9.30 16.04.2008 Yesterday I overdosed on writing deciding to begin with the final part of the summing up of the Diana, Princess of Wales Inquest and that of Dodi Al Fayed. And that set me off on thinking and remembering.
11.30. 15.04.2008 Yesterday I again slightly exceeded the space available for an individual Blog and therefore the last paragraph was not completed. I decided against shortening my personal contribution as in fact some repetition would have been necessary to achieve a more appropriate flow in the final part of the summing up of the Coroner in the Inquest of Diana, Princess of Wales, and Dodi Al Fayed.
Just before the mid morning break he said "Again, members of the jury, you must first decide what evidence you accept as to what the following drivers were actually doing and then you must decide
whether it amounted to gross negligence to the high level I have described and was a cause of the collision and the death of Dodi and Diana. These are two significant hurdles. Let me deal with them one by one. First, you will need to be sure about what was actually going on at the critical time. I have summarised the main features of the eye witness evidence, together with that of the paparazzi. I have mentioned that rarely in connection with any fast- moving event does one find an absolutely consistent account from different witnesses. It may be possible for you to disentangle from all the evidence a sequence of events and the involvement of identifiable following vehicles, such that you can be sure of where precisely any vehicle was and the part it played, if any, in causing the crash. "
(A short break)
(11.28 am) (Jury present) LORD JUSTICE SCOTT BAKER: members of the jury, returning for a moment to the paparazzi. I told you on Monday to be cautious about their evidence because it had not been tested, other than, of course, Darmon, and you may think that they had reason to distance themselves from the Mercedes. You may think that the evidence as a whole, and as Inspector Carpenter agreed, that Darmon and Rat were closer than they accepted, as were Arnal and Martinez. There is doubt that other paparazzi were close in the final stretch. I have been speaking about Mr Read's evidence as to where the Mercedes was and I did mention that -- and I perhaps should emphasise this -- you should not forget that the majority of eye witnesses put it firmly in the left-hand fast lane. Turning then to seat-belts. It is beyond dispute that neither Diana nor Dodi were wearing a seat-belt at the time of the collision. Tebbutt, Diana's driver, said that she normally did wear a seat-belt and this was confirmed by her comptroller/secretary, Gibbins. In the summer of 1997 when she was in London, Tebbutt was called on to drive her on three or four occasions a week. Wharfe said she automatically wore one. Trevor Rees told us that generally Dodi did not wear a seat-belt when he was in central London, but he did as he left London, for example when they went over the Hammersmith flyover and picked up speed. Trevor Rees was criticised for not ensuring that both his charges had their seat-belts fastened, but he was unable to remember whether he had asked them to do so in the vehicle. Why neither of them had their belts fastened is unclear, but you may think that, as adults, it was their responsibility and not that of their bodyguard. Would wearing seat-belts have made a difference? As
a matter of generality, seat-belts ordinarily reduce the severity of injuries and increase survival rates. Would Dodi and Diana have survived had they been wearing one? Read said that wearing one would have increased the prospect of survival. Dr Searle went a little further and said that had they been wearing one, their injuries would have been unlikely to have been fatal. Seat-belts are a significant factor in the cause of fatalities. Both Dodi and Diana suffered very severe injuries and you may think that it is impossible to say that either of them would necessarily have survived had they been wearing a seat-belt. The fact is that the Mercedes hit the 13th pillar and this certainly did contribute to the severity of the collision and the consequential injuries that the passengers suffered because of the very considerable force transmitted to the Mercedes through a small area. If you think Diana and Dodi would have survived had they been wearing a seat-belt, you should say so in your narrative verdict. Could Diana have been saved if she had been taken to hospital more quickly? Diana's death was the result of a severe chest injury, the most significant aspect being a aceration of the left superior pulmonary vein. The injuries were onsistent with a right-sided impact. As you will recall, the crash probably took place between 12.22 and 12.23 am. You heard many witnesses about treatment at the scene. Dr Mailliez was an ff-duty emergency doctor who was returning home from dinner. His call to the emergency services was at 12.27 am and there had been another a minute or so earlier. He quickly assessed the circumstances and ascertained that there were two dead and two seriously injured. Obviously, being off-duty, he did not carry fully equipment. He handed over to the doctor in the fire rescue vehicle that arrived at 12.32 am. When he left, he expected Diana to survive, but he was unaware that she had severe internal injury. wo vehicles attended. There were five people, including paramedics, in each. The first SAMU ambulance arrived at about 12.40 am. Diana was removed from the wreck of the Mercedes at 1 am exactly and put in the ambulance shortly after that so that the doctor could treat her under the best conditions. Now, that is not far short of an hour after the first call to the emergency services, but you have heard that a good deal was going on in the meantime. The ambulance set off at 1.41 am, arriving at the hospital at 2.07 am, having stopped on the journey when Diana's blood pressure dropped dangerously. Professor Lienhart, a French expert appointed in February 1998 to report on treatment, interviewed the key players and said that he was satisfied the standard procedure was followed. Members of the jury, different countries operate different systems and, as you have heard, there is, even today, no agreement at international level whether aking the patient immediately to hospital, known as "scoop and run", is preferable to treatment at the scene. It obviously depends to some extent on the nature of the injuries and the position is more difficult until you know what the injuries are. In France, in 1997, the procedure was that doctors routinely went to the scene of serious accidents accompanied by a good deal of medical resource. Dr Lejay was on duty as the medical dispatcher at the SAMU centre. In Paris there are always two dispatchers, so if one goes out to the scene, the other takes over. He referred to a timeline. He confirmed that Dr Martino arrived at the scene at 20 minutes to 1 with the SAMU ambulance. There was an initial but informative situation report at 12.43. Dr Derossi, the other SAMU dispatcher, arrived at 12.50. There may have been a second report to the dispatcher which was not documented. In any event, Dr Lejay says it was not until 1.19 am that Dr Derossi gave a detailed report of the condition of the injured and recommended Diana to a Pitie-Salpetriere Hospital, a recommendation with which Dr Lejay agreed. Admission to the hospital took only a few minutes to arrange. The ambulance in fact departed at 1.41. Dr Lejay was asked why he did not contact La Pitie-Salpetriere Hospital as soon as Dr Derossi arrived at the scene. His answer was that he needed complete assessment of the injuries and to decide which hospital to approach if La Pitie was not available, but he agreed that when he did telephone Professor Riou, he offered him two multiple trauma victims, which was information that he had had 40 minutes before. It is fair to say that he only had detailed information about the injuries at 1.19, a few minutes before he called Professor Riou. was suggested that there was a lost hour between he arrival of Drs Derossi and Martino at the scene and the departure of the ambulance to hospital, but he said that Diana had to be stabilised before transportation and in particular, her arterial blood pressure had to be recovered. Dr Martino did not give evidence until 24th January. It took us a long time to find him. He is now living in Germany. He was the doctor who treated Diana at the scene. He told us that he arrived at 12.40, inserted a drip and gave sedatives. He thought that Diana may have internal injuries but there was no evidence of them. He used an electrocardioscope and a pressure cuff to check her blood pressure and so forth. She was removed from the crashed vehicle on an olive tree board at 1 am. When removed she had no pulse. He intubated her and performed massage. A satisfactory heartbeat was regained quite quickly. the police record says that she was being treated in the ambulance by 1.18, but you heard from Dr Martino and Dr Derossi that she was probably in the ambulance a little before then. Once there, her arterial pressure dropped again. He gave her dopamine to increase her heart rate and blood pressure, inserting two surgical lines, one for the dopamine and the other to replace lost blood. He carried out a detailed examination. He found more serious injuries than had previously been apparent and, in particular, a thoracic injury, as Dr Derossi reported to Dr Lejay. He began the journey to hospital as soon as Diana's arterial pressure had been restored. He asked the driver to go slowly. He stopped the ambulance on the journey because the arterial pressure dropped again. Dr Martino was in charge from the moment he arrived at the scene until the ambulance reached hospital. He denied any deliberate delay. He said he followed correct procedures and gave appropriate care. He could not have set off sooner because he had to stabilise the patient. It took up to 30 minutes in the ambulance to resuscitate and stabilise her. After removal from the car, she had no pulse and no arterial blood pressure. Accordingly he had to perform cardiac massage. Then he had to intubate and ventilate her before putting her in the ambulance. Once in the ambulance, her blood pressure again became dangerously low. During the journey, there was another near-catastrophic fall in blood pressure. La Pitie-Salpetriere, which is the hospital to which Diana was taken, is the leading hospital in Paris for people suffering from multiple traumas. Professor Riou agreed to take her. She arrived at six minutes past 2. The situation was bleak. Her blood pressure was not measurable. X-rays showed a right haemothorax; that is blood between the lungs and the thorax on the right side.
A general surgeon opened the chest from the sternum to the back, known as a lateral thoracotomy. It was essential to find the source of the bleeding. Professor Pavie arrived and extended the thoracotomy. The source of the bleeding was found. It was coming from the point where the left superior pulmonary vein joins the pericardium of the heart. Professor Pavie said it was difficult to say whether the outcome would have been any different if Diana had been brought to hospital sooner. If a patient arrives at hospital with no arterial pressure, the prospects of success are nearly nil. Professor Pavie is the professor of cardiovascular surgery at La Pitie-Salpetriere Hospital and is President of the French College of Cardiovascular Surgeons. He was called at 2.10 am as a matter of extreme urgency and arrived at the hospital 12 minutes later. Having extended the thoracotomy, he managed to stitch up the tear of the pulmonary vein, but sadly efforts to resuscitate Diana failed. He said that in 30 years' experience, he had never, on any occasion, tried to repair a tear in the left superior pulmonary vein where it joins the atrium. Such patients, he said, do not usually make it to hospital. It was put to Professor Pavie that it would have been desirable for him to have been alerted earlier, and that if Diana had arrived at hospital sooner, she could have been saved. He would not agree and strongly defended the French system. She might have been brought to hospital an hour earlier but most probably she would have been dead on arrival. Every case is different and it is not possible to change the whole system for an
exceptional case. They could not have known at the scene that she had a tear in the left pulmonary vein which was bleeding into the thorax. In simply practical terms, it would have possible to have taken Diana straight to hospital and to have arrived some time earlier, but those at the scene did not know what the nature and the extent of the injury was. It was not like a knife or bullet wound where the track of the injury is known. A closed wound, you ere told, is different. The time that was taken at the scene was largely taken up with trying to stabilise Diana and improve her arterial pressure. If those efforts had not been made, she may have died before she ever got to hospital. As I have said, Professor Lienhart was satisfied that the standard procedures were followed. Nobody had previously seen somebody arriving alive at hospital with such injuries. Even with hindsight, he said, nothing should have been done differently. Members of the jury, you may think that doctors are naturally defensive of their own systems. That is one
of the reasons why I instructed Professor Treasure to have an independent look at the case. He had recently retired and was an expert in cardio-thoracic surgery. He was President of the European Association for Thoracic Surgery in 2005/2006. he size of the rupture, he said, was in the order of a hand's breadth. He had never seen such an injury in a survivor. Now Professor Treasure [disagrees] with Professor Pavie that, even with hindsight, nothing should have been done differently. He says the best option would have been to carry out what is called a "medial sternotomy". This involves opening up the chest from the front, but you need the right equipment, a saw, and an expert to do it. But this is with the hindsight of knowing where the tear was. he sensible thing, he said, was done if they wanted, as they did, to keep their options open so that the incision could be extended, as it was, to enable the surgeon to go into the other side. If the chest had been open from the front, an expert surgeon could have ontrolled the bleeding with a finger and then a clamp. Professor Treasure also made the point that there comes a time when you have exhausted what you can do in an ambulance rather than in a hospital; you simply do not have all the equipment that is available in a fully equipped and fully skilled hospital. He thought that fter Diana had been first stabilised at the crash scene, opportunities were lost and she might have been taken to hospital half an hour sooner. He thought it unfortunate that the hospital was not informed sooner that Dr Martino had discovered a right aothorax. If it had been, the hospital could have brought Professor Pavie there sooner. Professor Treasure was also critical of the massive doses of adrenaline that were administered as this tends to narrow blood vessels. However, looking at the overall picture, he said there was a very low likelihood that Diana's life could have been saved. It was, he said, theoretically possible, but it would have required a number of what he describes as "ifs" to have lined up perfectly.
These were: (1) If the time to get her to hospital was very short; (2) If the cardiac surgical team had been ready on standby -- this needs an early prior alert; (3) If the chest was opened up from the front. To this day, there is a debate between "scoop and run" on the one hand and "treatment at the scene" on the other. You are not in a position to resolve that difficult policy issue. You have not heard any evidence on it and it is certainly not possible to do so on the strength of one case. You may think that the ambulance team did their best in accordance with the prescribed procedures, albeit the period between the collision and arrival at hospital was a little outside the period expected. But you have heard there were reasons for that. They wanted to get her to hospital in the least poor condition possible. It was obviously going to take some time to get Diana to hospital, and Professor Pavie said that even if she had arrived 23 minutes earlier,which was put to him as a realistic possibility, it would have made no difference. There is no evidence that any of the doctors or members of the ambulance crew deliberately failed to do their best for Diana and very little evidence that if any different action had been taken, she would not have died. will recall that, in your narrative conclusion, you have the option of saying that Diana's death was contributed to by the loss of opportunities to render medical treatment. You should only include that as a cause if you are satisfied of two things: first, you would have to be satisfied that even within the framework of the French system, the treating clinicians lost opportunities to take particular steps to save Diana. Secondly, you would have to be satisfied that if those steps had been taken, Diana would probably not have died. Remember, you should only include this in your narrative verdict if you conclude that things could realistically have been done differently, rather than theoretical possibilities. Let me therefore conclude. So, members of the jury, we come to the point where you are to retire and consider your verdicts, not far from six months to the day when we started last October. You have listened to a vast amount of evidence with, if I may say so, obvious care and great commitment. I am grateful to counsel for sticking to the timescale that was agreed and to you for sitting inconvenient sitting hours that you have cheerfully accepted. The conspiracy theory advanced by Mohamed Al Fayed has been minutely examined and shown to be without any substance. There remain the suggestions of whether this might have been a staged accident, but for reasons that I have already explained, it is not open to you to return a verdict of unlawful killing on the part of anyone other than the driver of the Mercedes or the following vehicles or both together. Consider first whether you are satisfied so that you are sure that there was gross negligence on the part of the driver of the Mercedes or the following vehicles or both and that it caused the death of the deceased. If you are not so satisfied, you must go on to consider whether you are satisfied on balance of probabilities of accidental death. In considering each of these possible verdicts, you will consider the evidence that this was a staged accident. f that or anything else results in your not being satisfied to the relevant standard of proof of any of the other verdicts, you will return an open verdict. With each verdict, whether unlawful killing, accident or open, it must be the verdict of all 11 of you As I mentioned to you at the start, you are to complete one inquisition form for Dodi and one for Diana. You should write the verdict in section 4 of the inquisition form on the second page. So you may be sure that you get the wording of each verdict exactly right, they are listed in paragraph 1 of your handout of legal directions. The narrative conclusion goes in section 3 of each inquisition form. If you look at the box on page 1 of each form, you will see the introductory passage beginning either "Dodi" or "Diana". After the introductory passage, you will write in as many or as few as you wish of the five causes listed in 1 to 5 at paragraph 19 of your handout of legal directions, on the last page of that. If you now look at the top of page 2 of the inquisition form, you will see the sentence beginning, "In addition ..." After that sentence, you will write in as many or as few as you wish of the causes listed at 1 to 3 of paragraph 20 of your handout on legal directions. Please use the form of words in the legal directions. That form of words has been carefully composed so as to be as informative as possible while avoiding any risk of the rules being infringed. Any narrative conclusion you come to, as with your verdict, should likewise be the conclusion of you all. It is for you to decide which, if any, of the causes I have provided you wish to add to your narrative conclusion. Will you please now retire to consider your verdicts? There is no pressure of time. Take as long as is necessary. If your deliberations are still continuing at 4.15 today or on any other day or there abouts, I shall adjourn for the day, you will go home and we will resume at 10 o'clock on the following day. I am told that I said something which was a slip of the tongue which ought to be corrected and Mr Burnett will now tell you what it is. MR BURNETT: Sir, my microphones don't appear to be working. Sir, you said "Professor Treasure agrees with Professor Pavie ..." --
LORD JUSTICE SCOTT BAKER: It should be "disagrees". MR BURNETT: It should be, which I hope was obvious from what followed. LORD JUSTICE SCOTT BAKER: Thank you. So can the jury bailiffs now please be sworn? Jury bailiffs (sworn) LORD JUSTICE SCOTT BAKER: Mr Burnett, there is one point that occurs to me. Of course the jury are being provided throughout with the Live Note transcript. It will take a little time for this morning's Live Note to be transcribed and no doubt that can be taken to the jury room and handed in at the appropriate time?
MR BURNETT: I am sure everyone would agree with that. Yes, lots of nodding. LORD JUSTICE SCOTT BAKER: Thank you. (11.57 am) (Jury out) LORD JUSTICE SCOTT BAKER: I shall not take a verdict between 1 and 2 on this or any other day, if that is convenient for everyone to know that (11.58 am) (Adjourned for deliberations)"
A decade or so ago it would not have possible to have read not only the summoning up, but all the detailed examinations of witnesses and their statements together with explanatory information about the British system of Inquests. Because of eh development of the internet and the use of electronic recording and transmission anyone, anyone anywhere in the world can have access www.scottbaker-inquests.gov.uk/ There is a notice which explains that it is possible to do what I have done, that is reproduce what was said or part of what was said in its sectional entirety as long as appropriate attribution is made. Because all the information available at the Inquests is available it is in appropriate to make a secondary judgement without having digested all the information. It is possible for the parties involved to have questioned the verdict if for example it was felt the Coroner in summing up had omitted some relevant information or appeared to unfairly slant comments although it is significant that at the outset of the summing up the point was made that the jury had to adhere without deviation to the interpretation of the law but it was for them individually and then collectively to determine the judgement to be made on the evidence. The role of the Coroner in this respect was to help the Jury form their evaluation and conclusions and to test out their findings in the form required by the law.
I have no doubt that there will those in many countries, especially those who have already published work on the deaths who will have already commenced the work of reviewing the "evidence of their previous inquiries and the inquiries of others with that available and come to different conclusions or raised unanswered questions. There have been similar inquiries or events where inquiries have not settled the issues. The most famous in my lifetime was the assassination of President Kennedy, The circumstances of the death of Marilyn Monroe was another. The most expensive and longest enquiry is that into the events in Northern Ireland, known as Bloody Sunday. I have no doubt there will be similar expenditure in time and money, and controversy over the decision to go to War in Iraq.
My interest in this level if enquiry first occurred twenty five years ago when on the advice of the Department of Health I was invited to participate in a judicial led inquiry into the role of health and social services authorities and of others including the police, following the accidental but horrific death of a child who had been in care on several occasions and was under the supervision of the authorities. I was originally advised that the hearing of evidence would last four weeks after which I would be involved in the preparation of the report the report which was to be published. In fact the hearings lasted three months with a break of two weeks in between and I ended up drafting what became the majority report. There were some fifty members of the legal profession in attendance for the public opening of the inquiry, although the rest of the hearing of witnesses was closed as were their statements. The jury in the Diana and Dodi Inquest had 30 lever arch files of evidence and transcript and I ended up with a dozen without the transcripts which I have always regretted not getting a copy, and was the reasons why I supported the presentation of in effect two reports, that of the Chairman of the Panel which was based on both the transcripts and the written statements and records and the majority report which was based primarily on statements and other documentation.
The inquiry came about after a photograph and other information was leaked to the media and concerns were raised about the role of the statutory agencies before and after the conviction and imprisonment of the mother of the deceased child and two other surviving children. The media interest was heightened because the senior police officer involved in the case had received the George Medal for the Balcombe Street siege and was widely believed to have been responsible for confidential information making its way to the media. Such was the prior interest in the inquiry that Panorama had asked for access to the inquiry in order to undertake a programme once the findings were made public. This was of one of several lessons I learnt as consequence of my involvement in this inquiry. How the inquiry comes about and the involvement of the media beforehand can govern the terms of reference, the form of the inquiry, the selection of inquiry members and in turn the nature of the report and its findings.
This was not the first such inquiry of its kind as there has been several since the creation of Social Services Departments a decade beforehand. My selection as a panel member to represent Social Service expertise was a surprise to me and to others although by then the number of Directors of Social Services who had been qualified and experienced child care officers, with experience in senior management had reduced considerably, but because of my background and my writings I was a controversial figure and it was five years since I been active in national activities of the profession at any level. The department of Health would have known of the attention I paid to the published reports of other inquiries which I always reported to the Social Services Committee with and Ministerial or Department guidance in relation to recommendations. Such inquiries into individual case were always accompanied by recommendations of a general nature to which the government would formally respond and provide child care authorities and bodies with guidance as a consequence. I was also known to have been opposed to the development of generic social work and the abolition of specialist child care workers, and to having persuaded my local authority to begin the move back to create specialist practitioners and specialist managers within the umbrella of a social services department. I also had come to prominence because of a defence of the role of practitioners and critical of the media and others who rushed to judgement without the benefit of all the facts and an understanding of the complexity of individual situations.
Beforehand I obtained a list of all the inquiries which had taken place over the previous twenty years and then written for a copy of the reports and recommendations in so far these were sill available. Something I kept up over the next decade only to conclude that general recommendations were of little value in preventing further tragedies. However I was new to the process and quickly discovered that the approach varied according to the form of inquiry and the extent of legal involvement, In the instance of my involvement each of the main interests was represented by a QC which usually meant that a junior counsel was also used together with the instructing solicitor and their team. Even where a solicitor represented an interest such as the British Association of Social Workers, there would be at least an assistant. Although the chairman of the inquiry was a Recorder, a kind of junior judge, the inquiry panel had its own legal team comprising a QC, instructing solicitor and team. A solicitor to day will charge £100-£150 an hour, I would estimate at least £1000 a day and barristers and leading Counsel several times this amount depending on their experience and standing. I was paid a fee in addition to my normal salary plus expenses for accommodation food and travel other than that directly provided, so that a civic car met me at the station each morning to the civic centre where the hearings were held and then returned to the station each evening and a cooked meal was provided at lunch times. The fee was set at the commencement and was an overall sum rather than per day. Which applied to the lawyers. I would set the alarm for six and usually went to bed at midnight during week days. Over the first few weeks I travelled home from London on Fridays evenings and travelled down by early train on Monday mornings but it soon became evident that that in order to keep on top of the situation it was necessary to travel homeward on Saturday mornings and return late Sundays evenings as I needed to make notes, establish my own handwritten card database and prepare interrogations. This was a situation which no one could have foreseen because of what happened early on.
It is not generally understood that before such enquiries take place, as with criminal and other trials where there is to be oral evidence and interrogations, there is much planning and preparatory meetings including a formal meeting between all the legal representatives involved. This will cover the witnesses to be called and arranging their availability, and then some order for the various parties to be able to question. Thus in my involvement instance a list of witnesses was prepared by the Counsel for the Inquiry in consultation with the other interested parties, based on the witness statements and submitted documentation such the various records of the Local Authority, Health Visiting, Hospital attendance, involvement of the Police, other agencies. Such witnesses are often grouped to cover a particular aspect of the matters for example there were neighbours who had complained about the care of the children, and foster parents with whom they had been placed. It was therefore important to try and build up a chronological sequence of events over the period under review as well as of the various interests. My involvement was in days before the personal word processing computer so my recording tools were a manual portable typewriter and handwritten notes key dates, people and other information cards and which I had to transport with me together with what became a dozen lever arch boxed files of copies of the available records. Every witness was asked to submit a written settlement of their involvement together with their written record. In our instance as in the Diana and Dodi Inquest we were significantly handicapped by the refusal of the most important party to attend the hearing and be questioned. and by the disappearance of the official departmental record for the period which that individual had been responsible. Amazingly no one in the local authority subsequently tried to reassemble the information, reflecting the inadequacy of the professional training of the workers who were subsequently appointed to work with the family and the limitations of the management to the highest levels. Just before the tragedy occurred a health visitor had taken upon herself to try and assemble background information, and the then current social worker also decided it would be advantageous to do so. It was only consequently to the tragedy that a full search was made of all records to see if the file had been misplaced within the system. Two such searches were made and the failure to find the file can only indicate one thing. It was removed without approval from the premises of the local authority and one must assume subsequently destroyed. However even when the tragedy occurred, the criminal trial and then the inquiry was held the local authority failed to do all that it could within its power to re-assemble the missing record. It was possible to identify several foster parents who had looked after the children and they provided important information, but there was a gap and it was only during the proceedings when a senior officer of the department was being questioned about the lost file and attempts to retrieve, that it struck me that no reference was being made to the register of boarding out required by the boarding out regulations of 1948. This meant that there were at least three separate sources with a department of the history of the children when in the care of the local authority. There was the case file held by the social worker allocated responsibility for the family and which should have been examined by the supervising officer from time to time to ensure that statutory required visits and records were being maintained. There would be a file on each foster parent, on the enquiries made for their approval and on each child placed with them including the period of placement. But there was a third record where every child placed in a foster home had to be recorded in chronological order with the dates of placements and the names and address of the foster parents. It was evident under my questioning that the senior officer who did not have a child care background was unaware of this requirement and it appeared that this record had not been examined when reassembling a record for the Inquiry. Within a matter of hours the record was checked and two further foster parent placements were found. The foster parents were only two willing to given evidence and they had been surprised at not being contacted before and what they had to say was of significance.
A second aspect of the need to know something about how inquiries are organised and their limitations concerns the law and why I have reservations about inquiries which are exclusively legal processes and where the involvement of a jury is crucial and should not be set aside lightly. A central issue in the inquiry where I was a member was the law on child care and where more than one social service interest drew attention to the legal duty of officers to do all that was possible to prevent children entering and remaining in public care or appearing before the courts. One barrister made much of this to the extent that I felt obliged to intervene, in a room filled with lawyers, I enquired if the lawyer was suggesting that this law had greater weight over the duty of officers under the law to protect children from physical violence and other forms of abuse. The lawyer explained that it was her function to represent the interests of her client in the best way possible, This is also a point which the Coroner made when advising the jury about the weight to given to the representations by the lawyers on behalf the parties and the weight to be given to the expert witnesses and to others. This is not just a question of people not telling the truth but of slanting things in favour of one interest or viewpoint and away from another. A classical example of this was the subsequent admission, later denied and qualified by the former Butler of Princess Diana that he had not told the whole truth and had introduced a red herring or two. In the Princess Diana and Dodi Al Fayed Inquest the legal representations appeared balanced whereas in the inquiry where I was a panel member the legal representation was unbalanced because all the statutory bodies and their officers had legal representation whereas the foster parents and the neighbours who had complained or expressed concern about the welfare of safety of all the children were not represented. Counsel for the inquiry could have expected to have undertaken this role but was prevented from doing so after two of the professional experts on the panel supported by the Department of Health representative indicated that they were unwilling to proceed because they had understood the inquiry was to be more inquisitorial and significantly adversarial and objected strongly to the approach of Counsel for the Inquiry, threatening to resign. As a compromise the approach adopted was for one member of the panel to lead the interrogation of a witness, with other panel members and the Chairman being able to follow up with supplementary questions, then the legal representative for the witness and then the other legal representatives in the order which has previously been agreed and then the Counsel for the enquiry. Thus far from shortening proceedings they were lengthened as understandably the representatives for the witness and the others went through a questioning process whether we had covered the same subjects or issues beforehand.
I have mentioned these things because the chairman and Counsel for the enquiry and I came to very different conclusion about the role of the social services department and their officers in the case yet we sat through the same oral testimony and had access to the same written statements and records. This was the point of the Coroner when he advised the jury about their role in relation to the evidence submitted to them and the basis of coming to a judgement. The judgement of only one individual may be right, especially if they have had years of experience in the process but the judgement of a collective jury is safer despite all the likely prejudices and lack of experience in such matters. In the case of my involvement I was convinced that there has been errors in the judgements of social services workers because of their lack of specialist child care training and of child care law, and in good social work practice because they had never understood the importance of keeping accurate records and studying such records or of achieving the right balance between the need to try and keep children out of care and to protect them from harm, and of listening and giving priority to what children have to say about their lives and wishes and what those who know them also have to say, their families, their teachers and in the case in question the succession of foster parents who cared for them. However I suspect the biggest failure and on whom the burden of responsibility was likely to fall was on the individual who had been responsible, whose record of work was not available and who had refused to be questioned. On the basis of the hard information available there had been opportunity after opportunity to have protected the child who had experienced a horrible death and all those involved across the board had failed to see sign after sign. When it was evident from the conclusions of the draft report prepared by the Chairman and the Counsel for the Inquiry that my judgement was not shared I decided not to sign the report and wrote to Chairman and my colleagues to this effect, saying that I would simply indicate if required to the media that I disagreed but would make not separate comment. My two other colleagues then advised that they shared my reservations and asked that I set down my different understanding from the draft report submitted to us. I carefully considered the implications of this because I was back doing my paid job, I was concerned about the time and expense of the enquiry to that date and the implications of undertaking the additional work which would be involved. I decided first to review the written statements and records and then take a decision about oral transcript and having undertaken the task I realised that that the evidence for my conclusions was overwhelming and that there were about one hundred matters on which to base the conclusions. Each matter was further checked and double checked and then summarised in a schedule which was widely reproduced in national media subsequently and then a report written of some 200 doubled line spaced pages, My colleagues then had opportunity to consider my work and with their copies of the records and the oral testimony transcriptions. We then met and went through the report line by line and it was effectively rewritten to reflect our combined experienced and judgements. The two reports were complimentary as one covered the chronology of events, and a host of important appendices. All the witnesses were identified only by their roles and employers for neighbour 1, foster parent 2. What was presented was a legal viewpoint and a professional assessment covering social work, medicine and nursing. This was to my mind a good outcome which reflected the two processes which had taken place along side each other. My only concern in the subsequently amended minority legal report was that attention was drawn to an issue which in fact demonstrated a lack of thoroughness on the part of those drafting the amendments made after our majority report was submitted and which could be interpreted as an attempt to undermine the thoroughness and integrity of the majority report.. Those concerned has simple not studied the original records carefully enough because they overlooked that although there were two entries by one agency on a particular day, the writing and initials were different and therefore one officer who knew the situation had not returned as everyone came to believe including the officer in question.
The media accepted the majority judgements and conclusions there was no legal challenge that our findings should be set aside.
This has become the situation in the Diana and Dodi Inquest. There are always several ways of viewing any event, especially when there has been passage of time. There are always coincidences and individuals and agencies make well intentioned mistakes and errors of judgement and which can appear as pre meditated actions and conspiracies..
It is unlikely that I will ever have the time to read all the evidence of the Inquest to be able to make a substantive judgement on the summing up and Jury findings and therefore I accept them with reservation. The areas I would want to look at is how someone who was not a chauffer came to be driving that night and more about his work for the French secret service and if he was the only one of the 600 employees at the hotel who passed on information. I would want to know more about the search for the vehicle which collided with the Mercedes in the underpass. I would want to know a lot more about why the cameras inside the underpass were not working and what disciplinary action was taken against those who either switched them off or did not immediately arrange their maintenance when a fault occurred . I would also want to know why the movements of the Princess were not kept under surveillance as she had made herself into the number one target in the world for every dangerous crackpot and where the task of an assassination was made that much easier by being surrounded by the media day and night and where she would remain the mother of the future monarch whatever her own status had become. In my view it was negligent of the British Government not to maintain discrete surveillance as it does with former Prime Minister's and the like and to enlist the assistance of other governments when she was abroad. The other aspects which I would want to explore further except that I know there are no answers is the role of the other surveillance and intelligences services which come under the umbrella of the state including the use of freelancers for ad hoc and otherwise illegal operations. Recently I reviewed my experience of the film about the life of a senator who arranged the deployment of arms to the Afghans to fight the Russians, via an international arms dealer and a special disguised government fund which grew from a few million dollars to half a billion arranged with the help of one CIA operative and one powerful wife of an influential multi millionaire. This was all fact and not fiction. .And you mean to try and persuade me that the British do not have similar capacity? Governments although the Judiciary and police know better, like to kid us that decisions are always made after careful thought and the best advice available and in the national interest when they after often based on personal interests and inclinations and often have to made quickly without the time to consider all the available information and opinions. The extremes of good and bad decision taking were witnessed this evening in two TV programmes
The first was a documentary on the history of the aircraft carrier and the latest construction techniques which reduce the time to build from one to three years by constructing in sections and assembling. I had no idea that the first carrier which pioneered take off was developed by the USA and that the problems of landing were solved by the British with their Ark Royal, or that the latest craft do not have to be refuelled for twenty years, with only two nuclear reactors required and have become a town of 6000. There is no room for error in the work whether the crew person who fires the aircraft launching system which can get planes in the air every 20 seconds, to the cooks providing three meals a day every day without food poisoning, and to those who must try and maintain the morale of the whole team for the months spent away from families and other friends. No doubt the psychological profiling will be top notch as one individual going off he rails could destroy us all.
A different level of complexity, this time a fictional one, was the first two parter in the new Waking the Dead series. It was the story of three young women who came together at a Kaddafi Terrorist camp two decades ago and who form a mutual help cell, one from the IRA, one for ETA and one a Muslim fundamentalist. One comes to the attention of the Waking the Dead Team when is identified through DNA as having been present at unsolved murder fifteen years or so before when she becomes the mystery woman in as drama caught by CCTV at a railway station. A youth attempt to steal the bag of one of her daughters at a railway station and in preventing him from doing so he falls on to the line and is electrocuted but she gives mouth to mouth and resuscitates him.
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We learn that woman who met her husband when a waitress in France and had a daughter by a previous relationship has lived a quite life as a mother of two children, having trained and worked as a nurse, suddenly takes flight when news of the incident and station CCTV is shown on the national telly and CNN news where the footage is also seen by the former IRA member of the cell who comes in search with murderous intentions. She, the IRA member worked closely with ETA for a time believes that a bombing was intervened because of leak and assumed it was her Some time after the ETA lady whose function was in the style of Marta Hari receives a summons to assist their Muslim Fundamentalist friend. The reason of the call is to hand over a tape explaining why she is about to blow up herself and a plane together with her baby daughter who will get her on to the flight but instead the ETA lady shoots the Fundamentalist and brings up the baby as her own having realised she was not a terrorist and wished to change her life and could not accept the death of the child and those on the plane. She is helped by a poor specimen of humanity, an Algerian who combined a career exploiting women with that of a transport driver for the Kaddafi centre and becoming a CIA informant. He was responsible for the original leak which first killed an associated of the IRA cell member and then he had attempted to get rid of the body of the Fundamentalist shot by the ETA lady, When the ETA woman tries to run to France with her daughters and finds the authorities have sealed the exits she turns to the Algerian who runs a lap dancing club in London for help but he betrays her whereabouts to the IRA pursuer not realising that she had her children at the hotel and that they are soon in the hands of the IRA lady who demands to see her former ETA comrade at club, bringing the eldest daughter strapped with explosives as a protection. Being fiction the truth is established, the daughters are saved, there is not further killing and life goes on. Being fiction the young man who tried to steal the bag and whose life the ETA lady saved, was the estranged son of the head of the Waking the Dead team and alas when father decides to make one more attempt to communicate with the loving son he once had, he finds the young man has discharged himself and disappeared. What made this particular programme special was the quality and believability of the acting and the script and communicated the reality that terrorists are you and me pushed too far, but have to be dealt with as well as the causes of genuine grievances addressed.
And so as I have said many times now and will continue say what we do and say lives with us for eternity and there is always a price to be paid for everything by others if not by you
11.30. 15.04.2008 Yesterday I again slightly exceeded the space available for an individual Blog and therefore the last paragraph was not completed. I decided against shortening my personal contribution as in fact some repetition would have been necessary to achieve a more appropriate flow in the final part of the summing up of the Coroner in the Inquest of Diana, Princess of Wales, and Dodi Al Fayed.
Just before the mid morning break he said "Again, members of the jury, you must first decide what evidence you accept as to what the following drivers were actually doing and then you must decide
whether it amounted to gross negligence to the high level I have described and was a cause of the collision and the death of Dodi and Diana. These are two significant hurdles. Let me deal with them one by one. First, you will need to be sure about what was actually going on at the critical time. I have summarised the main features of the eye witness evidence, together with that of the paparazzi. I have mentioned that rarely in connection with any fast- moving event does one find an absolutely consistent account from different witnesses. It may be possible for you to disentangle from all the evidence a sequence of events and the involvement of identifiable following vehicles, such that you can be sure of where precisely any vehicle was and the part it played, if any, in causing the crash. "
(A short break)
(11.28 am) (Jury present) LORD JUSTICE SCOTT BAKER: members of the jury, returning for a moment to the paparazzi. I told you on Monday to be cautious about their evidence because it had not been tested, other than, of course, Darmon, and you may think that they had reason to distance themselves from the Mercedes. You may think that the evidence as a whole, and as Inspector Carpenter agreed, that Darmon and Rat were closer than they accepted, as were Arnal and Martinez. There is doubt that other paparazzi were close in the final stretch. I have been speaking about Mr Read's evidence as to where the Mercedes was and I did mention that -- and I perhaps should emphasise this -- you should not forget that the majority of eye witnesses put it firmly in the left-hand fast lane. Turning then to seat-belts. It is beyond dispute that neither Diana nor Dodi were wearing a seat-belt at the time of the collision. Tebbutt, Diana's driver, said that she normally did wear a seat-belt and this was confirmed by her comptroller/secretary, Gibbins. In the summer of 1997 when she was in London, Tebbutt was called on to drive her on three or four occasions a week. Wharfe said she automatically wore one. Trevor Rees told us that generally Dodi did not wear a seat-belt when he was in central London, but he did as he left London, for example when they went over the Hammersmith flyover and picked up speed. Trevor Rees was criticised for not ensuring that both his charges had their seat-belts fastened, but he was unable to remember whether he had asked them to do so in the vehicle. Why neither of them had their belts fastened is unclear, but you may think that, as adults, it was their responsibility and not that of their bodyguard. Would wearing seat-belts have made a difference? As
a matter of generality, seat-belts ordinarily reduce the severity of injuries and increase survival rates. Would Dodi and Diana have survived had they been wearing one? Read said that wearing one would have increased the prospect of survival. Dr Searle went a little further and said that had they been wearing one, their injuries would have been unlikely to have been fatal. Seat-belts are a significant factor in the cause of fatalities. Both Dodi and Diana suffered very severe injuries and you may think that it is impossible to say that either of them would necessarily have survived had they been wearing a seat-belt. The fact is that the Mercedes hit the 13th pillar and this certainly did contribute to the severity of the collision and the consequential injuries that the passengers suffered because of the very considerable force transmitted to the Mercedes through a small area. If you think Diana and Dodi would have survived had they been wearing a seat-belt, you should say so in your narrative verdict. Could Diana have been saved if she had been taken to hospital more quickly? Diana's death was the result of a severe chest injury, the most significant aspect being a aceration of the left superior pulmonary vein. The injuries were onsistent with a right-sided impact. As you will recall, the crash probably took place between 12.22 and 12.23 am. You heard many witnesses about treatment at the scene. Dr Mailliez was an ff-duty emergency doctor who was returning home from dinner. His call to the emergency services was at 12.27 am and there had been another a minute or so earlier. He quickly assessed the circumstances and ascertained that there were two dead and two seriously injured. Obviously, being off-duty, he did not carry fully equipment. He handed over to the doctor in the fire rescue vehicle that arrived at 12.32 am. When he left, he expected Diana to survive, but he was unaware that she had severe internal injury. wo vehicles attended. There were five people, including paramedics, in each. The first SAMU ambulance arrived at about 12.40 am. Diana was removed from the wreck of the Mercedes at 1 am exactly and put in the ambulance shortly after that so that the doctor could treat her under the best conditions. Now, that is not far short of an hour after the first call to the emergency services, but you have heard that a good deal was going on in the meantime. The ambulance set off at 1.41 am, arriving at the hospital at 2.07 am, having stopped on the journey when Diana's blood pressure dropped dangerously. Professor Lienhart, a French expert appointed in February 1998 to report on treatment, interviewed the key players and said that he was satisfied the standard procedure was followed. Members of the jury, different countries operate different systems and, as you have heard, there is, even today, no agreement at international level whether aking the patient immediately to hospital, known as "scoop and run", is preferable to treatment at the scene. It obviously depends to some extent on the nature of the injuries and the position is more difficult until you know what the injuries are. In France, in 1997, the procedure was that doctors routinely went to the scene of serious accidents accompanied by a good deal of medical resource. Dr Lejay was on duty as the medical dispatcher at the SAMU centre. In Paris there are always two dispatchers, so if one goes out to the scene, the other takes over. He referred to a timeline. He confirmed that Dr Martino arrived at the scene at 20 minutes to 1 with the SAMU ambulance. There was an initial but informative situation report at 12.43. Dr Derossi, the other SAMU dispatcher, arrived at 12.50. There may have been a second report to the dispatcher which was not documented. In any event, Dr Lejay says it was not until 1.19 am that Dr Derossi gave a detailed report of the condition of the injured and recommended Diana to a Pitie-Salpetriere Hospital, a recommendation with which Dr Lejay agreed. Admission to the hospital took only a few minutes to arrange. The ambulance in fact departed at 1.41. Dr Lejay was asked why he did not contact La Pitie-Salpetriere Hospital as soon as Dr Derossi arrived at the scene. His answer was that he needed complete assessment of the injuries and to decide which hospital to approach if La Pitie was not available, but he agreed that when he did telephone Professor Riou, he offered him two multiple trauma victims, which was information that he had had 40 minutes before. It is fair to say that he only had detailed information about the injuries at 1.19, a few minutes before he called Professor Riou. was suggested that there was a lost hour between he arrival of Drs Derossi and Martino at the scene and the departure of the ambulance to hospital, but he said that Diana had to be stabilised before transportation and in particular, her arterial blood pressure had to be recovered. Dr Martino did not give evidence until 24th January. It took us a long time to find him. He is now living in Germany. He was the doctor who treated Diana at the scene. He told us that he arrived at 12.40, inserted a drip and gave sedatives. He thought that Diana may have internal injuries but there was no evidence of them. He used an electrocardioscope and a pressure cuff to check her blood pressure and so forth. She was removed from the crashed vehicle on an olive tree board at 1 am. When removed she had no pulse. He intubated her and performed massage. A satisfactory heartbeat was regained quite quickly. the police record says that she was being treated in the ambulance by 1.18, but you heard from Dr Martino and Dr Derossi that she was probably in the ambulance a little before then. Once there, her arterial pressure dropped again. He gave her dopamine to increase her heart rate and blood pressure, inserting two surgical lines, one for the dopamine and the other to replace lost blood. He carried out a detailed examination. He found more serious injuries than had previously been apparent and, in particular, a thoracic injury, as Dr Derossi reported to Dr Lejay. He began the journey to hospital as soon as Diana's arterial pressure had been restored. He asked the driver to go slowly. He stopped the ambulance on the journey because the arterial pressure dropped again. Dr Martino was in charge from the moment he arrived at the scene until the ambulance reached hospital. He denied any deliberate delay. He said he followed correct procedures and gave appropriate care. He could not have set off sooner because he had to stabilise the patient. It took up to 30 minutes in the ambulance to resuscitate and stabilise her. After removal from the car, she had no pulse and no arterial blood pressure. Accordingly he had to perform cardiac massage. Then he had to intubate and ventilate her before putting her in the ambulance. Once in the ambulance, her blood pressure again became dangerously low. During the journey, there was another near-catastrophic fall in blood pressure. La Pitie-Salpetriere, which is the hospital to which Diana was taken, is the leading hospital in Paris for people suffering from multiple traumas. Professor Riou agreed to take her. She arrived at six minutes past 2. The situation was bleak. Her blood pressure was not measurable. X-rays showed a right haemothorax; that is blood between the lungs and the thorax on the right side.
A general surgeon opened the chest from the sternum to the back, known as a lateral thoracotomy. It was essential to find the source of the bleeding. Professor Pavie arrived and extended the thoracotomy. The source of the bleeding was found. It was coming from the point where the left superior pulmonary vein joins the pericardium of the heart. Professor Pavie said it was difficult to say whether the outcome would have been any different if Diana had been brought to hospital sooner. If a patient arrives at hospital with no arterial pressure, the prospects of success are nearly nil. Professor Pavie is the professor of cardiovascular surgery at La Pitie-Salpetriere Hospital and is President of the French College of Cardiovascular Surgeons. He was called at 2.10 am as a matter of extreme urgency and arrived at the hospital 12 minutes later. Having extended the thoracotomy, he managed to stitch up the tear of the pulmonary vein, but sadly efforts to resuscitate Diana failed. He said that in 30 years' experience, he had never, on any occasion, tried to repair a tear in the left superior pulmonary vein where it joins the atrium. Such patients, he said, do not usually make it to hospital. It was put to Professor Pavie that it would have been desirable for him to have been alerted earlier, and that if Diana had arrived at hospital sooner, she could have been saved. He would not agree and strongly defended the French system. She might have been brought to hospital an hour earlier but most probably she would have been dead on arrival. Every case is different and it is not possible to change the whole system for an
exceptional case. They could not have known at the scene that she had a tear in the left pulmonary vein which was bleeding into the thorax. In simply practical terms, it would have possible to have taken Diana straight to hospital and to have arrived some time earlier, but those at the scene did not know what the nature and the extent of the injury was. It was not like a knife or bullet wound where the track of the injury is known. A closed wound, you ere told, is different. The time that was taken at the scene was largely taken up with trying to stabilise Diana and improve her arterial pressure. If those efforts had not been made, she may have died before she ever got to hospital. As I have said, Professor Lienhart was satisfied that the standard procedures were followed. Nobody had previously seen somebody arriving alive at hospital with such injuries. Even with hindsight, he said, nothing should have been done differently. Members of the jury, you may think that doctors are naturally defensive of their own systems. That is one
of the reasons why I instructed Professor Treasure to have an independent look at the case. He had recently retired and was an expert in cardio-thoracic surgery. He was President of the European Association for Thoracic Surgery in 2005/2006. he size of the rupture, he said, was in the order of a hand's breadth. He had never seen such an injury in a survivor. Now Professor Treasure [disagrees] with Professor Pavie that, even with hindsight, nothing should have been done differently. He says the best option would have been to carry out what is called a "medial sternotomy". This involves opening up the chest from the front, but you need the right equipment, a saw, and an expert to do it. But this is with the hindsight of knowing where the tear was. he sensible thing, he said, was done if they wanted, as they did, to keep their options open so that the incision could be extended, as it was, to enable the surgeon to go into the other side. If the chest had been open from the front, an expert surgeon could have ontrolled the bleeding with a finger and then a clamp. Professor Treasure also made the point that there comes a time when you have exhausted what you can do in an ambulance rather than in a hospital; you simply do not have all the equipment that is available in a fully equipped and fully skilled hospital. He thought that fter Diana had been first stabilised at the crash scene, opportunities were lost and she might have been taken to hospital half an hour sooner. He thought it unfortunate that the hospital was not informed sooner that Dr Martino had discovered a right aothorax. If it had been, the hospital could have brought Professor Pavie there sooner. Professor Treasure was also critical of the massive doses of adrenaline that were administered as this tends to narrow blood vessels. However, looking at the overall picture, he said there was a very low likelihood that Diana's life could have been saved. It was, he said, theoretically possible, but it would have required a number of what he describes as "ifs" to have lined up perfectly.
These were: (1) If the time to get her to hospital was very short; (2) If the cardiac surgical team had been ready on standby -- this needs an early prior alert; (3) If the chest was opened up from the front. To this day, there is a debate between "scoop and run" on the one hand and "treatment at the scene" on the other. You are not in a position to resolve that difficult policy issue. You have not heard any evidence on it and it is certainly not possible to do so on the strength of one case. You may think that the ambulance team did their best in accordance with the prescribed procedures, albeit the period between the collision and arrival at hospital was a little outside the period expected. But you have heard there were reasons for that. They wanted to get her to hospital in the least poor condition possible. It was obviously going to take some time to get Diana to hospital, and Professor Pavie said that even if she had arrived 23 minutes earlier,which was put to him as a realistic possibility, it would have made no difference. There is no evidence that any of the doctors or members of the ambulance crew deliberately failed to do their best for Diana and very little evidence that if any different action had been taken, she would not have died. will recall that, in your narrative conclusion, you have the option of saying that Diana's death was contributed to by the loss of opportunities to render medical treatment. You should only include that as a cause if you are satisfied of two things: first, you would have to be satisfied that even within the framework of the French system, the treating clinicians lost opportunities to take particular steps to save Diana. Secondly, you would have to be satisfied that if those steps had been taken, Diana would probably not have died. Remember, you should only include this in your narrative verdict if you conclude that things could realistically have been done differently, rather than theoretical possibilities. Let me therefore conclude. So, members of the jury, we come to the point where you are to retire and consider your verdicts, not far from six months to the day when we started last October. You have listened to a vast amount of evidence with, if I may say so, obvious care and great commitment. I am grateful to counsel for sticking to the timescale that was agreed and to you for sitting inconvenient sitting hours that you have cheerfully accepted. The conspiracy theory advanced by Mohamed Al Fayed has been minutely examined and shown to be without any substance. There remain the suggestions of whether this might have been a staged accident, but for reasons that I have already explained, it is not open to you to return a verdict of unlawful killing on the part of anyone other than the driver of the Mercedes or the following vehicles or both together. Consider first whether you are satisfied so that you are sure that there was gross negligence on the part of the driver of the Mercedes or the following vehicles or both and that it caused the death of the deceased. If you are not so satisfied, you must go on to consider whether you are satisfied on balance of probabilities of accidental death. In considering each of these possible verdicts, you will consider the evidence that this was a staged accident. f that or anything else results in your not being satisfied to the relevant standard of proof of any of the other verdicts, you will return an open verdict. With each verdict, whether unlawful killing, accident or open, it must be the verdict of all 11 of you As I mentioned to you at the start, you are to complete one inquisition form for Dodi and one for Diana. You should write the verdict in section 4 of the inquisition form on the second page. So you may be sure that you get the wording of each verdict exactly right, they are listed in paragraph 1 of your handout of legal directions. The narrative conclusion goes in section 3 of each inquisition form. If you look at the box on page 1 of each form, you will see the introductory passage beginning either "Dodi" or "Diana". After the introductory passage, you will write in as many or as few as you wish of the five causes listed in 1 to 5 at paragraph 19 of your handout of legal directions, on the last page of that. If you now look at the top of page 2 of the inquisition form, you will see the sentence beginning, "In addition ..." After that sentence, you will write in as many or as few as you wish of the causes listed at 1 to 3 of paragraph 20 of your handout on legal directions. Please use the form of words in the legal directions. That form of words has been carefully composed so as to be as informative as possible while avoiding any risk of the rules being infringed. Any narrative conclusion you come to, as with your verdict, should likewise be the conclusion of you all. It is for you to decide which, if any, of the causes I have provided you wish to add to your narrative conclusion. Will you please now retire to consider your verdicts? There is no pressure of time. Take as long as is necessary. If your deliberations are still continuing at 4.15 today or on any other day or there abouts, I shall adjourn for the day, you will go home and we will resume at 10 o'clock on the following day. I am told that I said something which was a slip of the tongue which ought to be corrected and Mr Burnett will now tell you what it is. MR BURNETT: Sir, my microphones don't appear to be working. Sir, you said "Professor Treasure agrees with Professor Pavie ..." --
LORD JUSTICE SCOTT BAKER: It should be "disagrees". MR BURNETT: It should be, which I hope was obvious from what followed. LORD JUSTICE SCOTT BAKER: Thank you. So can the jury bailiffs now please be sworn? Jury bailiffs (sworn) LORD JUSTICE SCOTT BAKER: Mr Burnett, there is one point that occurs to me. Of course the jury are being provided throughout with the Live Note transcript. It will take a little time for this morning's Live Note to be transcribed and no doubt that can be taken to the jury room and handed in at the appropriate time?
MR BURNETT: I am sure everyone would agree with that. Yes, lots of nodding. LORD JUSTICE SCOTT BAKER: Thank you. (11.57 am) (Jury out) LORD JUSTICE SCOTT BAKER: I shall not take a verdict between 1 and 2 on this or any other day, if that is convenient for everyone to know that (11.58 am) (Adjourned for deliberations)"
A decade or so ago it would not have possible to have read not only the summoning up, but all the detailed examinations of witnesses and their statements together with explanatory information about the British system of Inquests. Because of eh development of the internet and the use of electronic recording and transmission anyone, anyone anywhere in the world can have access www.scottbaker-inquests.gov.uk/ There is a notice which explains that it is possible to do what I have done, that is reproduce what was said or part of what was said in its sectional entirety as long as appropriate attribution is made. Because all the information available at the Inquests is available it is in appropriate to make a secondary judgement without having digested all the information. It is possible for the parties involved to have questioned the verdict if for example it was felt the Coroner in summing up had omitted some relevant information or appeared to unfairly slant comments although it is significant that at the outset of the summing up the point was made that the jury had to adhere without deviation to the interpretation of the law but it was for them individually and then collectively to determine the judgement to be made on the evidence. The role of the Coroner in this respect was to help the Jury form their evaluation and conclusions and to test out their findings in the form required by the law.
I have no doubt that there will those in many countries, especially those who have already published work on the deaths who will have already commenced the work of reviewing the "evidence of their previous inquiries and the inquiries of others with that available and come to different conclusions or raised unanswered questions. There have been similar inquiries or events where inquiries have not settled the issues. The most famous in my lifetime was the assassination of President Kennedy, The circumstances of the death of Marilyn Monroe was another. The most expensive and longest enquiry is that into the events in Northern Ireland, known as Bloody Sunday. I have no doubt there will be similar expenditure in time and money, and controversy over the decision to go to War in Iraq.
My interest in this level if enquiry first occurred twenty five years ago when on the advice of the Department of Health I was invited to participate in a judicial led inquiry into the role of health and social services authorities and of others including the police, following the accidental but horrific death of a child who had been in care on several occasions and was under the supervision of the authorities. I was originally advised that the hearing of evidence would last four weeks after which I would be involved in the preparation of the report the report which was to be published. In fact the hearings lasted three months with a break of two weeks in between and I ended up drafting what became the majority report. There were some fifty members of the legal profession in attendance for the public opening of the inquiry, although the rest of the hearing of witnesses was closed as were their statements. The jury in the Diana and Dodi Inquest had 30 lever arch files of evidence and transcript and I ended up with a dozen without the transcripts which I have always regretted not getting a copy, and was the reasons why I supported the presentation of in effect two reports, that of the Chairman of the Panel which was based on both the transcripts and the written statements and records and the majority report which was based primarily on statements and other documentation.
The inquiry came about after a photograph and other information was leaked to the media and concerns were raised about the role of the statutory agencies before and after the conviction and imprisonment of the mother of the deceased child and two other surviving children. The media interest was heightened because the senior police officer involved in the case had received the George Medal for the Balcombe Street siege and was widely believed to have been responsible for confidential information making its way to the media. Such was the prior interest in the inquiry that Panorama had asked for access to the inquiry in order to undertake a programme once the findings were made public. This was of one of several lessons I learnt as consequence of my involvement in this inquiry. How the inquiry comes about and the involvement of the media beforehand can govern the terms of reference, the form of the inquiry, the selection of inquiry members and in turn the nature of the report and its findings.
This was not the first such inquiry of its kind as there has been several since the creation of Social Services Departments a decade beforehand. My selection as a panel member to represent Social Service expertise was a surprise to me and to others although by then the number of Directors of Social Services who had been qualified and experienced child care officers, with experience in senior management had reduced considerably, but because of my background and my writings I was a controversial figure and it was five years since I been active in national activities of the profession at any level. The department of Health would have known of the attention I paid to the published reports of other inquiries which I always reported to the Social Services Committee with and Ministerial or Department guidance in relation to recommendations. Such inquiries into individual case were always accompanied by recommendations of a general nature to which the government would formally respond and provide child care authorities and bodies with guidance as a consequence. I was also known to have been opposed to the development of generic social work and the abolition of specialist child care workers, and to having persuaded my local authority to begin the move back to create specialist practitioners and specialist managers within the umbrella of a social services department. I also had come to prominence because of a defence of the role of practitioners and critical of the media and others who rushed to judgement without the benefit of all the facts and an understanding of the complexity of individual situations.
Beforehand I obtained a list of all the inquiries which had taken place over the previous twenty years and then written for a copy of the reports and recommendations in so far these were sill available. Something I kept up over the next decade only to conclude that general recommendations were of little value in preventing further tragedies. However I was new to the process and quickly discovered that the approach varied according to the form of inquiry and the extent of legal involvement, In the instance of my involvement each of the main interests was represented by a QC which usually meant that a junior counsel was also used together with the instructing solicitor and their team. Even where a solicitor represented an interest such as the British Association of Social Workers, there would be at least an assistant. Although the chairman of the inquiry was a Recorder, a kind of junior judge, the inquiry panel had its own legal team comprising a QC, instructing solicitor and team. A solicitor to day will charge £100-£150 an hour, I would estimate at least £1000 a day and barristers and leading Counsel several times this amount depending on their experience and standing. I was paid a fee in addition to my normal salary plus expenses for accommodation food and travel other than that directly provided, so that a civic car met me at the station each morning to the civic centre where the hearings were held and then returned to the station each evening and a cooked meal was provided at lunch times. The fee was set at the commencement and was an overall sum rather than per day. Which applied to the lawyers. I would set the alarm for six and usually went to bed at midnight during week days. Over the first few weeks I travelled home from London on Fridays evenings and travelled down by early train on Monday mornings but it soon became evident that that in order to keep on top of the situation it was necessary to travel homeward on Saturday mornings and return late Sundays evenings as I needed to make notes, establish my own handwritten card database and prepare interrogations. This was a situation which no one could have foreseen because of what happened early on.
It is not generally understood that before such enquiries take place, as with criminal and other trials where there is to be oral evidence and interrogations, there is much planning and preparatory meetings including a formal meeting between all the legal representatives involved. This will cover the witnesses to be called and arranging their availability, and then some order for the various parties to be able to question. Thus in my involvement instance a list of witnesses was prepared by the Counsel for the Inquiry in consultation with the other interested parties, based on the witness statements and submitted documentation such the various records of the Local Authority, Health Visiting, Hospital attendance, involvement of the Police, other agencies. Such witnesses are often grouped to cover a particular aspect of the matters for example there were neighbours who had complained about the care of the children, and foster parents with whom they had been placed. It was therefore important to try and build up a chronological sequence of events over the period under review as well as of the various interests. My involvement was in days before the personal word processing computer so my recording tools were a manual portable typewriter and handwritten notes key dates, people and other information cards and which I had to transport with me together with what became a dozen lever arch boxed files of copies of the available records. Every witness was asked to submit a written settlement of their involvement together with their written record. In our instance as in the Diana and Dodi Inquest we were significantly handicapped by the refusal of the most important party to attend the hearing and be questioned. and by the disappearance of the official departmental record for the period which that individual had been responsible. Amazingly no one in the local authority subsequently tried to reassemble the information, reflecting the inadequacy of the professional training of the workers who were subsequently appointed to work with the family and the limitations of the management to the highest levels. Just before the tragedy occurred a health visitor had taken upon herself to try and assemble background information, and the then current social worker also decided it would be advantageous to do so. It was only consequently to the tragedy that a full search was made of all records to see if the file had been misplaced within the system. Two such searches were made and the failure to find the file can only indicate one thing. It was removed without approval from the premises of the local authority and one must assume subsequently destroyed. However even when the tragedy occurred, the criminal trial and then the inquiry was held the local authority failed to do all that it could within its power to re-assemble the missing record. It was possible to identify several foster parents who had looked after the children and they provided important information, but there was a gap and it was only during the proceedings when a senior officer of the department was being questioned about the lost file and attempts to retrieve, that it struck me that no reference was being made to the register of boarding out required by the boarding out regulations of 1948. This meant that there were at least three separate sources with a department of the history of the children when in the care of the local authority. There was the case file held by the social worker allocated responsibility for the family and which should have been examined by the supervising officer from time to time to ensure that statutory required visits and records were being maintained. There would be a file on each foster parent, on the enquiries made for their approval and on each child placed with them including the period of placement. But there was a third record where every child placed in a foster home had to be recorded in chronological order with the dates of placements and the names and address of the foster parents. It was evident under my questioning that the senior officer who did not have a child care background was unaware of this requirement and it appeared that this record had not been examined when reassembling a record for the Inquiry. Within a matter of hours the record was checked and two further foster parent placements were found. The foster parents were only two willing to given evidence and they had been surprised at not being contacted before and what they had to say was of significance.
A second aspect of the need to know something about how inquiries are organised and their limitations concerns the law and why I have reservations about inquiries which are exclusively legal processes and where the involvement of a jury is crucial and should not be set aside lightly. A central issue in the inquiry where I was a member was the law on child care and where more than one social service interest drew attention to the legal duty of officers to do all that was possible to prevent children entering and remaining in public care or appearing before the courts. One barrister made much of this to the extent that I felt obliged to intervene, in a room filled with lawyers, I enquired if the lawyer was suggesting that this law had greater weight over the duty of officers under the law to protect children from physical violence and other forms of abuse. The lawyer explained that it was her function to represent the interests of her client in the best way possible, This is also a point which the Coroner made when advising the jury about the weight to given to the representations by the lawyers on behalf the parties and the weight to be given to the expert witnesses and to others. This is not just a question of people not telling the truth but of slanting things in favour of one interest or viewpoint and away from another. A classical example of this was the subsequent admission, later denied and qualified by the former Butler of Princess Diana that he had not told the whole truth and had introduced a red herring or two. In the Princess Diana and Dodi Al Fayed Inquest the legal representations appeared balanced whereas in the inquiry where I was a panel member the legal representation was unbalanced because all the statutory bodies and their officers had legal representation whereas the foster parents and the neighbours who had complained or expressed concern about the welfare of safety of all the children were not represented. Counsel for the inquiry could have expected to have undertaken this role but was prevented from doing so after two of the professional experts on the panel supported by the Department of Health representative indicated that they were unwilling to proceed because they had understood the inquiry was to be more inquisitorial and significantly adversarial and objected strongly to the approach of Counsel for the Inquiry, threatening to resign. As a compromise the approach adopted was for one member of the panel to lead the interrogation of a witness, with other panel members and the Chairman being able to follow up with supplementary questions, then the legal representative for the witness and then the other legal representatives in the order which has previously been agreed and then the Counsel for the enquiry. Thus far from shortening proceedings they were lengthened as understandably the representatives for the witness and the others went through a questioning process whether we had covered the same subjects or issues beforehand.
I have mentioned these things because the chairman and Counsel for the enquiry and I came to very different conclusion about the role of the social services department and their officers in the case yet we sat through the same oral testimony and had access to the same written statements and records. This was the point of the Coroner when he advised the jury about their role in relation to the evidence submitted to them and the basis of coming to a judgement. The judgement of only one individual may be right, especially if they have had years of experience in the process but the judgement of a collective jury is safer despite all the likely prejudices and lack of experience in such matters. In the case of my involvement I was convinced that there has been errors in the judgements of social services workers because of their lack of specialist child care training and of child care law, and in good social work practice because they had never understood the importance of keeping accurate records and studying such records or of achieving the right balance between the need to try and keep children out of care and to protect them from harm, and of listening and giving priority to what children have to say about their lives and wishes and what those who know them also have to say, their families, their teachers and in the case in question the succession of foster parents who cared for them. However I suspect the biggest failure and on whom the burden of responsibility was likely to fall was on the individual who had been responsible, whose record of work was not available and who had refused to be questioned. On the basis of the hard information available there had been opportunity after opportunity to have protected the child who had experienced a horrible death and all those involved across the board had failed to see sign after sign. When it was evident from the conclusions of the draft report prepared by the Chairman and the Counsel for the Inquiry that my judgement was not shared I decided not to sign the report and wrote to Chairman and my colleagues to this effect, saying that I would simply indicate if required to the media that I disagreed but would make not separate comment. My two other colleagues then advised that they shared my reservations and asked that I set down my different understanding from the draft report submitted to us. I carefully considered the implications of this because I was back doing my paid job, I was concerned about the time and expense of the enquiry to that date and the implications of undertaking the additional work which would be involved. I decided first to review the written statements and records and then take a decision about oral transcript and having undertaken the task I realised that that the evidence for my conclusions was overwhelming and that there were about one hundred matters on which to base the conclusions. Each matter was further checked and double checked and then summarised in a schedule which was widely reproduced in national media subsequently and then a report written of some 200 doubled line spaced pages, My colleagues then had opportunity to consider my work and with their copies of the records and the oral testimony transcriptions. We then met and went through the report line by line and it was effectively rewritten to reflect our combined experienced and judgements. The two reports were complimentary as one covered the chronology of events, and a host of important appendices. All the witnesses were identified only by their roles and employers for neighbour 1, foster parent 2. What was presented was a legal viewpoint and a professional assessment covering social work, medicine and nursing. This was to my mind a good outcome which reflected the two processes which had taken place along side each other. My only concern in the subsequently amended minority legal report was that attention was drawn to an issue which in fact demonstrated a lack of thoroughness on the part of those drafting the amendments made after our majority report was submitted and which could be interpreted as an attempt to undermine the thoroughness and integrity of the majority report.. Those concerned has simple not studied the original records carefully enough because they overlooked that although there were two entries by one agency on a particular day, the writing and initials were different and therefore one officer who knew the situation had not returned as everyone came to believe including the officer in question.
The media accepted the majority judgements and conclusions there was no legal challenge that our findings should be set aside.
This has become the situation in the Diana and Dodi Inquest. There are always several ways of viewing any event, especially when there has been passage of time. There are always coincidences and individuals and agencies make well intentioned mistakes and errors of judgement and which can appear as pre meditated actions and conspiracies..
It is unlikely that I will ever have the time to read all the evidence of the Inquest to be able to make a substantive judgement on the summing up and Jury findings and therefore I accept them with reservation. The areas I would want to look at is how someone who was not a chauffer came to be driving that night and more about his work for the French secret service and if he was the only one of the 600 employees at the hotel who passed on information. I would want to know more about the search for the vehicle which collided with the Mercedes in the underpass. I would want to know a lot more about why the cameras inside the underpass were not working and what disciplinary action was taken against those who either switched them off or did not immediately arrange their maintenance when a fault occurred . I would also want to know why the movements of the Princess were not kept under surveillance as she had made herself into the number one target in the world for every dangerous crackpot and where the task of an assassination was made that much easier by being surrounded by the media day and night and where she would remain the mother of the future monarch whatever her own status had become. In my view it was negligent of the British Government not to maintain discrete surveillance as it does with former Prime Minister's and the like and to enlist the assistance of other governments when she was abroad. The other aspects which I would want to explore further except that I know there are no answers is the role of the other surveillance and intelligences services which come under the umbrella of the state including the use of freelancers for ad hoc and otherwise illegal operations. Recently I reviewed my experience of the film about the life of a senator who arranged the deployment of arms to the Afghans to fight the Russians, via an international arms dealer and a special disguised government fund which grew from a few million dollars to half a billion arranged with the help of one CIA operative and one powerful wife of an influential multi millionaire. This was all fact and not fiction. .And you mean to try and persuade me that the British do not have similar capacity? Governments although the Judiciary and police know better, like to kid us that decisions are always made after careful thought and the best advice available and in the national interest when they after often based on personal interests and inclinations and often have to made quickly without the time to consider all the available information and opinions. The extremes of good and bad decision taking were witnessed this evening in two TV programmes
The first was a documentary on the history of the aircraft carrier and the latest construction techniques which reduce the time to build from one to three years by constructing in sections and assembling. I had no idea that the first carrier which pioneered take off was developed by the USA and that the problems of landing were solved by the British with their Ark Royal, or that the latest craft do not have to be refuelled for twenty years, with only two nuclear reactors required and have become a town of 6000. There is no room for error in the work whether the crew person who fires the aircraft launching system which can get planes in the air every 20 seconds, to the cooks providing three meals a day every day without food poisoning, and to those who must try and maintain the morale of the whole team for the months spent away from families and other friends. No doubt the psychological profiling will be top notch as one individual going off he rails could destroy us all.
A different level of complexity, this time a fictional one, was the first two parter in the new Waking the Dead series. It was the story of three young women who came together at a Kaddafi Terrorist camp two decades ago and who form a mutual help cell, one from the IRA, one for ETA and one a Muslim fundamentalist. One comes to the attention of the Waking the Dead Team when is identified through DNA as having been present at unsolved murder fifteen years or so before when she becomes the mystery woman in as drama caught by CCTV at a railway station. A youth attempt to steal the bag of one of her daughters at a railway station and in preventing him from doing so he falls on to the line and is electrocuted but she gives mouth to mouth and resuscitates him.
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We learn that woman who met her husband when a waitress in France and had a daughter by a previous relationship has lived a quite life as a mother of two children, having trained and worked as a nurse, suddenly takes flight when news of the incident and station CCTV is shown on the national telly and CNN news where the footage is also seen by the former IRA member of the cell who comes in search with murderous intentions. She, the IRA member worked closely with ETA for a time believes that a bombing was intervened because of leak and assumed it was her Some time after the ETA lady whose function was in the style of Marta Hari receives a summons to assist their Muslim Fundamentalist friend. The reason of the call is to hand over a tape explaining why she is about to blow up herself and a plane together with her baby daughter who will get her on to the flight but instead the ETA lady shoots the Fundamentalist and brings up the baby as her own having realised she was not a terrorist and wished to change her life and could not accept the death of the child and those on the plane. She is helped by a poor specimen of humanity, an Algerian who combined a career exploiting women with that of a transport driver for the Kaddafi centre and becoming a CIA informant. He was responsible for the original leak which first killed an associated of the IRA cell member and then he had attempted to get rid of the body of the Fundamentalist shot by the ETA lady, When the ETA woman tries to run to France with her daughters and finds the authorities have sealed the exits she turns to the Algerian who runs a lap dancing club in London for help but he betrays her whereabouts to the IRA pursuer not realising that she had her children at the hotel and that they are soon in the hands of the IRA lady who demands to see her former ETA comrade at club, bringing the eldest daughter strapped with explosives as a protection. Being fiction the truth is established, the daughters are saved, there is not further killing and life goes on. Being fiction the young man who tried to steal the bag and whose life the ETA lady saved, was the estranged son of the head of the Waking the Dead team and alas when father decides to make one more attempt to communicate with the loving son he once had, he finds the young man has discharged himself and disappeared. What made this particular programme special was the quality and believability of the acting and the script and communicated the reality that terrorists are you and me pushed too far, but have to be dealt with as well as the causes of genuine grievances addressed.
And so as I have said many times now and will continue say what we do and say lives with us for eternity and there is always a price to be paid for everything by others if not by you
