
of this prior to analysis, the analytical result for the chloroform
concentration in the liver must be regarded as anomalously low when contrasted
with the blood level. In his view the concentration of chloroform in the liver
was best regarded as so unreliable that it should be discounted.
[69] By contrast with the liver sample, both the
blood sample and the stomach contents which were analysed were stored under
very similar conditions until the time of analysis. There were no available
scientific data on the relative losses of chloroform from blood as opposed to
stomach content samples under the conditions of storage in this case, and
speculations on such matters were futile in his opinion. What was undeniable
was that the two samples were taken at autopsy, the blood was analysed so that
the results were reported on 18 January 2001 and the stomach contents were analysed so that the
results were reported on 30 March 2006. The interval between autopsy and sample analysis was four
times greater for the stomach contents than for the blood and if, as was
reasonably likely, loss of chloroform from any sample was time-dependent, then
there was an expectation that any fall in concentration in chloroform in blood
would be mirrored by an even greater fall of concentration of chloroform in
stomach contents.
[70] Following the ingestion of chloroform, the chloroform
would be found in high concentrations in the stomach until it was absorbed,
when only traces would remain. Following inhalation of chloroform, some chloroform
could be expected to be found in the stomach contents, if only as a result of
diffusion from the blood into the stomach contents in life. Additionally,
during inhalation of chloroform, the swallowing of air and saliva contaminated
with chloroform would introduce chloroform into the stomach. The limited data
which were available suggested that the chloroform concentration in stomach
contents might be up to twice that in blood in cases of presumed chloroform
inhalation. In the present case, there was an approximately five-fold difference
between the concentration in stomach contents and the concentration in blood,
without correcting for any storage-time differential loss of chloroform. This
was compelling evidence that chloroform was ingested. In Professor Pounder's
opinion, the analytical results clearly indicated that there had been ingestion
of chloroform and the analytical results in their entirety could be accounted
for as a consequence of ingestion of chloroform without inhalation. On the
other hand, a combination of both the ingestion and inhalation of chloroform
was an open possibility, but inhalation of chloroform without ingestion of chloroform
could be excluded with reasonable certainty. Taking the analytical results in
blood and stomach contents alone (or together with liver) it was not possible
to indicate the relative probability of ingestion alone as against ingestion
combined with inhalation (or inhalation combined with ingestion). In his view,
the autopsy findings did not assist in assessing the relative probability of
these two possibilities.
[71] Professor Pounder addressed the
scientific propositions advanced by the Crown at the trial in support of the
argument that inhalation rather than ingestion was the primary method of chloroform
administration: (1) that the autopsy findings which would be expected if chloroform
had been ingested were not present; (2) that the toxicological findings,
including those in the liver, were consistent with inhalation of chloroform
without ingestion of chloroform; and (3) that there were autopsy findings
corroborative of inhalation of chloroform. He reported:
"In summary, the pathology and toxicology in this death make it a difficult case. These difficulties were compounded by the fact that the true nature of the cause of death, chloroform intoxication, escaped detection initially. The failure to analyse the liver and stomach contents prior to trial further compounded the problem of interpreting the significance of the findings. The medical opinion offered at trial that the autopsy findings excluded the possibility of ingestion of a lethal dose of chloroform was wrong as a matter of science ... [T]he autopsy findings are consistent with ingestion of chloroform and ... the concentration of chloroform now found in the stomach contents is irrefutable evidence that ingestion of chloroform took place. The evidence now available indicates that at least some, if not all, of the chloroform was ingested. It can no longer be said that ingestion of chloroform as a possibility can be excluded, it is now a fact. Of the three scientific propositions advanced by the prosecution to counter the defence argument that chloroform could have been ingested ... the Crown pathologist has resiled from the first, the analysis of stomach contents has put paid to the second, and the third can only stand if it is qualified by an acceptance that some chloroform was ingested. The Crown case on the now available scientific evidence could only be advanced on the basis that there was both inhalation and ingestion of chloroform.
As the trial Judge noted in the charge to the jury ..., an acceptance that the chloroform was ingested would mean that the jury could not convict of the charge. Thus the erroneous scientific advice offered to the jury to the effect that ingestion of chloroform could be excluded as a possibility was on a critical issue."
[72] Professor Pounder had published more
papers about post mortem redistribution than anyone else in Europe, and probably in the
world. The more abnormal the case, the greater was the necessity to perform
more extensive analysis. In the present case he would have analysed all the
samples as soon as there was a suggestion that chloroform was involved in the
death. Professor Pounder said that he would agree with
Professor Forrest's views about the means by which chloroform could reach
the stomach following inhalation (see paragraph [61] above). He added that chloroform
in the body would diffuse from the blood into the stomach contents. But here
the concentration in the stomach contents was compelling evidence that at last
some chloroform had been ingested. The possibility of swallowing a few drops
from a cloth pressed against the face was lay speculation and was not found in
the literature.
Professor Flanagan
[73] At the time of the appeal, Professor
Flanagan, as he had become, was a consultant clinical scientist in the
department of toxicology at King's College Hospital, London.
He was Honorary Professor in Analytical Toxicology at the University of London. Before us, he said that
if he had been in charge of the investigation into the death of the deceased he
would have wanted to analyse all available fluids, tissues and body samples for
chloroform, using the method most likely to detect it at a temperature of 35ºC.
He was shocked when he received the information that the liver analysis had
yielded a concentration of chloroform of 1064mg/kg for the first time on the
morning of the day when he had been due to give evidence. The only explanation
he could think of was that a large part or all of the chloroform in the
deceased's body had entered it by ingestion. Although the workings which
produced this figure were not there, it looked like a thorough piece of work
and he took it at face value. In retrospect he should have spotted something
flawed in the analysis. This led to his giving the evidence in the passages
quoted above. He had not had time to look in the literature, and it had all
come as such a shock.
[74] He subsequently learned that Dr Fineron had
given evidence about the gross effects of the ingestion of chloroform and about
post mortem redistribution. Contrary to what Dr Fineron said, chloroform was
not a corrosive poison, it was an irritant which could cause reddening or
bleaching of the skin. He himself had been asked about post mortem
redistribution in the course of cross-examination. This was based on
information provided by Dr Okely. When Dr Okely came to give evidence,
what he said was wrong. A substance such as chloroform could not be
concentrated from one tissue to another after death against the concentration
gradient. Professor Flanagan described the process by which post mortem
redistribution might occur where a substance had been ingested. He disagreed
with Dr Okely's redistribution hypothesis, given that the Crown disallowed the
possibility of oral ingestion. Once he had been informed in 2006 of the
analysis of the stomach contents, where the concentration of chloroform was
reported as being 163mg/kg, in his view this provided support for the most
likely route being ingestion of a significant proportion if not all of the dose
of chloroform. At that time it was still understood that the concentration of chloroform
in liver was 1064mg/kg. Thereafter it was discovered that the true figure was
1000 times less. This gave rise to different considerations. Given what could
be established about the conditions in which the liver had been stored and
manipulated, he thought that a significant amount of chloroform must have been
lost from it, but he could not say how much. There were then
two possibilities. Either the original concentration was so low that chloroform
had nothing to do with the death; or the loss of chloroform from the liver was
so great that the liver was of no evidential value.
[75] In a report dated 20 December 2006, prepared following
receipt of information about the recalculation of the liver chloroform
concentration, Professor Flanagan wrote:
"In my opinion it remains possible that either ingestion of chloroform for whatever reason, or a combination of inhalation and ingestion, could be the origin of the chloroform found in the blood - notwithstanding speculation as to changes in chloroform concentration since the samples were collected, the chloroform concentration reported in stomach contents ... is considerably higher than that measured in the blood sample .... However, given that the liver chloroform concentration now reported ... is so low, I do not feel confident in ascribing death either to chloroform poisoning alone, or to chloroform poisoning in the presence of a low concentration of amphetamine. Indeed, it could be that the finding of chloroform is incidental to the actual cause of death."
[76] Before us, Dr Flanagan stated emphatically
that, had the true figure for the concentration of chloroform in the liver, and
the figure for concentration of chloroform in the blood, been available prior
to the trial, he would at the trial have had a much stronger basis for saying
that at least part of the dose had entered the deceased's body by ingestion.
He would have been far less confident in saying that ingestion was the only
route, because the liver concentration was so low. If he had been called after
the Crown case had closed, he could have disputed the unsound explanation that
what was then understood to be a high concentration of chloroform in the liver
was attributable to post mortem redistribution. He would also have been in a
position to dispute the evidence which had been given that chloroform was
corrosive, when it was in fact irritant.
Professor Busuttil
[77] By the time of the appeal Professor Busuttil
had retired from his academic post, but continued to work as a pathologist.
Before us, he said that, now knowing the correct figure for the concentration
of chloroform in the liver, and the figure for the concentration of chloroform
in the stomach contents, he did not depart from his view that chloroform was a
major cause of the deceased's death. Hypothermia had no bearing on the
toxicological findings, and might have been a contributory cause. It would
have taken a massive dose of chloroform to produce a concentration of 1064mg/kg
in liver, but if the true figure was 1.064mg/kg that would not reflect a
massive dose. Given that chloroform had been found in the stomach contents,
this could have produced irritation, but not blackening, of the stomach
lining. Chloroform from the upper air passages could have reached the stomach
mixed with saliva which had been swallowed. The presence of chloroform in the
stomach meant either that it must have been ingested, or that it had been
swallowed mixed with saliva.
[78] Professor Busuttil had seen
Professor Pragst's report, which he described as "very impressive".
Professor Pounder was, he said, a worldwide expert in post mortem
redistribution. There was nothing he disagreed with in his report. Toxicology
was not his own expertise, so he had no basis on which he could disagree with
Professor Flanagan. He believed, however, that the only value of
toxicology so long after the event was qualitative not quantitative. The blood
analysis (which had been available at the trial) was the most accurate. He
would be very circumspect about taking a particular value and building a circumstantial
case on it.
Dr Okely
[79] By the time of the appeal Dr Okely was
section leader in toxicology at the Scottish Police Services Laboratory,
Edinburgh. He explained that all the samples which had been taken at the post
mortem examination were received at the laboratory on 8 February 1999. With the exception of
the liver, they were refrigerated. The liver was placed in the freezer. On 7 December 2000 the liver was taken from
the freezer and sent in a cool box to the Scottish Agriculture Science Agency
for a pesticide determination. It was received back about two years
later. In their report dated 14 March 2002 he and Sylvain Denieul stated that the liver and the
vitreous humour were further examined, and chloroform (unquantified) was found in
each. Each was examined for other chlorinated hydrocarbons with a negative
result. Following a suggestion by Dr Flanagan that other chlorinated
hydrocarbons might give rise to a finding of chloroform on analysis, this test
had been carried out. Dr Flanagan had suggested that the chloroform found
during the initial analysis might be due to the conversion of trichloroacetic
acid to chloroform, which occurs when the acid is heated at 40ºC. It was found
that if during the analysis the samples were heated at the lower temperature of
35ºC this conversion did not take place. The quantitation of chloroform in the
liver was performed at the lower temperature and gave a concentration (as they
reported) of 1064mg/kg. He gave evidence to that effect at the trial. He was
not aware before the trial that the Crown case was that the chloroform had been
inhaled, and the defence case that it had ingested, otherwise he would have
taken a different approach to analysis. It was not general practice to analyse
stomach contents, and this was not done before the trial, as there was no
indication to do so.
[80] Asked about the evidence he had given at the
trial about post mortem redistribution, he said that he was aware of this but
had no specialist knowledge: he knew too little to comment and he wished to
withdraw that evidence, which was clearly erroneous. Had he been aware of the
true result he would not have postulated post mortem redistribution. The
picture was complicated by the conditions of storage of the samples and the
length of time for which they had been stored. It was very difficult to
interpret the figures. The concentration which had been found in the blood
sample was consistent with that which had been found in fatal cases. But there
was insufficient blood in the glass container in which the sample for analysis
for alcohol had been stored, so they used a sample from one of the plastic
containers. It was not possible to back-calculate because of the number of
unknowns. This was especially so with the liver.
[81] Had he known at the time of the trial of the
concentration of chloroform in the stomach contents and the true figure for the
concentration of chloroform in the liver, he would not have been able to
express an opinion as to whether the deceased died comparatively quickly or
slowly. Looking at the matter now, it was not within his area of expertise to
offer any opinion as to the route by which chloroform had entered the
deceased's body. He now accepted that ingestion could not be ruled out.
Dr Fineron
[82] By the time of the appeal Dr Fineron was a
consultant histopathologist in the Department of Laboratory Medicine at the Western General Hospital, Edinburgh. He was taken over his locus and
post mortem reports, and the evidence which he gave at the trial. By the time
of the appeal he had been made aware of the correct figure for the
concentration of chloroform in the liver, and of the figure for concentration
of chloroform in the stomach contents. He had also had occasion to reconsider
the evidence that he gave at the trial about the signs which he would have
expected to find if chloroform had been ingested. He said: "I think it is
fair to say I overstated the case in the initial trial". He referred in
particular to the evidence he had given about blackening of the stomach. He
now accepted that blackening might not be present if death ensued very
rapidly. He had reached this view on the basis of reflection, thinking more
deeply about the matter. Acute haemorrhagic gastritis could be consistent with
the ingestion of chloroform, but this was in no way specific. He had been
supplied with copies of reports by Professors Pounder and Flanagan. In giving
evidence at the trial on the basis of a reported concentration of chloroform in
the liver of 1064mg/kg, and in the view he expressed about post mortem
redistribution, he accepted that he had no expertise apart from reading
literature and he was contending with what was understood to be a grossly high
level in the liver by comparison by blood. Overall, he said:
"On reflection I accept I mis-stated the position. The explanation I gave the court [in the passages quoted at paragraphs [43] to [45] above] was incorrect".
He was confident that chloroform was a major cause of the deceased's death, but ultimately he could not say how it entered her body.
[83] In summary, Dr Fineron said that as a
pathologist he would like every sample to be analysed. That would have been of
substantial help in the present case. He accepted the presence of chloroform
in the stomach, though he did not smell it at autopsy. It followed that the
significance of not smelling it was overstated. He accepted that he was wrong
about the blackening of the stomach and the other signs which he said at the
trial would have been produced by the ingestion of chloroform, but were not
present. He said:
"I was trying to be as helpful as possible. With hindsight, based on very scanty literature, we were all somewhat grappling in the dark".
While his view remained that chloroform was the sole or the main cause of the deceased's death, he accepted that there was no way of establishing the exact mechanism of the death. He concluded:
"I have to concede that, knowing what we do today, the trial would have been conducted entirely differently by both the prosecution and the defence".
Fresh evidence and the law
The legislation
[84] By section 106(1) of the Criminal
Procedure (Scotland) Act 1995 any person
convicted on indictment may, with leave, inter alia appeal against such
conviction. Subsection (3) provides that by such an appeal a person may
bring under review of this Court any alleged miscarriage of justice, which may
include such a miscarriage based on inter alia "(a) subject to
subsections (3A) to (3D) below, the existence and significance of evidence
which was not heard at the original proceedings". By subsection (3A) such
evidence may found an appeal only where there is a reasonable explanation of
why it was not so heard. Subsection (3B) is not relevant for present
purposes. Subsection (3C) provides inter alia that where evidence such
as is mentioned in subsection (3)(a) is evidence which is from a person who
gave evidence at the original proceedings, and which is different from, or
additional to, the evidence so given, it may not found an appeal unless there
is a reasonable explanation as to why the evidence now sought to be adduced was
not given by that person at those proceedings, which explanation is itself
supported by independent evidence. Subsection (3D) provides that for the
purposes of subsection (3C) "independent evidence" means evidence which (a) was
not heard at the original proceedings, (b) is from a source independent of the
person referred to in subsection (3C), and (c) is accepted by the court as
credible and reliable.
The authorities
[85] The following passages in the authorities to
which reference was made in the course of the hearing appear to us to be of
relevance for present purposes. In Megrahi v HM Advocate 2002 JC 99, Lord Justice-General Cullen, in delivering the opinion of the
court, and under reference to Cameron v HM Advocate 1991 JC 251
and Kidd v HM Advocate 2000 JC 509, said at paragraph 219:
"We summarise the approach adopted in those cases in the following propositions: (1) The court may allow an appeal against conviction on any ground only if it is satisfied that there has been a miscarriage of justice. (2) In an appeal based on the existence and significance of additional evidence not heard at the trial, the court will quash the conviction if it is satisfied that the original jury, if it had heard the new evidence, would have been bound to acquit. (3) Where the court cannot be satisfied that the jury would have been bound to acquit, it may nevertheless be satisfied that a miscarriage of justice has occurred. (4) Since setting aside the verdict of a jury is no light matter, before the court can hold that there has been a miscarriage of justice it will require to be satisfied that the additional evidence is not merely relevant but also of such significance that it will be reasonable to conclude that the verdict of the jury, reached in ignorance of its existence, must be regarded as a miscarriage of justice. (5) The decision on the issue of the significance of the additional evidence is for the appeal court, which will require to be satisfied that it is important and of such a kind and quality that it was likely that a reasonable jury properly directed would have found it of material assistance in its consideration of a critical issue at the trial. (6) The appeal court will therefore require to be persuaded that the additional evidence is (a) capable of being regarded as credible and reliable by a reasonable jury, and (b) likely to have had a material bearing on, or a material part to play in, the determination by such a jury of a critical issue at the trial."
At paragraph 249 the court said, of a circumstantial case:
"The assessment of the significance of the additional evidence must, therefore, in our view, be conducted in the context of the whole circumstantial evidence laid before the trial court."
[86] In Fraser v HM Advocate 2008 SCCR 407 Lord Justice-Clerk Gill said at paragraphs 131 to 134:
"[131] Sections 106(3) and 106(3A) of the 1995 Act regulate fresh evidence appeals in the context of the single ground of appeal that the 1995 Act allows, namely miscarriage of justice. Before new evidence can be considered by the court, the appellant must furnish a reasonable explanation why it was not heard at the trial. Unless there is a reasonable explanation, the appeal cannot succeed, no matter how significant the proposed new evidence may be (Campbell v HM Advocate 1998 JC 130 at pp. 150, 176-178; Barr v HM Advocate 1999 SCCR 13, at pp. 17-18).
[132] If the appellant provides such an
explanation, the onus being on him, the court must consider whether the new
evidence would have been capable of being regarded by a reasonable jury as
credible and reliable. If the court is so satisfied, it must next consider the
cogency of the new evidence. The new evidence must be important evidence of
such a kind and quality that it was likely to have been found by a reasonable
jury, under proper directions, to have been of material assistance in their
consideration of a critical issue that emerged at the trial (Cameron v HM
Advocate 1991 JC 251, per Lord Justice-General Emslie at p 262).
[133] At that stage the appeal can succeed only if
the court is satisfied that if the jury had heard the new evidence, it would
have been bound to acquit; or that the new evidence is of such significance
that it is reasonable to conclude that the verdict of the jury, reached in
ignorance of its existence, must be regarded as a miscarriage of justice
(section 103(3)(a); Cameron v HM Advocate, supra, at
pp. 261-262). Since there is a danger that fresh evidence may assume
greater strength than it would have had if it had been led at the trial (Gallacher
v HM Advocate 1951 JC 38, at p. 47), it is essential that this
Court should assess it in the context of the whole evidence led at the trial (Megrahi
v HM Advocate 2002 JC 99, at para. 249; c.f. Lyon v HM
Advocate 2003 SCCR 692).
[134] These principles are based, in my view, on
the assumption that the proposed new evidence, if available to the defence at
the trial, would in fact have been led. In this case I am not persuaded that
we should make that assumption; but if we are required to make it for the
purposes of section 106, it follows, in my view, that we must consider that
evidence in its entirety, taking into account those elements that were
unfavourable as well as those that were favourable to the appellant."
[87] Reference may also be made to Smith v
HM Advocate 2001 SCCR 143. In that case the medical evidence at trial
was that the deceased had died from a head injury consistent with his having
been kicked on the head while he was lying on the floor. The fresh medical
evidence at the appeal was that death had been caused by the deceased being
knocked over and the back of his head striking the floor. The Crown accepted
that there had been a miscarriage of justice, but submitted that in setting
aside the verdict of guilty of murder the Court should substitute a verdict of
guilty of culpable homicide. The court held that the conviction must be
quashed unless the court was satisfied that, on the basis of all the relevant
evidence, a reasonable jury, properly instructed, would have found that the
Crown had proved that the appellant was guilty of culpable homicide. At
paragraphs 23 to 24 the Court said:
"[23] The contention of the advocate-depute was that, even though the original proceedings had been affected in this way, nevertheless we could simply use the appropriate parts of the evidence as it came out at the trial and supplement that evidence with the facts as now agreed between the parties in the joint minute. If that were done, he said, the court could reach the view that the Crown evidence taken as a whole was such that a reasonable jury would have rejected the defence of self-defence and would have convicted the appellant. In advancing that submission the advocate-depute at one point argued that we should consider the new agreed facts but should take the other evidence frozen into the form in which it emerged at the flawed trial. While it will often - and indeed perhaps usually - be appropriate to proceed in this way, we are satisfied that such an approach would be inappropriate, and would indeed be productive of manifest injustice, in this particular case. That approach presupposes that the area of new evidence, or in this case the area of the new agreed factual basis, can simply be regarded as 'additional' to the rest of the evidence in the case. Here, however, as we have sought to explain, the evidence of Professor Harland and Dr Watson did not form a discrete chapter but, rather, it influenced the way in which other witnesses were examined and cross-examined and indeed played a role in counsel's advice that the appellant should not give evidence. Therefore the new facts do not just add to the evidence led at the trial: they actually replace the medical evidence which lay at its heart. That being so, it would in this particular case be artificial to pretend that justice could be done by testing matters simply on the basis of the other parts of the evidence at the original trial with the addition of the new agreed facts.
[24] In these circumstances, when we ask
ourselves whether we are satisfied that a reasonable jury properly directed
would have convicted the appellant of culpable homicide, we must reply in the
negative since we are unable to say what the evidence before that jury would
have been, far less how they might have reacted to it. ... [I]n any trial based
on the true medical position the position of self-defence would have been explored
against the wholly different background provided by that evidence. That
background would indeed have fitted with certain of the points made by the
appellant in his voluntary statement and might therefore have led the
reasonable jury to take a favourable view of the parts of the statement where
the appellant claimed that he had acted in self-defence. We cannot know. But
precisely because we cannot know, it is impossible for us to affirm that a
reasonable jury properly directed would in any event have convicted the
appellant of culpable homicide. That being our conclusion, we must reject the
Crown's contention. ..."
The effect of the fresh evidence in
this appeal
[88] The
Crown concede, as is inevitable, that there is a reasonable explanation why the
fresh evidence we have heard was not heard at the original trial. The
requirements of section 106(3A) of the 1995 Act are therefore met.
Several of the witnesses who gave evidence before us - Dr Fineron, Dr Okely,
Professor Busuttil and Dr (now Professor) Flanagan - also gave evidence at
the trial, and accordingly fall into the category of persons to whom subsection
(3C) applies. It is not in dispute that the requirements of a reasonable
explanation and support by independent evidence provided by that subsection and
subsection (3D) are met. More generally, and uniquely in our experience, there
is no issue about the credibility or reliability of the evidence of the
witnesses before us. Applying head (6) of the passage from Megrahi v HM
Advocate quoted above, it is not therefore in dispute that the additional
evidence is capable of being regarded as credible and reliable by a reasonable
jury. The issue before us is whether it is likely to have had a material
bearing on, or a material part to play in, the determination by such a jury of
a critical issue at the trial.
[89] In considering this issue we have been
greatly assisted by the fact that the solicitor advocate for the appellant also
appeared for him at the trial, so that his argument was informed throughout by
his own direct experience of the course of the trial. This should be standard
practice, especially in complex cases, unless there is good reason to the
contrary. We do not of course intend by this to criticise the Advocate depute
who appeared before us, since the Advocate depute who appeared at the trial has
subsequently demitted office.
Submissions for the appellant
[90] The solicitor advocate for the appellant submitted
that at the trial the jury was misled in respect of material evidence. He relied
on the fact that the two key witnesses for the Crown, Dr Fineron and
Dr Okely, had admitted, in light of subsequent developments, that their
evidence at the trial was wrong and misled the jury. He also relied on the
evidence of Professors Pragst, Forrest and Pounder. The consensus of expert
opinion was now that ingestion could not be excluded. There could, he
submitted, be no doubt that the preparation and presentation of the defence
would have been completely different had the true facts been known at the time
of the trial. It was difficult, he submitted, to see how it could be argued
that the presentation of the appellant's defence was not prejudiced in the
whole circumstances. Everything pointed to there having been a miscarriage of justice.
Submissions for the Crown
[91] The
Advocate depute sought to argue that the significance of the fresh evidence had
to be assessed in the context of the evidence led and arguments advanced by the
Crown and the defence. The starting point was the evidence of Stewart and
Espie, who spoke to a special knowledge confession by the appellant.
Corroboration was provided by the finding of chloroform in the blood of the
deceased and urine on the carpet. The Crown also relied on other facts and
circumstances, as set out above at paragraph [18]. Had the fresh evidence, in
the form of the correct figure for the concentration of chloroform in the
liver, and the presence of chloroform in the stomach contents, been available
at the trial, the Crown could have responded by arguing that inhalation and
ingestion were not mutually exclusive. Proof of ingestion was incidental to
proof of inhalation. The presentation at the trial came to suggest an
artificial distinction between ingestion and inhalation. Ingestion, in the
sense of drinking, was advanced as a result of the explanation suggested by
Dr Flanagan as to the apparently heavy concentration of chloroform in the
liver. It did not arise out of any other element of the defence case. No
evidence was led suggesting that the deceased actually had ingested chloroform,
through the malice of another, or her own state of mind, or propensity on her
part. The precise mechanism of death, as opposed to the cause of death, could
not be ascertained before or after the fresh evidence had come to light. It
could not be said that the fresh evidence was of such significance that it was
reasonable to conclude that the verdict of the jury, reached in ignorance of
its existence, must be regarded as a miscarriage of justice. The fresh
evidence did not impact directly upon the confession in its essentials - the
confession to killing the deceased, and that chloroform was used - and did not
open up lines of cross-examination of Crown witnesses as to fact. The theory
of ingestion was unsupported by any evidence to the effect that the deceased,
or anyone else, would drink it, or that the deceased had drunk it. There was
no incrimination by the appellant, no evidence was led of proclivity on the
part of the deceased to take chloroform and there was no evidence of her
feeling suicidal. The trial Judge's charge, in the passage quoted above at
paragraph [21], tended to raise the Crown's hurdle higher than it should have
been (see Fraser v HM Advocate at paragraphs 107, 174 and 185).
The miscalculation of the concentration of chloroform in the deceased's liver
provided a line of defence where none had existed before. This miscalculation,
and the absence of any analysis of the stomach contents for the presence of chloroform,
did not constrain the defence. The defence at the trial were not prevented
from relying on any other line of defence, by their adoption of the argument
relating to ingestion of chloroform. This position was not contradictory of
any other position which was adopted, or which might have been adopted. The
consequences of the miscalculation of the concentration of chloroform in the
deceased's liver were that the defence were given a basis for an argument which
did not exist on the basis of the true figures. An artificial distinction
arose between inhalation and ingestion, based on explanations given for the
liver concentration figure, which was apparently important given the
unnecessary precision with which the Crown had libelled the murder charge on
the indictment. Alternatives to the administration of chloroform to the
deceased in the manner libelled in the indictment were fanciful and
speculative. The fresh evidence of the concentration of chloroform in the
liver and the presence of chloroform in the stomach contents would not have
assisted the jury to a material extent in their consideration of whether the
appellant murdered the deceased, in the context of the other evidence
available. It was enough to corroborate the evidence of the special knowledge
confession by evidence that chloroform was found in the body of the deceased.
In the course of discussion, however, the Advocate depute accepted two things.
Firstly, he conceded, that knowing what was now known, the trial would have
been conducted entirely differently by both the prosecution and the defence.
Secondly, he did not seek to contradict Professor Pounder's opinion that
the jury were seriously misled.
Discussion
[92] In our opinion the position of the Crown is
untenable. The charge on which the Crown proceeded to trial libelled that the
appellant placed chloroform at the deceased's mouth and nose and caused her to
inhale it. The efforts of the Crown were directing to proving that averment,
among others, and in due course the Advocate depute at the trial invited the
jury to hold that averment proved: see the passage from the Advocate depute's
speech quoted at paragraph [13] above. The defence did not of course require
to prove anything. It was enough for them if the jury entertained a reasonable
doubt as to whether the Crown case was proved. They did this in various ways,
including the canvassing of the ingestion hypothesis. There was no need for
them to explain how or why the deceased might have ingested chloroform. It was
enough for them if the ingestion hypothesis raised a reasonable doubt in the
minds of the jury as to whether the Crown case, based on inhalation, was
proved. It was precisely for that reason that the Advocate depute, in the
passage in his speech to the jury quoted at paragraph [19] above, felt obliged
to invite them to reject the ingestion "scenario". The defence position was
encapsulated in the short passage from the Solicitor Advocate's speech quoted
at paragraph [20] above. It was because of these competing positions that the trial
Judge directed the jury very clearly, in the passage quoted at paragraph [21]
above, on the Crown case based on inhalation and the defence case based on
ingestion. In this situation, it is simply not open to the Crown to argue now
that it did not matter whether the route by which the chloroform entered the
deceased's body was inhalation or ingestion. Had the indictment been so
framed as to cover either hypothesis, and had the trial been conducted
accordingly, it would have been an entirely different trial from the one which
took place.
[93] At the trial, the Crown relied to a large
extent on the evidence of Dr Fineron in support of the inhalation hypothesis.
The information at that time was that the deceased's blood contained 31mg/l of chloroform
on analysis, and that the liver contained 1064mg/kg of chloroform on analysis.
Dr Fineron gave evidence that chloroform was corrosive and, if ingested, would
have left gross signs such as blackening of the stomach. He also gave evidence
that the high liver reading could be accounted for by post mortem
redistribution. He rejected the ingestion hypothesis. The fresh evidence that
we have heard establishes the following: (1) the figure for the concentration
of chloroform in the liver was overstated by a factor of 1000: the true figure
was 1.064mg/kg; (2) the stomach contents have been analysed and found to
contain 162mg/l of chloroform, and this is consistent with ingestion; (3) Dr
Fineron's evidence that chloroform was corrosive and would have left gross
signs was erroneous: the signs actually found were consistent with ingestion.
His evidence about post mortem redistribution was also erroneous. (The figures
for the concentration of chloroform in the liver and in the stomach contents
only represent of course the concentration at the time of analysis.)
[94] We entirely agree with Professor Pounder's
robust criticism: the presentation at trial of the scientific evidence with
respect to the possibility of ingestion was erroneous as a matter of science,
carried the flavour of bias when seen in the context of the totality of the
scientific evidence, and was seriously misleading on a critical matter for
consideration by the jury. The investigations conducted before the trial fell
far short of what, on any reasonable view, should have been done. Dr Fineron
appears to have regarded it as sufficient that there was, in his view, evidence
consistent with the hypothesis of inhalation, without considering any
alternative hypothesis, such as ingestion, and the means by which each might,
in accordance with basic scientific principles, be tested. It is remarkable
that the liver was not analysed for chloroform until after the start of the
trial, and then only at Dr Flanagan's suggestion. The calculation was then
botched. As a result the reported concentration of 1064mg/kg was dramatically
high (and must in itself for that reason have impressed the jury), and pressure
of time resulted, not in re-checking the calculation, but in ill-thought-out
and erroneous attempts to explain the concentration. It is also remarkable
that, despite a suggestion by Dr Flanagan in the course of his evidence at the
trial, the stomach contents were not analysed for chloroform until a much later
stage. Had the result (which might have been higher at an earlier date) been
known at the time of the trial, not one witness would have been able to reject
the ingestion hypothesis, as Dr Fineron in particular did in giving evidence. Bad
theories were erected on wrong and incomplete facts.
[95] It is accepted by both the solicitor
advocate for the appellant and the Advocate depute that had the true state of
the facts, as they are now known, been known at the time of the trial then,
subject to such opportunity as might have been needed for further
investigation, the trial would have been conducted on an entirely different
basis by both Crown and defence. It is not our task to decide what the outcome
of the trial would have been: in a case such as this, that would involve
fruitless speculation. It is enough to say that we are entirely satisfied that
the statutory test, read in light of the authorities set out above, has been
met in the present case, and that a miscarriage of justice has occurred.
Result
[96] The
appeal must accordingly be allowed on the first ground of appeal, and the
conviction for murder quashed. In the circumstances it is unnecessary for us
to dispose of the second ground of appeal.
[97] We should add that we announced that the
appeal was to be allowed, giving brief reasons for doing so, on the date which
this Opinion bears. We said that we would issue full reasons at a later date,
which we now do. Once we had quashed the conviction, we heard submissions,
under reference to sections 118(1)(c) and 119 of the 1995 Act, on the question
whether we should grant authority to the Crown to bring a new prosecution. We
decided by a majority that in the whole circumstances it was not in the
interests of justice that we should grant the Crown application.