Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Broader implications of the Sally Clark case
- Tim J Cole, Alan Lucas (24 February 2006)
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FPP should resign
- david baker (27 February 2006)
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The GMC - working against doctors
- ted willis (27 February 2006)
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Dwindling confidence in GMC
- William H Konarzewski (1 March 2006)
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Medical experts and their reliability.
- Brian Morgan (4 March 2006)
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Fighting Appeals with Members' Money
- Jay Ilangaratne (4 March 2006)
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Blanket immunity for expert witnesses is dangerous.
- Steven Ford (8 March 2006)
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Meadow should be disciplined
- Richard Robinson (22 July 2006)
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The principal outstanding concern of the Sally Clark case.
- Ivor T Rowlands (26 August 2006)
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Meadow should never have been brought before the GMC
- C Frank Lockyer (15 September 2006)
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Tim J Cole, Professor of medical statisics UCL Institute of Child Health WC1N 1EH, Alan Lucas
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Sir, The Sally Clark case is in the news again.[1] Throughout, the debate has focused – incorrectly – on Meadow’s evidence about the rarity of two SIDS cases occurring in the same family. We write to emphasise another, more important issue that the case raised about the interpretation of evidence in Court. Equally importantly, we wish to highlight the broader implications; the same issue arises in other contexts, e.g. care proceedings for infants failing to thrive where parental neglect is suspected. As an illustration, we reviewed an 11 month infant with failure to thrive growing below the 1st weight velocity centile (slowest-growing 1% of the population).[2] Failure to thrive (FTT) was the key reason that Social Services sought a Care Order to remove the baby from the parents, on the grounds of neglect. The growth pattern was so rare that the parents were deemed unlikely to be innocent. Legal proceedings in the two cases, ours and Sally Clark’s, gave weight to the rarity of the event (<1% and 1 per 73 million [3] respectively, though the second figure was incorrect for at least three reasons [4]). However, it is flawed reasoning to base parental innocence or guilt on the proportion of the population in which the rare event occurs. It is quite a different statistic that is relevant to Court proceedings. The critical issue is the chance in such rare cases that the parents are innocent – in what proportion of FTT cases, or in what proportion of double unexplained infant deaths, are the parents blameless? This probability of parental innocence can range from 100% (no parents guilty) to 0% (all guilty). In Sally Clark’s case the relevant figure, i.e. the proportion of families with two unexplained deaths in which the parents were considered innocent, has been estimated as 82-90%.[4] In our own FTT example the probability of innocence is similar; Skuse et al [5] found that over 90% of 2609 cases of faltering growth were not related to parental neglect or abuse. So, in stark contrast to the initial assumption of guilt, based on the rarity of the event, the parents in both situations were nine times more likely to be innocent than guilty. Thus in Court proceedings, rarity of presentation is not relevant. The key issue is the statistical chance, in the presence of this rare presentation, that the accused party is innocent. This principle that we highlight applies equally in other medico-legal areas. 1. Dyer C. Meadow should never have been brought before the GMC. BMJ 2006;332:439. 2. Cole TJ. Conditional reference charts to assess weight gain in British infants. Arch Dis Child 1995;73:8-16. 3. Fleming P, Blair P, Bacon C, Berry PJ, editors. Sudden unexpected deaths in infancy: the CESDI SUDI studies 1993-1996. London: The Stationery Office; 2000, p 92. 4. Hill R. Multiple sudden infant deaths – coincidence or beyond coincidence? Paediatr Perinat Epidemiol 2004;18:320–326. 5. Skuse DH, Gill D, Reilly S, et al. Failure to thrive and risk of child abuse: a prospective study. J Med Screen 1995;2:145-149. Competing interests: None declared |
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david baker, gp principal poole
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It is disappointing to read that the GMC is "expected" to appeal. Better that they should accept the views of the judge, & try to learn from their mistakes. This is a damning judgement, and the members of this FPP should resign immediately. An unreserved apology to Sir Roy would also be in order. David Baker Competing interests: on GMC register |
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ted willis, gp brigg n lincs
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I and my colleagues were thrilled to hear that a common sense judge has found in Prof Meadows favour. The GMC have been made to look very foolish, in taking an unnecessary action which has damaged the reputation of the profession that they are supposed to be upholding, and which has scared doctors away from involving themselves in child protection work. In this and several other cases they seem to have been desperate to prove that they are tough on doctors, irrespective of justice in a particular case. They now say they are going to waste more of our money by appealing against the recent judgement. They seem desperate to kowtow to the fickle media and the even more fickle politicians. This leads to poor justice for unlucky colleagues such as Professor Meadow. It is time that the GMC stands up for the medical profession - one of the important elements that a free society depends on. Competing interests: i have been helping to pay for the gmc legal bills. |
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William H Konarzewski, Consultant Anaesthetist Colchester General Hospital, Colchester CO4 5JL
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I was delighted to hear that a judge has overruled the GMC decision to strike of Professor Roy Meadow. The GMC decision was badly flawed, as Clare Dyer's excellent article clearly illustrates. I have no doubt that many other doctors are suffering currently from the GMC's determination to "restore public confidence" in the medical profession at the expense of the basic principle of justice, namely that an accused person is innocent until proved guilty. The late Lord Denning, in his wisdom, held that it was acceptable for a doctor, acting in good faith, to make a mistake. This no longer appears to be the case. I do not know if the public's confidence in the GMC was greatly increased when they struck of Roy Meadow, but my confidence sank to a new low. It would be good if the GMC had the integrity to accept that it had made a mistake, and the good manners to apologise to Roy Meadow. However, unsurprisingly, they are going to appeal against the judge's decision, and I have no doubt the medical profession will have to fund that appeal through its subscriptions. I find the attitude of the GMC profoundly disappointing. Competing interests: None declared |
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Brian Morgan, Freelance Journalist CF11 6LF
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If a piece of equipment was being relied upon for patient care in the clinical setting, or in court for convictions, and it proved to have a significant failure rate, false positives, false negatives or whatever, its use would be discontinued. If the design proved to be faulty, or its quality control neglected in some way those responsible would be held liable. No one is saying that Professor Sir Roy Meadow has not in the past contributed significantly to medicine or the care of children. But it's the present and the future that matter. When medical experts may be past their best, no longer in clinical practice and their continuous professional development no longer monitored by regulatory or professional bodies then the public is at risk. The Royal College of Paediatrics and Child Health should be admired and commended because unlike any other colleges I can trace it puts its CPD list in the public domain. You can check whether your specialist, your expert in court, the author of a journal article, if a paediatrician, is fully up to date and on the RCPCH's List-A: (http://www.rcpch.ac.uk/education/cpd/alist.html). Absence of a name from the List-A does not necessarily mean a specialist is not fully up date by other means, but it should raise questions. I have as a journalist raised questions with trusts when names of paediatric consultants do not appear on the List-A. Competing interests: I am researching cases where testimony by experts resulted in convictions or family court findings of abuse. |
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Jay Ilangaratne, Founder medical-journals.com
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It is understandable that some doctors are miffed as the GMC would be incurring further funds of its membership in appealing the High Court decision in favour of Prof Meadow.However,for a large member-funded medical organisation, the GMC's decision in this regard is not unusual. For an example, in the case of Mr Chaudhary, the BMA were unsuccessful at an employment tribunal, and again on appeal to the EAT[1]; yet,the BMA is appealing to the Court of Appeal.Similarly, in the case of Dr Sadek[2],Medical Protection Society('MPS') unsuccessfully appealed all the way to the Court of Appeal.MPS is of course, another member-funded organisation. So the main difference in Prof Meadow's case seems to be that he is in a high profile position, and a caucasian. In contrast,both Mr Chaudhary and Dr Sadek are from ethnic minorities,not from high profile backgrounds, and with a few people to openly protest about arguably disproportionate spending on appeals by respective organisations which they are members of.It is time that decision making in relation to appeal-funding became more transparent and accountable, rather than just telling us, it is on legal merit. References [1]British Medical Association v Mr R Chaudhary [2004] UKEAT 1351 01 2403. [2]Medical Protection Society & Others v Dr S Sadek [2004] EWCA Civ 865 Competing interests: None declared |
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Steven Ford, GP Haydon & Allen Valleys Medical Practice. NE47 6HJ
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Sir Blanket immunity for expert witnesses is dangerous - it places them above the law. In the case in question, the judgement of the GMC can be doubted but a mechanism must be found for identifying those witnesses who stray beyond objectivity or their own knowledge limits, fabricate evidence or allow themselves to be influenced by other factors. There has been enough correspondence on the subject of failures by expert witnesses to have drawn attention to the problem but as yet no solution is apparent. Those who misuse the great responsibilty of providing expert testimony should be subject punishment in proportion to their departure from the required standard but first they must be apprehended and tried. For expert witnesses to be truly subject to the law, not only should testimony given in court be actionable but also statements made at any time prior to trial too, as they may affect the efficacy of the justice we would all like to see, in a far more sinister manner. Yours sincerely Steven Ford Competing interests: I am dissatisfied with the GMC's response to an issue I raised. |
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Richard Robinson, Senior Risk Engineer 31 Burnet Close, Padgate, Warrington WA2 0UH
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As an ordinary member of the (non-medical) public, I completely disagree with Mr Justice Collins (BMJ Vol 332 25 February 2006 page 439) that "Meadow should never have been brought before the GMC". Professor Sir Roy Meadow allowed himself to be presented in the Sally Clark trial as an expert witness. On that premise he asserted, completely wrongly, that the chance of two cot deaths in one family is 1 in 79 million. He allowed the jury to believe that that statistic was correct. Even if he gave this evidence "in good faith", as has been said in his defence, Prof. Meadow should (surely) have revealed to the jury that his area of expertise did not include statistics, and that he had obtained the figure from somewhere outside of his own knowledge. It is that failure, not the error in itself, that is so reprehensible, and (in my opinion) a just cause for a severe sanction. Honest members of the medical profession should not fear giving expert evidence in court. All the public would ask is that any such evidence be properly qualified, for example with a statement of the scientific uncertainty and/or that another person's work is being relied upon. Competing interests: None declared |
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Ivor T Rowlands, retired Frodsham, WA6 6EY.
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The rapid responses to this article have understandably been addressed to the statistics of two SIDS [Sudden Infant Death Syndrome] deaths. I may be mistaken - and if so I apologise in advance - that Richard Robinson [Meadow should be disciplined, 22nd July 2006], a recent contributor, is under the impression that these statistics were the principal medical issue at the trial whereas the judge, however naively, ordered the jury to disregard them. In the first posted response, Professor Cole states that the focus of the debate on Roy Meadow's statistics is incorrect but does not say why, since that is incidental to the main thrust of his letter. It is perhaps timely to remind ourselves that the reason SIDS was not an issue at the trial is that no evidence that either of the deaths was a SIDS death was presented to the court by any medical expert. For the convenience of your readers a summary of the current medical opinion on the cause of death of the Clark children as recorded in court and GMC hearing transcripts follows. There is inevitably a very small element of subjective judgement in this summary because of the nature of the hearings but all are on the public record. At the trial itself, excluding the opinions of Meadow and Williams for this present purpose, all four experts stating a clear opinion as to cause of death with regard to Christopher [Berry, Rushton, Green and Keeling] gave “unascertained”. In the case of Harry all seven experts stating an opinion [four above plus Smith, Whitewell and David] gave “unascertained”. No expert was prepared to classify the deaths as SIDS. At the second appeal, following the existence of the bacteriological tests becoming known, only two experts gave evidence and were examined. Professor Morris gave his opinion of the cause of Harry's death as septicaemia but Dr. Klein did not agree. Of these two witnesses the judges said “We wish to record that we found both Professor Morris and Dr Klein to be equally impressive medical witnesses. If we had been required to reach a conclusion as to which of their compelling views was correct, we should have found it a very difficult decision to make.” Later, the GMC hearings concerning the actions of the pathologist Dr Williams also examined the cause of death of Harry closely and at length. The situation is summarised by the panel itself in their findings as follows “Dr Armour and Dr Anscombe were of the opinion that failing to mention those tests [that is the bacteriological tests] at all fell below an acceptable standard, although neither of them, nor most of the other experts, in fact considered that those results indicated the cause of Harry’s death. Professor Morris, however, considered the findings highly material.” Dr Armour gave her opinion that the death of Harry was non-natural and would have stated the cause of death as unascertained. In this hearing Professor Morris's opinion [which was as in the appeal] was in a minority with at least five others of the opinion that the cause of death was "unascertained" [Spillman, Rushton, Manscombe, Berry and Armour]. Thus, so far as the large majority of medical evidence currently on record indicates, the cause of death of the two Clark babies is unresolved and, in my opinion, remains the principal outstanding concern. Ivor Rowlands The writer is a lay person concerned with justice and human rights. I have supported paediatricians in obtaining a fair hearing. I have no personal knowledge or opinion as to the cause of death of the Clark children. http://www.gmc-uk.org/concerns/decisions/search_database/ftp_panel_williams_20050603.asp Court of Appeal [Criminal Division], Case No.. 200203824Y3 Judgement 11th April 2003, Hearings 27th - 29th January 2001. Before Lord Justice Kay, Mr Justice Holland and Mrs Justice Hallet. Competing interests: None declared |
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C Frank Lockyer, Retired 2 The Meadows, Milford, Salisbury SP1 2SS
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Medical correspondents seem unwilling to accept that the Meadow case was not about an expert witness getting his sums wrong on one occasion. Leaving aside other cases, the Sally Clark case went far deeper than that. It was about accountability, impartiality, objectivity, the duty to be balanced and fair; not to be selective towards only that which suits the side calling the expert; to distinguish theory from fact particularly if without foundation in science or literature. It was about the expert's responsibility for proper research and not to stray beyond expertise nor quote statistics which had no authenticity other than, when challenged, he vaguely recalled having seen "on a blackboard somewhere". The expert who follows the Legal and GMC rules has nothing to fear. Those who pontificate on the rights and wrongs of this affair have a similar duty not to be selective to what suits their agenda. Ivor Rowlands does not mention that the Clark's first child was first certified as natural causes. Suspicion arose only following the second death, the cause of which he chooses to present as a contradiction at the Appeal Court between two doctors. Whereas in truth, the Court having reached a decision, it was unnecessary to call the eleven other medical experts who would have testified that any cause other than natural was unsustainable. Even the original experts' opinions relied primarily on the initial pathology since discredited by experts on all sides and found wanting by both the GMC and the Appeal Court. It was not the Defence which claimed SIDS, only that it was not homicide. Meadow introduced SIDS supported by the erroneous statistic further embellished by bizarre horse racing analogies. Whereas, over the page, the very Government Report, he later blamed as misleading, recorded five double deaths within three years. Mistaken he may have been but it also reflects upon the depth of research which any expert, particularly in a murder case, has a duty to ensure. The Family has never questioned but that Professor Meadow has done much good work in his time; only that he was wrong on this occasion and is not infallible. The Family is content to leave the question of sanctions to others but in the absence of any admission or apology sought accountability which has been unequivocally established. Ivor Rowlands merely decribes himself as "retired". He discloses that he has 'no personal knowledge or opinion of the cause of deaths of the Clark children'. Whether or not he has any expertise, to persist in speculating on matters which on his own admission he knows nothing about, compounds precisely all that went wrong in the Sally Clark case. Yours faithfully,
Reference: John Batt. Stolen innocence. Ebury Press, 2004. Competing interests: Sally Clark's Father |
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