An Open Verdict

By Rod Collin

Dr David seeks to establish the truth behind the unnatural cause of death of Stephen, one of his patients. He promises Stephen’s parents, that he would search out the explanation, having a strong suspicion that Stephen’s death was caused by a new psychiatric medication. Dr David did not realise that his quest for answers would lead to him being the target of an assassination attempt, and also endanger the lives of others. The story has many twists, unfolding to reveal a major pharmaceutical company’s cover up plot and attempt to conceal the truth using deadly force. Police involvement in the case introduces Dr David to a soulmate and romance.

• Language: English
• Publisher: Austin Macauley Publishers
• Release date: Mar 31, 2022
• ISBN: 9781398412408

Rod Collin

Rod Collin was graduated in Biochemistry from Oxford in 1972, and in Medicine from Sheffield University in 1978. He trained in Haematology and worked as an NHS Consultant Haematologist for 22 years. He met his future wife at Sheffield University, and he has two adult sons and a boisterous Labrador. He had a passion for rowing and spent most of his undergraduate days at Oxford rowing for Worcester College and for the University Isis crew in his final year at university. He enjoys cycling and fishing and lives on the outskirts of Sheffield on the edge of the Peak District.

Book preview

Prologue

There are many incurable diseases that affect mankind, many of which can shorten life expectancy. Modern medicine is now very good at cheating death. Current medicines and treatments allow some patients to survive today who would have undoubtedly succumbed to diseases had they been alive decades earlier.

I am currently staring at the body of a young male patient in ICU whose life is inevitably drifting away.

My years of medical practice have taught me that a patient’s chances of survival in ICU are inversely proportional to the number of wires, lines, tubes, and catheters going to and from the patient and directly proportional to the complexity of the electrical equipment used to monitor him or her.

I look at Simon lying unconscious in the ICU bed in front of me and have estimated his chances of survival as fast approaching that of zero.

Simon is only still alive because his blood is being filtered through machines that function as his kidneys, a tube is placed in his throat pushing ever-increasing concentrations of oxygen into his lungs with rhythmic pulses of inflation, and the ITU staff are filling his veins with all manner of medicines and fluids trying in vain to keep his blood pressure at just about recordable levels, and with sufficient pressure to keep vital organs alive, but still slowly losing the battle. Simon has no central nervous system reflexes or cranial nerve functions on testing and his electroencephalography indicates no signs of meaningful brain activity.

Phil Reed, one of our senior intensive care consultants sees me and says, ‘Thanks for coming, the parents were anxious for me to let you know that they had arrived, and they value your presence at this moment. They know that there is nothing more that we can do. We have their permission to switch off the ventilator.’

I watch the distressed mother and father looking at their beloved son lying motionless and unconscious before them. There are no words being spoken. What can they say, or what can anyone say, that has not already been said? I stand at the end of this ITU bed looking at the tragedy unfolding before me. If only this scene was a tragic play and not a reality, then one could wait for the final curtain to fall in front of the stage before applauding the tragedy and watching all the players walk healthily off stage. This is no play and it is a real-life tragedy unfolding before my eyes. There will be no applause from this audience when this tragedy has ended.

Phil draws the curtains around the bed shutting out any other personnel. He turns to the parents and said, ‘I am so sorry for you both. Is there anything you want to ask? Do you want more time?’ The parents turn toward him and silently nod their heads from side to side as a negative reply to Phil’s last question. Their eyes glisten with the moisture of fresh tears. They reach across the bed and hold hands, with each of them also firmly gripping one hand of their son.

Phil reaches to the wall sockets and with a simple flick of the finger switches off the mains supply. He quickly turns away and lifts the corner of the curtain to exit. The ventilator releases one last hiss of air and then falls silent. Within a matter of moments, the ECG trace displays the agonal activity of a dying heart and then becomes as flat and unwavering as a pencil line. Simon’s face turns initially a tinge of blue as the blood becomes de-oxygenated and then pales as the blood ceases to be pumped into the facial capillaries. The pale mask of death takes over his appearance as all the colour drains from his face. I bow my head in reverence at Simon’s death, as tears run down the cheeks of his parents who still cling to his hands.

Phil returns a few minutes later. Stethoscope in hands, he listens to the patient’s chest and heart to look for the signs of life, the presence of breath sounds and audible heart beats. He feels for the presence of a carotid pulse in the neck and raises the patient’s eyelids shining a torch light briefly into each pupil in turn. There is no light reaction of the pupils. There had been a loss of pupillary light reflex for some days before as his brain function rapidly failed and his cranial nerve reflexes with it. There is no carotid pulse palpable, no chest movements, no heart sounds. Phil turns to the mother and father and says, ‘Simon has died, may he rest in peace.’

Phil and I looked at each other. There is no need for any verbal communication between us. We both recognise the tragedy of the situation and that this was one death that should not have occurred. We leave the parents to grieve in silence with the body of their son and we moved away from behind the curtain screen.

Phil spoke to me and said, ‘I have never seen anything quite as bad as this. It was as though every organ in Simon’s body just died without any hope of recovery, nothing we did could stop him from deteriorating. It is a crazy thing for me to say but it was almost as though he was too ill to possibly be able to survive. We rarely have a case that so utterly defeats us.’

Simon’s parents came out from behind the curtains and his mother said to me:

‘Dr David, thank you for everything, we really appreciate you being here today and we know that Simon was grateful for all your help and support to him over these last weeks.’

They shook my hand and then Phil’s, turned away from the bed and walked off the ward with their arms locked together and bodies leaning in towards each other for support.

I knew that this was a death that should not have happened. Simon’s death had to have been caused by the drug he had been taking for his depression. There was in my mind no other possible explanation to account for the death of a previously fit and healthy young man in his twenties with no chronic medical conditions and a bountiful life ahead of him. I had to find evidence that Simon’s medication was harmful. I had to find the proof, if possible, and if my suspicions were validated then the drug would have to be re-evaluated by the licensing authorities and if necessary withdrawn from further use to prevent any further harm to patients.

I felt a keen sense of duty to Simon and his grieving parents. I had vowed to Simon before his death that I would do everything in my power to find the truth about what had happened to him. Simon’s parents had told me that they did not want vengeance for what had happened to their son if indeed it was the medication that had caused his death, but they hoped for justice so that Simon’s death would not have been in vain and to ensure that no other patients would similarly suffer.

If I had known then that my search for the truth would have proven to be so difficult and hazardous, would I have still continued with the quest? If I am being absolutely honest with myself, I do not know but one thing I did know for certain was that I was determined, if possible, to keep my promise both to Simon and his parents.

Chapter 1

48 hours later I received a call from Dr Peter Hardy, one of our pathologists, to notify me that he was shortly to undertake the post mortem examination on Simon. I had expressed a desire to speak to him about the gross anatomical findings when he had conducted the post mortem and to try and understand what had happened to cause Simon’s death. I fully realised that it may take some time and histological tissue examinations in order to come to any firm conclusions. It was the start of the day and I said that I would join Peter shortly after 9.00 am as Simon was his first case on the morning list of the post mortems he was performing.

I started to make my way to the mortuary and I always found it slightly quicker to take a short cut through the A&E department to reach the mortuary rather than walk endless yards down hospital corridors. Hospital mortuaries are not usually clearly signposted for directions for the obvious reason that it can be upsetting to patients and relatives. I thought it must have been quite insightful for the hospital planners to locate the mortuary close to the A&E department when the planning for the hospital build was being developed. It meant that the unfortunate victims of road traffic accidents and other patients brought in ‘dead on arrival’ to the hospital by ambulance crews could be swiftly moved out of the department and into the mortuary without the need to make the transfer of the bodies too publicly obvious.

A&E departments are normally quite quiet in the first few morning hours before customers start turning up for attention but on this occasion, I was mindful that there was a lot of activity already. I was passing a cubicle when I heard the worried voices of two nurses behind the screens saying, ‘She was comfortable but in some pain a few minutes ago and she had been seen by the duty doctor who wanted to wait for the chest x-ray results and then to call him when the x-ray had been performed. Her vital signs are changing fast now. Her oxygen saturations are falling, her pulse is rising, her blood pressure is falling and her conscious state is deteriorating. We need to recall the doctor urgently. I don’t like how she is looking! I know that he was called away to attend to a cardiac arrest in the resus room but I fear that we may have one here very soon as well!’

A nursing sister, Angie Gee, pulled the green drapes of the screen aside and came rushing out and collided with me in her haste. ‘Can I help Angie? I could not help but overhear what you were saying just now.’ Angie and I had previously worked together on the wards before she became an A&E sister.

She replied, ‘Dr David, I am glad that you are here, we need medical help and a doctor straight away. Thank you, please help us if you can, we are very worried about the patient.’

She opened the drapes and I entered the cubicle with the nurse. Lying on the bed was a young woman in a police uniform and I could see from the monitor that her vital signs were not good and she was developing a cyanotic colour to her lips and finger nails indicating low blood oxygen levels. She was breathing very shallowly and groaning in pain. I turned to Angie and asked her to explain to me what happened to bring her to casualty. ‘She was a passenger in a police patrol car that was involved in a high-speed car chase following a smash and grab raid on a grocery store. Unfortunately, the car spun off the road and hit a wall on side-impact throwing her into the passenger door and the door got crushed on the impact. She was wearing her seat belt. When the ambulance crew brought her in to A&E, she was fully conscious but in a lot of pain in her ribs. All her vital signs were entirely normal on arrival. The doctor who initially examined her noticed bruising on the left side of her chest and her ribs were very tender and too sore to touch. He thought she may have some rib fractures but her chest examination initially was normal otherwise. He wanted us to arrange a chest x-ray. Unfortunately, he was rapidly called away to attend to a cardiac arrest in the resuscitation room and he has not been back yet to review her again. The x-ray has not been performed yet.’

‘What’s her name?’ I asked.

‘Detective Jill Paisley, but she is not speaking to us anymore as her conscious state is poor.’

I had a strong suspicion based on the story that I had just heard we were dealing with a tension pneumothorax. I said to the nurses that I thought that we may be dealing with a tension pneumothorax and that we would need to relieve the pressure immediately.

A tension pneumothorax can be caused by crush injuries to the chest that lead to rib fractures. The rib fracture punctures the lung and this allows air to escape into the pleural cavity. The tension arises because air is drawn into the pleural cavity with each inspiratory effort but if the punctured lung tissue seals itself off during expiration then the air cannot escape. Inspiration efforts draw progressively more air into the pleural space which does not escape and the air pressure builds in the pleural space increasingly compressing and collapsing the underlying lung and also putting excessive pressure on the large blood vessels in the mid thorax. This leads to the deadly combination of low oxygen and poor blood supply to the rest of the body leading to death. This emergency requires immediate action to allow the increasing air pressure in the pleural cavity to escape, to expand the collapsed lung, and also take pressure off the large blood vessels to improve blood supply. An emergency incision through the chest wall was needed to release the trapped air and reduce the air pressure.

I turned away from Angie and the nurse to look at the patient. ‘Jill, my name is Dr David and I need to quickly examine your chest.’ She was wearing a loose-fitting white blouse and blue neck tie. I percussed her chest and realised that she was hyper-resonant, a bit like a drum sound, on her left side, which was the same side as her injury. I quickly felt for her trachea in the suprasternal notch and this was pushed over to the right. This was a clear sign to me that the whole of her left hemithorax was being forcibly pushed across the midline under severe pressure. I looked at the two nurses and said, ‘I need to release the pneumothorax immediately. I have to cut into her chest now otherwise she may die. I need a long-handled scalpel and a piece of tubing.’ I looked around the cubicle and spotted the wall-mounted vacuum suction pump and its plastic tubing. ‘Can you cut me off a piece of the tubing at least six inches long?’

Angie looked at me a bit aghast and said, ‘I have nothing that is sterile with which to cut it, and the tubing itself is not sterile either.’

I replied, ‘We can forget about the issue of sterility, if we don’t act now we are going to lose the patient! Sterility is the last thing we need to concern us.’

The second nurse had already handed a long-bladed scalpel to me and I said to her, ‘We need to get the blouse off her now!’

She started to try to undo the blouse buttons and was struggling in the anxiety of the moment. I said, ‘We have no time to preserve the blouse,’ and with my left hand, I grabbed the blouse and pulled hard. The blouse ripped apart with buttons flying, across the room. Modesty prevailed and I did not ask the nurse to remove Jill’s bra as well. I said, ‘Quickly pour some skin prep over the left side of Jill’s chest wall and also my hands, this is as good as it can be at the moment to try and clean the area. We can worry about infection later.’

I palpated Jill’s ribs in the mid-axillary line and feeling for a rib in the mid thorax, I placed the scalpel blade immediately above a rib, so as to avoid injuring nerves and blood vessels that run along the underside of ribs and I cut down hard through her skin and then deeper through the muscle layer and eventually pushed the blade through her chest wall and into the pleural cavity. There was very little response from Jill while I was doing this without any local anaesthetic. There was an immediate audible rush of air as the pressure was released from inside the chest. I did not remove the scalpel blade and held it in place with my right hand. I asked the nurse to hand me the length of rigid plastic tubing and using the scalpel as a guide I pushed the tubing down the side of the scalpel and in through the skin and muscles until I felt a definite give in the resistance to my pushing telling me that I had pushed the tube into the pleural cavity. I asked Angie to give me some sleek Elastoplast to try and fix the tube in place before it could slide out of position and I secured the tube as best I could. I then removed the scalpel and left the tube protruding through the skin. I held my right index finger over the opening in the tube every time Jill took an inspiration so as to seal the opening but released my finger every time she exhaled. I was optimistic that by doing this she would eventually expel out all the air trapped in her pleural cavity as she breathed out and that the lung would expand progressively during her inspiration efforts. This was only a temporary solution as she would need to have a proper chest drain inserted and left in place until the lung healed itself and there was no more leakage of air into the pleural cavity.

There was a very rapid colour change in Jill once the pressure had been released with her lips and finger nails regaining a healthy pink colour. Her pulse started to fall and her blood pressure rapidly returned to normal. Jill opened her eyes and looked around her, with her conscious state returning to normal. I said, ‘Jill, my name is Dr Christopher David, how are you feeling now?’

Jill looked at me and said, ‘What has happened to me? I feel as though I have been stabbed with a knife!’ She looked down at her chest and saw me holding the plastic tube protruding through her rib cage.

I said, ‘Yes, I am sorry about that, it was me who stabbed you in the chest. Your left lung was punctured by a broken rib and it had collapsed and there was a dangerous build-up of air pressure inside your chest that required urgent release. You are out of danger now but you will need to be admitted to the hospital and the cardiothoracic team will need to keep you in hospital until the lung is fully expanded and the leak sealed off. You will also need a much bigger tube inserted into the chest and this time it will be done with some local anaesthetic.’

Jill looked at her blouse in shreds hanging limply across her chest and then said, ‘Did I get attacked by a wild animal at the same time? What happened to my blouse?’

‘Ah yes,’ I said. ‘I do owe you a new blouse. It was me that ripped it off you in order to cut into your chest. I am sorry about that.’

She laughed and said, ‘Well I have never had a man rip my clothes off before, it is a good job that I had put on some clean underwear today!’

Angie and the nurse were laughing loudly at Jill’s last comment and I broke out in a smile and said, ‘Jill, I am glad that you have a good sense of humour in all of this. I am not in the habit of ripping off women’s clothing, but in the circumstances, I could not wait to get your permission! At least let me do the honourable thing of replacing the blouse for you.’

‘If I had known that I was going to get a new outfit out of the deal then I would have let you rip off the trousers as well.’

Angie and the nurse blushed at this last remark from Jill and I said, ‘No comment.’

I turned to speak to Angie and said, ‘I need one of you to contact the on-call medical team and explain what has happened and that Jill will need to be admitted to the wards and have a formal chest drain inserted to treat the pneumothorax. One of you must stay with Jill and do exactly as I am doing by holding a finger over the opening of the tube when Jill breathes in and when she breathes out release your finger to allow any trapped air to escape under the force of her expiration and this will progressively allow her lung to expand.’

I looked at Jill and smiled at her and said, ‘You are now in good hands and will recover.’

Chapter 2

I left Angie and the staff nurse in charge and made my way to the mortuary realising that Dr Hardy had probably already finished the post mortem examination of Simon. I buzzed the intercom at the entrance to the mortuary and announced that I was Dr David and had come to speak to Dr Hardy. The receptionist opened the door remotely, allowing me to enter and I explained that I had hoped that I was not too late to see the post mortem on Simon but suspected that Dr Hardy may have already finished. The receptionist said that Dr Hardy had finished the post mortem on Simon and was already started on the second case for the morning list, but if I wanted to speak to him I could go through to the viewing area to talk to him. I went through to the viewing area and spotted Dr Hardy with his arms buried deep inside a corpse’s chest cavity. I have performed a few post mortems myself during a training year in pathology and I always found it impossible to accommodate to the smell surrounding dead human bodies even if there was no decomposition. I wonder if it is a primitive survival instinct that if one smells the death of one’s own kind it acts as a warning of danger and to flee from the danger. Pathologists train themselves to breathe through their mouths rather than nostrils to avoid too much olfactory stimulation. It was a skill that I never properly learnt and the smell of the mortuary suite now rekindled bad memories. I spoke to Dr Hardy and said, ‘Peter, I am sorry to have been delayed. I was taking the shortcut through A&E when an emergency needed my help as I was the only doctor on the spot as it were! I believe that I may have helped to save someone’s life.’

Peter smiled and said, ‘Well done, sir! I wish I could say the same about my clientele but sadly they are past human help and intervention!’ He continued, ‘There was not a lot to see with Simon’s post-mortem except that his organs were already showing signs of necrosis and much more advanced than one might expect from only two days in cold storage. A very sad case and I understand there is a concern that it was a drug-related death. I have taken specimens of tissue from most organs for histological examination and I may be able to give more information once these have been processed and I have examined them. I understand that Simon had been receiving an anti-depressant drug that is relatively newly licensed and that our psychiatric unit had been treating him and was greatly encouraged by his response and improvement. His death seems to have been completely unexpected and his ’illness’, if that is the name we can ascribe to what happened to him, was both rapid in onset and equally rapidly fatal.’

I said, ‘He presented to the hospital about two weeks ago with an infection and low blood counts and that is how I got involved in his care, but we were unable to do much for him as all his major organs started failing. We tried everything we could but unsuccessfully whilst all the while hoping that if his illness was caused by some toxic effects of his medication that he would recover once the offending drug had been withdrawn and with the appropriate medical supportive measures in the meantime’

Peter stopped what he was doing and stood looking at me with a somewhat anguished visage.

’What you have just said to me has triggered a memory for me about a rather similar case that came to me only a couple of months ago. I was asked to perform a coroner’s post mortem on a young person found dead at home and the subsequent inquest about the death gave an open verdict as the exact cause of death could not be assigned with certainty. Simon’s circumstances sound almost identical.

If my memory serves me correctly, the case was again a young patient who had been under the psychiatrists and was under routine clinic follow up. She failed to attend her last clinic appointment on a routine three monthly follow up programme and the clinic staff contacted the patient’s GP to ask if they knew of any reason why she had not attended her appointment. The surgery checked their GP records and established that she had not been to the surgery for any recent consults and said that they would therefore get their practice nurse to make a visit to the patient’s address to check that all was okay