1
 1
 2
 3
 4
 5
 6                       - - - - - - - - - -
 7
 8
 9                 PUBLIC INQUIRY INTO THE DEATH OF
10                          ROBERT HAMILL
11
12                       - - - - - - - - - -
13
14
15                             Held at:
16                            Interpoint
17                        20-24 York Street
18                             Belfast
19
20                 on Wednesday, 14th January 2009
21                     commencing at 12.00 noon
22
23                              Day 2
24
25
     1
 1                                   Wednesday, 14th January 2009
 2   (12.00 noon)
 3   Extracts of medical witness statements and post mortem read
 4                         by MR UNDERWOOD
 5   MR UNDERWOOD:  Good morning, sir, I was addressing you
 6       yesterday on the medical questions.  What I was
 7       proposing to do was read some materials created by
 8       Professor Crane, Dr Herron and Dr Lawler.
 9           Had we not been running so ahead of schedule,
10       I would have called those learned gentlemen before
11       reading on, but what I propose to do instead is read
12       some of their materials so as to make sense of what
13       I will then propose to read, which is a series of
14       witness statements from other doctors.
15           May I start with the post mortem report of
16       Professor Crane, which one finds at page [00954].
17       I hope I will be forgiven for not referring explicitly
18       to a great deal of this, but, rather, to go to the
19       conclusions which one finds starting at page [00959].
20       Perhaps we could highlight everything from "Commentary"
21       down.  Thank you.
22           "This young man died in hospital eleven days after he
23       had been assaulted.
24           "Death was as a result of the head injuries which he
25       had sustained.  Externally his injuries appeared
     2
 1       trivial; there was a small area of abrasion on the left
 2       side of the forehead, a bruise on the upper eyelid of
 3       the left eye and a small spot of abrasion close to the
 4       left nostril.  Even internally, the injuries did not
 5       seem particularly severe, with only two areas of
 6       bruising on each side of the undersurface of the scalp
 7       and a small almost hairline fracture in the front part
 8       of the skull running into the roof of the left eye
 9       socket.
10           "Detailed examination of the brain, however, and in
11       particular its microscopic examination, revealed
12       widespread damage within its substance of a type known
13       as diffuse axonal injury.  This condition, most
14       frequently encountered in acceleration/deceleration
15       injury as a result of road traffic accidents, is also
16       well recognised as occurring as the result of repeated
17       blows to the head such as by punching or kicking and
18       this would seem the most likely mechanism of injury in
19       this case.  It was ultimately the effects of the brain
20       injury which were eventually responsible for his death
21       in hospital.
22           "He had also sustained some other injuries, although
23       none of these were serious enough to have played any
24       part in his death.  There was a fading bruise on the
25       front of the abdomen and some further bruising in the
     3
 1       muscles of the abdominal wall, which could have been due
 2       to blows during the assault.  There were numerous
 3       bruises on the left upper limb, particularly on the
 4       forearm and hand, which could have been sustained if the
 5       arm was struck whilst raised in a defensive gesture.
 6       A few further bruises were located on the right upper
 7       limb, but some of these were probably related to
 8       injections given whilst in hospital.  A fairly large
 9       area of bruising overlying the right side of the pelvis
10       was due to blunt force and might have been caused by
11       a kick."
12           Then going over the page, if we may, to [00960],
13       and, again, could we highlight all of it, please:
14           "The autopsy also revealed some changes in the lungs
15       caused in part probably by a period of assisted
16       ventilation and also by the terminal aspiration of
17       stomach contents, but these findings are unlikely to
18       have contributed to or accelerated death.
19           "In view of the lapse of time between the assault
20       and his death, an analysis for the presence of alcohol
21       was not carried out following the autopsy.  On his
22       initial admission to hospital, however, an analysis
23       carried out at that time revealed an alcohol
24       concentration of 221 mg per 100 ml.
25           "Such a level would leave no doubt that he was
     4
 1       moderately intoxicated at the time of the incident.
 2       Also, it is well recognised that alcohol intoxication
 3       exacerbates the effects of head injuries and may well
 4       have played a part in the fatal outcome in this case."
 5           So there we have the post mortem analysis revealed
 6       as it was by November 1997.
 7           If we move on then to material produced by
 8       Dr Herron, we see at page [31395] some notes.  As I have
 9       said, he is a neuropathologist.  Professor Crane asked
10       him to examine sections of the brain and advise
11       Professor Crane.
12           These are notes which bear two dates.  If we look
13       over on page [31396] briefly, one sees two dates,
14       7th August 1997 and 29th October 1997.  Dr Herron will
15       be asked to explain the distinction between those two
16       dates and their importance.
17           Going back over to [31395] if we could magnify under
18       "Histology", please, the lower half of the page:
19           "Histology.
20           "Sections were taken from the right and left frontal
21       lobes, corpus callosum, left and right hippocampi,
22       hypothalamus, cerebellum, midbrain and pons.
23           "Frontal lobe: examination of the sections from the
24       right and left frontal lobes shows the presence of white
25       matter contusions.  This is associated with tissue
     5
 1       necrosis and macrophage reaction.  Surrounding this
 2       there is extensive diffuse axonal damage.  There
 3       is no evidence of hypoxic/ischaemic necrosis of the
 4       adjacent cortex.  There is no meningoencephalitis.
 5           "Corpus callosum: examination shows diffuse axonal
 6       damage.
 7           "Left internal capsule: examination shows extensive
 8       diffuse axonal damage.
 9           "Hypothalamus: examination shows no evidence of
10       haemorrhagic necrosis.  There is, however, axonal damage
11       in the hypothalamic region."
12           Then if we go over the page, [31396] and if all of
13       it can be highlighted, please:
14           "Mid-brain: examination shows diffuse axonal damage.
15       There is no secondary brain stem haemorrhage.  The
16       substantia nigra shows no evidence of degenerative
17       change.
18           "Pons: examination shows the features of severe
19       diffuse axonal damage.
20           "Cerebellum: examination shows no evidence of
21       cortical necrosis.  The Purkinje cells are preserved.
22       A small gliotic scar is present in the white matter.
23           "Immunohistochemistry for neurofilament protein
24       and for the myelin stain LFB/H&E confirms the
25       distribution and severity of diffuse axonal damage.
     6
 1           "Comment:
 2           "In summary, the predominant finding in this case is
 3       the severe diffuse axonal damage.  Diffuse axonal damage
 4       is thought to be due to interruption of movement of
 5       cytoplasm through axons, with subsequent accumulation of
 6       axonal material seen on H&E examination as small
 7       eosinophilic bulbs.  In this case, it was distributed
 8       throughout the deep white matter, corpus callosum and
 9       brain stem.  This pattern of damage is consistent with
10       being caused by trauma.  It is indicative of a severe
11       head injury."
12           So that was, as it were, the intricate finding upon
13       which Professor Crane based his conclusions as to the
14       cause of death.
15           As I said yesterday, the Inquiry thought it best not
16       left there, bearing in mind the degree of contention
17       there had been about this, and so instructed Dr Lawler.
18           What I would like to do now is take you to three
19       reports of his.  As I say, I am going to call, in due
20       course, Professor Crane, Dr Herron and Dr Lawler.
21           If we go to page [72226], one sees Dr Lawler's
22       initial opinion.  If I just for the moment pause on the
23       documents that the doctor read, under "Documents":
24           "I have read all the documents provided to me by
25       Ms Fitzmaurice.
     7
 1           "The deceased's medical records
 2           " - Craigavon Area Hospital notes
 3           " - Royal Victoria Hospital, Belfast, notes
 4           " - Neurosurgical Unit notes
 5           " - Coroner's investigation file
 6           "Professor Crane's autopsy report
 7           "The Cory Collusion Inquiry Report
 8           "Transcripts of the evidence given at trial by
 9       Professor Crane"
10           He had also looked at photographs and copies of the
11       slides prepared for Professor Crane.  We will see in due
12       course that he was also informed by what I read out
13       yesterday from Dr Helen Reid, who herself looked at the
14       slides which had been considered by Dr Herron.
15           If I can take you to page [72238], I will run
16       through quite a lot of this, if I may, because what
17       Dr Lawler carefully does is set out for us in a fairly
18       neat fashion, if I might respectfully say so, all the
19       findings on autopsy.  They go to the degree of physical
20       injury that may or may not have had anything to do with
21       the head injuries, but which may assist you, of course,
22       in determining the assault or what happened during the
23       assault.
24           So picking it up at "Injuries sustained on
25       27.04.97":
     8
 1           "I must confess that I find determination of the
 2       injuries sustained by the deceased on 27.04.97 much
 3       more difficult than I had anticipated.  This is,
 4       I think, partly due to the inadequacy of the clinical
 5       and the nursing notes made on 27.04.97, and partly due
 6       to the duration of survival of eleven days before death,
 7       with the consequent modifications, by healing, of the
 8       injuries.
 9           "Perhaps I could address each body area in turn, and
10       try to draw some reasonable conclusions:-
11           "(a) SIDES OF THE HEAD.
12           "Clearly there was a bruise on each side."
13           I need to say I think no more than that in that
14       paragraph.  If I go down to the next paragraph:
15           "These presumably represent at least one blunt force
16       impact to each side, and more than one impact may well
17       have been involved; I would have thought that punches,
18       kicks and/or stamps are likely to have been responsible.
19           "I note referenceS in the Nursing Notes to
20       an abrasion on the left side.  This suggests possible
21       contact with a rough surface (eg the roadway) and
22       I therefore wonder whether the left side of the
23       deceased's head was in contact with the roadway when the
24       injury to the right side of his head was inflicted."
25           Going over the page, [72239] under (b), "BACK OF THE HEAD":
 2           "At one point, this was described as a 'small wound
 3       approximately 1 cm long occiput'."
 4           Going down two paragraphs:
 5           "The Cory Report refers to 'blood on the collar and
 6       back of Robert Hamill's jacket'", it gives a page
 7       reference, "and the forensic scientist that worked on the
 8       case noted that the back and collar of Robert Hamill's
 9       jacket was 'extensively bloodstained'.  The presence of
10       an open wound in the area of the back of the deceased's
11       head could, I am sure, explain the source of some, if
12       not all, of the blood responsible for this
13       blood staining."
14           If I go down to (c), "LEFT EYE":
15           "The autopsy photographs clearly show bruising into
16       the left upper eyelid and there may also be some more
17       extensive, local, fading and diffusing bruising."
18           Over the page, [72240], (d), "IMPACT WITH THE ROADWAY?":
19           "There is a constellation of four findings in this
20       case, all of which, in my opinion, could have resulted
21       from a forceful impact with the roadway - as in, for
22       example, a fall over backwards following a punch or
23       a push.  Two of these have been considered above, but
24       there are two others; these four are:-
25           "(i).  Occipital scalp injury.  There is no doubt
    10
 1       that the injury to the back of the head, considered under
 2       (b) above, could have resulted from an impact with the
 3       roadway.
 4           "(ii).  Left orbital roof fracture.  It is very well
 5       recognised that fractures of the orbital roof, where the
 6       bone is very thin, can be caused indirectly by forces
 7       transmitted from an occipital impact (ie a contre-coup
 8       phenomenon).  This possibility in this case would
 9       certainly explain the location of the fracture and also
10       why, as pointed out in evidence by Professor Crane at
11       trial, 'it didn't relate to bruising of the scalp'."
12           If I then go down to (iii), "Left eyelid bruising":
13           "It is also very well described that eyelid bruising
14       may not result from a direct blow into the eye socket
15       but that it may follow percolation of blood into the
16       orbit from a fracture of the orbital roof."
17           If I go down to (iv), "Bilateral frontal lobe
18       contusions":
19           "Although no contusions were seen on either of the
20       CT scans taken during life or macroscopically at
21       autopsy, and although no contusions were identified
22       histologically by Dr Reid, Professor Crane's report
23       clearly states, 'examination of the sections from the
24       right and left frontal lobes showed the presence of
25       white matter contusions'.  If present, these must surely
    11
 1       represent a contre-coup phenomenon and thus provide
 2       support for a significant fall backwards."
 3           Over the page at [72241] under (e), "Brain":
 4           "It is Dr Reid's assessment that the major
 5       neuropathological finding was one of traumatic diffuse
 6       axonal injury (TDAI), although she adds that, in her opinion, it
 7       was not severe.
 8           "TDAI represents direct traumatic damage to the
 9       brain as a consequence of shearing or twisting forces.
10       These forces are often complex and involve acceleration,
11       deceleration, rotation and, sometimes, shaking.
12       Consequently, whilst TDAI often results from road
13       traffic incidents, it is well recognised to occur during
14       assaults, particularly when the head is subjected to
15       repeated kicking, punching or stamping.
16           "In this case, therefore, I have no doubt that the
17       deceased's TDAI must have been caused during the assault
18       shortly after 01.20 or so on 27.04.97.  Furthermore,
19       I think that the identification of significant, even if
20       not severe, TDAI must reflect the severity of that
21       assault."
22           If I go down to (f), "Abdominal wall":
23           "I think that there are several bruises on the left
24       side externally and Professor Crane documented one
25       internally on the right side.  I can not imagine that
    12
 1       these were caused during the deceased's stay in
 2       hospital; I therefore think they represent areas of
 3       blunt force impact and I would suggest that they are
 4       likely to have been caused by punching and kicking.
 5       Clearly, the amount of force involved must have been
 6       sufficient to produce the bruising", overleaf, [72242],
 7       "but was obviously insufficient to cause damage to any
 8       of the intraperitoneal contents."
 9           Going down to (h), "Right buttock and thigh":
10           "I can not imagine that this bruising was related to
11       treatment, and I therefore think that it reflects trauma.
12       Its appearance on photograph 14 suggests that it
13       resulted from the partial coalescence of several smaller
14       bruises, and these could have been caused by punching,
15       kicking and/or stamping."
16           Starting at the bottom of the page is
17       a paragraph headed "Cause of death", but if I pick it up
18       over the page, [72243]:
19           "... the immediate cause for the deceased's death
20       was the Neuroleptic Malignant Syndrome.
21           "This is a rare, and probably the most serious,
22       complication of neuroleptic medication and it has been
23       reported following treatment with Chlorpromazine.
24           "Criteria for making the diagnosis of NMS seem to
25       vary somewhat between papers, but the major findings
    13
 1       seem to include:-
 2           "Fever, particularly over 38.5 Centigrade.
 3           "Neurological features, eg rigidity, dysphagia,
 4       tremor", etc.
 5           "Autonomic instability, eg hypertension, hypotension
 6       tachycardia", etc.
 7           "Laboratory abnormalities, eg elevated CK levels"
 8       and others.
 9           "Absence of other identifiable physical illness.
10           "In this particular case, I would point to the
11       following findings documented over the last 24 hours or
12       so of the deceased's life:-
13           "Marked fever -- 'over 40 degrees Centigrade' and
14       '42 degrees Centigrade' were mentioned;
15           "Autonomic problems -- hypertension, hypotension,
16       tachycardia, tachypnoea and sweating;
17           "Significantly elevated serum creatinine kinase
18       enzyme" -- that's CK -- "concentration;
19           "Elevated serum aspartate aminotransferase enzyme (AST) concentration;
20           "Possible mild/early renal function impairment;
21           "No other explanation for these findings ..."
22           If we go over the page to [72244] under the heading
23       "Causation":
24           "In my opinion, there is an unequivocal and
25       incontrovertible, direct cause and effect relationship
    14
 1       between the assault on 27.04.97 and the deceased's
 2       death on 08.05.97.
 3           "I believe that the sequence of events can be
 4       summarised as follows:
 5           "ASSAULT causing significant and permanent traumatic
 6       diffuse axonal injury and temporary unconsciousness;
 7       this necessitated:
 8           "ADMISSION TO HOSPITAL, where treatment included:
 9           "ADMINISTRATION OF CHLORPROMAZINE.  Although I am
10       not a clinician, the prescribing of chlorpromazine in
11       this case seems to be perfectly reasonable, given the
12       agitation, the restlessness and the apparent lack of
13       cooperation documented in the notes.  This caused:
14           "DEVELOPMENT OF THE NEUROLEPTIC MALIGNANT SYNDROME.
15       This is a well recognised but very rare complication of
16       treatment with chlorpromazine and other similar drugs.
17       This then caused:
18           "DEATH."
19           That's all I want to take from that.  If I then go
20       to Dr Lawler's next document prepared for the Inquiry,
21       that's at page [72270].  What Dr Lawler very kindly did
22       here was a glossary of terms referred to both in his and
23       others' reports.  I point it out rather than intend to
24       refer to very much of it.  For example, I pick up two of
25       his explanations.  On that page we see "Chlorpromazine".
    15
 1       Perhaps we can highlight it:
 2           "This is a drug (major trade name Largactil) ... and
 3       it is used largely as a neuroleptic, ie to treat various
 4       psychiatric conditions or states, including
 5       schizophrenia, paranoid psychosis, mania, anxiety,
 6       agitation and violent or dangerously impulsive
 7       behaviour."
 8           I should, of course, say there is no suggestion of
 9       any of those on the part of Mr Hamill.  It was obviously
10       used because he was unconscious and thrashing about
11           Can we then go, please, to page [72272]?  The final
12       paragraph of that page, "Hypoxic/Ischaemic Changes", if
13       we can highlight that:
14           "By definition, hypoxia is the inadequacy of oxygen
15       supply to organs or tissues; in contrast ischaemia
16       represents inadequacy of blood supply to the relevant
17       area.  In practice, both often occur simultaneously at
18       least to a greater or lesser extent, eg during
19       cardio-respiratory arrest, where failure of respiration
20       causes hypoxia and cessation of the heart produces
21       ischaemia."
22           Finally in this document if we went to page [72274],
23       neuroleptic malignant syndrome is there referred to
24       again.  This probably does not add anything to the
25       substance of the report, but nonetheless:
    16
 1           "This is a rare but potentially very serious and
 2       sometimes fatal reaction to antipsychotic drugs,
 3       especially phenothiazines in general and chlorpromazine
 4       (please see above) in particular.  It is described in
 5       detail in my report... and it may be associated with many of
 6       the features defined and discussed in this list."
 7           Then if I briefly go to page [72278], Dr Lawler has
 8       also appended here a diagram of a skull with labelling
 9       of some of the regions for those of us who are not
10       familiar with these medical terms
11           Then can I move, please, to the third of Dr Lawler's
12       documents, which we find at page [72809]?  What has
13       happened by this stage is that the Inquiry had
14       interviewed Professor Crane and Dr Herron.  For the
15       purposes of the hearing what will happen is that you
16       will see witness statements which have been put together
17       from those transcripts and will have been signed off by
18       Professor Crane and Dr Herron and they will be asked
19       about them.  What generated the document we are looking
20       at instantly is that the transcripts of those interviews
21       were sent to Dr Lawler for him to comment on to see what
22       differences there were between him and the other experts
23           If I pick this up at the final paragraph.  Perhaps
24       we could highlight that, please:
25           "In the light of my reading not only of the
    17
 1       neuropathology report by Dr Reid but also of the
 2       transcripts of the evidence given by Professor Crane and
 3       Dr Herron, I think that the absolutely fundamental
 4       point, and one on which we are all agreed, is that the
 5       major cause for the deceased's cerebral damage following
 6       the incident at approximately 01.30 on 27.04.97 was
 7       Traumatic Diffuse Axonal Injury, and that there was only
 8       a mild and", over the page [72810], "insignificant
 9       degree of hypoxic/ischaemic damage present.  In other
10       words, it must have been the assault in its entirety
11       (and this would be with or without any associated fall
12       to the ground) which was responsible for his ultimately
13       fatal head injury (whatever the terminal mechanism), and
14       it therefore follows that any possible delay in the
15       provision of first aid at the scene neither contributed
16       significantly to, nor exacerbated, this traumatic damage.
17       The inevitable conclusion from this, therefore, is that
18       the outcome would have been the same, even if the
19       deceased had been given first aid immediately after the
20       assault."
21           There you have then encapsulated in those documents
22       the areas of agreement and disagreement between these
23       eminent gentlemen, which, of course, you will hear more
24       about when I ask them questions over the next day or
25       two, but I hope that gives some context to what I am
    18
 1       about to read, which is the witness statements of
 2       various of the clinicians who I hope I said yesterday
 3       are regarded as important, but not controversial.  Hence
 4       they can be read
 5           With that introduction, I will read, first, the
 6       statement of Dr Gormley.  This is at page [80327].  What
 7       I am proposing to do with these is simply highlight
 8       areas of them which I hope will be of assistance to the
 9       Panel.  If anybody else wants me to read any other part,
10       then, of course, I am happy to do so.
11           This is the statement of William Paul Gormley.  If
12       we go to paragraph 2 of it, perhaps I could highlight
13       that:
14           "I am a Consultant Anaesthetist at the Mater
15       Hospital in Belfast.  On the night of 26/27 April 1997
16       I was the Senior Registrar on call for anaesthetics at
17       the Craigavon Area Hospital (CAH).  My role was to
18       provide emergency anaesthetic cover for general surgery,
19       an epidural service for maternity and cover for patients
20       in intensive care, including resuscitations, as well as
21       to be on call for the Accident and Emergency Unit (A&E) for any emergencies.
22           "3.  I commenced my shift at around 1300 on 26
23       April 1997 and I worked through until 0900 on 27
24       April.  I cannot recall what time I was called to attend
25       to Mr Hamill in A&E.  It would have been somewhere
    19
 1       between 0200 and 0400 but I have not recorded the time
 2       in my notes.  I was called to assess a person admitted
 3       with head injuries.  I may have been given other
 4       information at that stage but I cannot remember it now.
 5       I cannot recall who called me down but I assume it would
 6       have been the Senior House Officer (SHO) in A&E."
 7           If we go over the page, [80328], and highlight
 8       paragraph 6, please:
 9           "I can recall there being blood on Mr Hamill's face
10       but I cannot recall if he was actually bleeding or how
11       much blood there was.  The document headed 'Nursing Care
12       Plan' which commences at page 38665 is a form that
13       I assume a member of the nursing staff completed, rather
14       than a doctor.  I have not made any entries on that
15       document but I note it mentions that Mr Hamill had blood
16       on his face.  The phrase 'bloody + + head + face'
17       indicates that his head and face were very bloody.  The
18       plus signs indicate the amount of blood present.  I do
19       not know who made that entry or any other entry on that
20       document, including the note 'attacked by group, hit on
21       head by ?? bottle'.  I do not recall whether Mr Hamill
22       had any injuries to indicate that he had been hit on the
23       head with a bottle or a sharp instrument."
24           That's all I can I think usefully derive from that
25       witness statement.  You will be hearing, as I said
    20
 1       yesterday, from two of the nurses, who I hope can give
 2       evidence about that nursing care plan and those entries.
 3           Then we go to the statement of Dr Lavery.  That's to
 4       be found at page [80633].  Again I will take selected
 5       passages from this, if I may.  It is the statement of
 6       Gavin Lavery.  If I pick it up at paragraph 3.
 7       Highlight that and paragraph 4, please:
 8           "In April 1997 I worked in the same department as
 9       I do now at the Royal Victoria Hospital and I was
10       a Consultant in intensive care and anaesthesia.  Along
11       with my colleagues, I was responsible for providing the
12       senior medical input into the care of patients in the
13       intensive care unit (ICU).  I was not directly involved in the
14       care of Robert Hamill until 29 April 1997, the day on
15       which he was transferred from the ICU to the
16       Neurosurgical Unit.
17           "The clinical notes contained at page 38599 show
18       that Mr Hamill arrived at the hospital by ambulance at
19       0630 on 27 April 1997, having been transferred from Craigavon
20       Area Hospital."
21           If we go over the page, please, [80634],
22       paragraph 6:
23           "I would have become the doctor in charge of
24       Mr Hamill's care in the ICU at around 0800 to 0900 on
25       29 April 1997 and I would have stayed in charge until
    21
 1       he was transferred to the Neurosurgical Unit at 1300
 2       that day.  I was only responsible for his care in the
 3       ICU.  From the notes I can see that the Consultant
 4       neurosurgeon in charge of Mr Hamill's care on 29 April 1997
 5       was Mr Tom Fannin.  This is confirmed by Mr Fannin's
 6       final summary letter which is contained at pages 38772
 7       [onwards]."
 8           Then over the page [80635], paragraph 13:
 9           "A CT scan was undertaken on Mr Hamill's brain and
10       Mr Fannin's comments are recorded in the notes contained
11       at page 38551: 'CT scan of the brain which shows soft
12       tissue swelling in the scalp over the left temporal
13       parietal region and also over the right temporal
14       occipital region'.  In other words, Mr Hamill had very
15       obvious bruising in two separate areas of his head which
16       was outside his skull.  It is almost certain that there
17       was a bruise or possibly a haematoma on his left temple
18       parietal (above the left ear) and the right temple
19       occipital (behind the right ear)."
20             Over the page, [80636], he says:
21           "However, although the scan showed physical injury
22       to his head in terms of bruising and swelling, and
23       probably bleeding under the scalp on both sides, the
24       scan did not show any evidence of any physical injury to
25       the brain."
    22
 1           Again that's all I seek to get from that statement.
 2           If we go then to the statement of Mr Fannin, who is
 3       at page [80245], this is the statement of
 4       Thomas Francis Fannin.  If I pick it up at paragraph 2:
 5           "In April 1997 I was Senior Consultant Neurosurgeon
 6       in the Regional Neurosurgical Unit at the Royal Victoria
 7       Hospital (RVH) in Belfast.  I retired in April 2000.  On
 8       27th April 1997 I was the Consultant Neurosurgeon on call at
 9       RVH and any cases admitted in that 24-hour period would
10       have been under my care.
11           "3.  After Mr Hamill's death I prepared a 'Final
12       Comment', which is dated 14th May 1997 and is contained
13       at pages 38551 to 38552."
14           We saw that yesterday:
15           "I later gave a statement to the police
16       investigating the death of Robert Hamill which is dated
17       11th July 1997 and is contained at page 09205.
18           "4.  Robert Hamill arrived at RVH by ambulance at
19       0630 on 27th April 1997, having been transferred from
20       Craigavon Area Hospital (CAH).  This arrival time is stated in
21       my Final Comment ... and in the clinical notes."
22           If we go over the page, [80246], paragraphs 9 and
23       10:
24           "I would normally have got in at around 8.15am and
25       I assume I saw Mr Hamill for the first time shortly
    23
 1       thereafter.  I say this is an assumption because I have
 2       not got a written note of exactly when I saw Mr Hamill
 3       and I cannot now recall the time.  After that I would
 4       have seen Mr Hamill at least once a day and possibly
 5       more frequently as I used to walk through the ward
 6       regularly.
 7           "In my police statement I said, 'We were given to
 8       understand that he had been hit by a bottle and put on
 9       the ground and immediately rendered unconscious'."
10           Over the page [80247]:
11           "This information may have come from the CAH notes
12       at page 38669 and 38670 or it may have been passed on to
13       me verbally."
14           Again that's something which we will ask the two
15       ladies who were nursing at the time.
16           "12.  When I first saw Mr Hamill he was deeply
17       unconscious.  He would have been chemically paralysed
18       and sedated, and on a ventilator.  I do not recall
19       whether he had any open wounds or a wound to the back of
20       head and none is recorded in the notes.  I have read in
21       the notes that Mr Hamill had a bruise on the left
22       temporal region, although I did not record this.  I have
23       also seen the reference in [other] notes at page 38601
24       to there being a scalp haematoma, but I cannot recall
25       this either.
    24
 1           "14.  My view after I initially examined Mr Hamill
 2       on 27th April was that he had a closed head injury, as
 3       a result of which he was deeply unconscious.  The
 4       results of the CT scan, combined with my overall
 5       impression of that type of injury, led me to think that
 6       whilst Mr Hamill was still deeply unconscious, he did
 7       not have a major head injury.  We felt that he would
 8       probably start to wake up over a period of days."
 9           Then if I go to page [80251] finally on this,
10       paragraphs 29 through to the end:
11           "I prepared the discharge summary, which is purely
12       for the hospital records.  The information recorded on
13       it reflects the suspicion we had that the cerebral
14       hypoxia had made the head injury worse, and that
15       a widespread blood infection or septicaemia had caused
16       his sudden collapse.  We did not know why he had
17       deteriorated so suddenly ten days after his injury and
18       this seemed a reasonable theory as to the cause of death
19       at the time.
20           "31.  I have seen the autopsy report of
21       Professor Crane which concludes that cause of death is
22       a diffuse axonal injury and I would entirely agree with
23       him.  Diffuse axonal injury is a perfectly acceptable
24       diagnosis."
25           That's all I seek to derive from that statement.
    25
 1           We then go to Dr McCann, whose statement is at
 2       page [80821].  He is John Patrick McCann.  At
 3       paragraph 2:
 4           "In April 1997 I was a consultant in rehabilitation
 5       medicine at the Royal Victoria Hospital.  My department
 6       is responsible for assessing patients' rehabilitation
 7       needs.  I had a regular commitment to the neurosurgical
 8       unit dealing with people who had suffered head injury or
 9       other causes of acquired brain injury.  I first became
10       involved in the care of Robert Hamill on 5 May 1997.
11       I don't recall who requested that I see Mr Hamill, but
12       at that time we had a routine whereby any patient
13       admitted with a head injury would have been seen by me.
14       Sometimes I would have learned of their admission by
15       memo or word of mouth from medical or nursing staff or
16       I may have asked whether there were any new patients
17       with head injury."
18           If we go down to paragraph 4:
19           "With regard to Mr Hamill, having checked over my
20       notes, I can see that it was a Bank Holiday and I was on
21       call.  I went in and made an assessment of him, reviewed
22       his notes and looked to see the nature of injury and
23       then briefly assessed to see whether anything specific
24       required in a rehabilitation context at that stage.
25       I only saw him the once."
    26
 1           Over the page, [80822], paragraphs 5 and 6:
 2           "I think I would have been told that he had been
 3       assaulted but I can't recall whether I was given any
 4       detailed information.  I did, however, examine Mr Hamill
 5       and can see from my notes (page 38608) and recorded that
 6       he was 9 days post injury.  He was sedated on the basis
 7       of possible cerebral irritation secondary to hypoxia;
 8       that his Glasgow Coma Scale is 6, ie he remained deeply
 9       unconscious, and that he did not show any evidence of
10       spasticity or rigidity and was non-responsive.
11       Therefore, there was no indication that I needed to treat
12       at that stage but I would reassess.  He would have been
13       receiving physiotherapy provided through the
14       neurosurgical unit.
15           "6.  When I examined him, I would have recorded any
16       open injuries if I had seen any, but would not have
17       recorded bruising."
18           Then if we go to the statement of Dr Patel, which is
19       at page [81076], it is Umang Jashbai Patel.
20       Paragraphs 2 and 3:
21           "In April 1997 I was a Specialist Registrar in
22       Neurosurgery at the Royal Victoria Hospital and had been
23       for 16 months.  I am not certain but I assume that
24       I first became involved in the care of Robert Hamill on
25       5 May 1997 when I returned from holiday, which was
    27
 1       a Monday. [...]
 2           "3.  The procedure for admitting a patient to the
 3       neurosurgery ward was that we would get a phone call
 4       from a peripheral hospital about a trauma case which had
 5       been admitted to A&E or any other case.  If the doctors
 6       felt that they required neurosurgical advice or
 7       assessment they rang the neurosurgeons.  The
 8       neurosurgeons would accordingly advise, get scans, see
 9       the scans, and advise, keep the patient there, treat
10       as such or bring the patient across or whatever was
11       needed.  In the case of Robert Hamill the doctors had
12       decided that he was comatose, had to be ventilated and
13       they needed to do a brain scan.  I understand that in
14       Craigavon Area Hospital the scanner was not working so
15       they had to get him transferred to Royal Victoria, for
16       scanning and to manage his head injury.  Patients are
17       usually consulted with neurosurgeons first, accepted by
18       neurosurgeons, but the point where they arrive depends
19       on whether they", over the page, [81077], "come
20       ventilated or not ventilated."
21           All I need to do is pick up paragraph 5, if I may:
22           "In respect of physical injuries I do not recall if
23       there was a scalp haematoma.  If I attended to Robert
24       Hamill, it would have been so far down the line
25       I wouldn't be looking for a scalp haematoma unless there
    28
 1       was a problem with it, for example, if it was bleeding
 2       or infected."
 3           That's all I get from that statement.
 4           If we go then to Dr Sloan found at page [81171],
 5       this is Samantha Anne Sloan.  We see from paragraph 3,
 6       although we don't need to highlight it, that in April
 7       1997 she was the senior house officer attached to the
 8       neurosurgery unit at the Royal Victoria Hospital.
 9           If I go to page [81180], can I highlight
10       paragraph 45, please?
11           "I am told that Mr Patel said the following in his
12       interview for the Inquiry, 'When Robert Hamill was
13       admitted he had a minor head injury and was hypoxic at
14       the scene of the assault.  He was initially treated for
15       a minor head injury with hypoxic damage'.  I would agree
16       that we were managing a man with a head injury, but
17       I would probably disagree with the terminology 'minor'.
18       This is because Mr Hamill was admitted with a Glasgow
19       Coma Scale of 4 and that indicates to me that his head
20       injury was more severe than minor.  Mr Patel may have
21       said minor because the CT scan did not show any evidence
22       of a blood clot or contusion."
23           Then Dr Gray, whose statement is at page [80337].
24       If I can pick up paragraphs 2 to 4, please.  This is
25       William John Gray:
    29
 1           "In April 1997 I was a consultant neurosurgeon at
 2       the Royal Victoria Hospital.  I continue to hold that
 3       post.  I have no recollection of being involved in the
 4       care of Robert Hamill, but looking at the medical
 5       records it would appear that I was present at the time
 6       of his death."
 7           If we go to paragraph 4:
 8           "I have looked today at the autopsy report and all
 9       I can say is that I do not have any disagreements with
10       Professor Crane's conclusion.  My view from a casual
11       review of the notes, copies of which I received today,
12       is that Mr Hamill died from the effects of a brain
13       injury.  I'm afraid there is nothing further I can
14       add."
15           Finally in reading these statements I go to that of
16       Dr Unni, who we find at page [81224].  If I can pick up
17       paragraphs 1 to 3.  Paragraph 2:
18           "In April 1997 I was a consultant anaesthetist at
19       the Royal Victoria Hospital.  I worked mostly with
20       neurological patients, so technically I was
21       a neuro-anaesthetist.
22           "3.  I first became involved in the care of
23       Robert Hamill shortly before he died on 8 May 1997.
24       I take this from the notes, as I do not recall
25       specifically treating this patient."
    30
 1           Those are the statements I wanted to read to you.
 2       They vary, of course, in the weight that they may carry.
 3           What I am quite keen to impress is that every care
 4       has been taken to interview anybody who was involved in
 5       the care of Mr Hamill to discern whether there is any
 6       useful evidence that can possibly be gleaned about the
 7       assault itself and about the actual cause of death after
 8       his admission to hospital.
 9           As I say, in the light of all that and in the light
10       also of the specific instructions given to independent
11       experts, we have a limited range of people to call.
12           As I have repeatedly said now I think, I am
13       proposing to call Professor Crane, Dr Herron and
14       Dr Lawler, all of whom are slated for tomorrow onwards.
15           We have one other doctor, Dr Low, who has very
16       kindly rescheduled himself from tomorrow to today, for
17       which I am extremely grateful.  He is going to attend at
18       2 o'clock.
19           We will also again, as I have repeatedly said,
20       endeavour to call the two nurses this week -- that's
21       Maureen Millar and Maureen Hagan -- to give evidence
22       about what they saw and recorded and indeed heard about
23       the nature of the assault when Mr Hamill was admitted to
24       hospital initially.
25           With that, may I invite you, unless there is
    31
 1       anything else I can help with, to rise at this stage so
 2       that we can reconvene at 2 o'clock with Dr Low?
 3   THE CHAIRMAN:  Yes.  2 o'clock.
 4   (12.55 pm)
 5                    (The luncheon adjournment)
 6   (2.00 pm)
 7   MR UNDERWOOD:  I am very sorry for the delay, sir.  Can
 8       I call Dr Low, please?
 9   THE CHAIRMAN:  Yes.
10                     DR BOON KEE LOW (called)
11   THE CHAIRMAN:  Dr Low, I gather you have had to rearrange
12       your schedule for today in order to come unexpectedly
13       and you have come virtually straight from the hospital
14       theatre.
15   DR LOW:  No, I was not in theatre.  I was transferring
16       a patient.
17   THE CHAIRMAN:  I see.  We are grateful to you for putting
18       yourself at our service.
19   MR UNDERWOOD:  Could Dr Low be given the oath, please?
20                     DR BOON KEE LOW (sworn)
21                   Examination by MR UNDERWOOD
22   MR UNDERWOOD:  Doctor, can you give us your full name,
23       please?
24   A.  My name is Boon Kee Low, L-O-W.
25   Q.  Your professional address?
    32
 1   A.  Lagan Valley Hospital.
 2   Q.  Thank you very much.
 3           In front of you there is a screen and on it in
 4       a moment you will see page [80691].  I am going to ask
 5       for that document to be scrolled through fairly slowly.
 6       Is that the witness statement you signed for the Inquiry
 7       on page [80699]?
 8   A.  That's correct.
 9   Q.  Is that accurate?
10   A.  Yes.
11   Q.  Thank you.  I want to ask you some specific matters.
12       About that.  Perhaps we could go back to page [80691],
13       please.
14           In paragraphs 2 and 3, we see from paragraph 2:
15           "On the night of 26/27 April I was the Senior House
16       Officer on duty at the A&E department at Craigavon Area
17       Hospital."
18           Is that correct?
19   A.  That's correct.
20   Q.  You say there you were the only doctor on duty at A&E
21       that night.  Are you clear about that?
22   A.  Within A&E, yes.
23   Q.  Again, I think you there say you don't recall whether it
24       was a busy night or not?
25   A.  I wouldn't recall that, no.
    33
 1   Q.  You refer in paragraph 3 to some notes which are at
 2       page [38677].  You signed them.  Can we have a look at
 3       [38677], please?
 4           I think we are going to have to enlarge this part by
 5       part.  We see these are notes for Robert Hamill.  Before
 6       we enlarge any part of it, can I ask you: what is this
 7       form?
 8   A.  This is the A&E notes and it is written by myself for
 9       Mr Robert Hamill.
10   Q.  How does one of these forms come about?  Do you walk
11       around armed with blank forms or does somebody give you
12       a form before you see the patient, or what?
13   A.  Generally what happens, when a patient comes to A&E
14       department they are registered by the reception staff in
15       the computer.  Then this is generated.
16           So I gather in Mr Hamill's case the reception must
17       have got the history and the details from somebody,
18       I presume the ambulance, because this patient was
19       brought in by the ambulance.
20   Q.  Then how does it come to you?
21   A.  What normally happens in most patients is that the
22       patient is seen by the triage nurse first.  The triage
23       nurse's job is to quickly identify if there are any
24       worrying features in a clinical state, usually based on
25       the history and physiological scoring.  Then he is
    34
 1       assigned to which triage category.
 2           However, in this case, I think it was obvious to the
 3       ambulance he was in serious distress and he was, I am
 4       sure, probably brought straight to a resuscitation room
 5       so he would simultaneously be seen by myself, the
 6       nurses, as well as the reception staff getting details
 7       as well.
 8   Q.  Can we go down this form, as it were, block by block?
 9       If we pick up and magnify the first part, which has,
10       "Name: Hamill, Robert", on it, we see the name.  The
11       part that has been blanked out, of course, is the
12       address.  We have a date of birth, the GP's name and
13       address there, the age, sex, occupation and telephone
14       number.  Then:
15           "Initiator: brought by ambulance.
16           "Arrival: brought by ambulance."
17           So that would all have been completed by the time
18       you saw Mr Hamill, would it?
19   A.  Not necessarily.  As I say, in an emergency situation
20       like that, quite often it goes on simultaneously, so it
21       is possible I could have seen the patient first before
22       the note was generated.
23   Q.  Then, if we go back and highlight the next block,
24       "History", can you help us with, in the first place, who
25       wrote any part of that?
    35
 1   A.  That's my writing.
 2   Q.  Okay.  Can you decipher it for us, please?  That was not
 3       meant to be rude.
 4   A.  This is the bit about history:
 5           "Assaulted?", which is a query.  "Hit on left side
 6       of head with bottle", that bit I think is, "allegedly by
 7       9 people."
 8   Q.  Could it be "attacked"?
 9   A.  "Attacked".  Sorry.  You are right.
10   Q.  Could you help us with where you would have got that
11       history from?
12   A.  I think Mr Hamill came in and his GCS was 5, so it is
13       obviously not from himself.  It could be from the notes
14       that's written by the ambulance.  It could be from being
15       told by the ambulance during handover or it is possible
16       it could be from the nurse as well.  It is not specific
17       where that came from.
18   Q.  Going back to the picture you painted for us a moment
19       ago, that where somebody comes in urgently, as it were,
20       and comes to see you very urgently, and perhaps this
21       form has not yet been created, would there have been any
22       other piece of paper created, a triage form, for
23       example?
24   A.  Yes.  The triage nurse -- I can't remember how
25       specifically it is done in Craigavon Hospital at that
    36
 1       time --
 2   Q.  Okay.
 3   A.  -- but certainly the nurses do make a note in the sheet
 4       as well, and in most departments it is the same sheet
 5       itself attached together, but I am not sure specifically
 6       at that time what happened in Craigavon.
 7   Q.  Fair enough.  Towards the bottom of that page we have
 8       enlarged:
 9           "... pupils size 3".
10           Is that your writing?
11   A.  No, I believe that would be a nurse writing.
12   Q.  Can we go back and move down to the examination part,
13       please?  Is this your writing?
14   A.  Some of it is.  The pulse of 100, that's not my writing.
15       "BP of 160/103."  There would be a nurse writing as
16       well.  I am not sure what the squiggle is with the
17       GCS --
18   Q.  Okay.  Can you --
19   A.  -- but the rest of that --
20   Q.  Sorry.  Go on.
21   A.  The small writing would be mine.
22   Q.  Although it is not your writing, can you just help us
23       with what the significance is of pulse of 100 and blood
24       pressure of 160/103?
25   A.  The normal pulse rate for an adult, a 25 year old, would
    37
 1       be between 60 and 100.  In fact, a resting pulse would
 2       be somewhere in the region of 80, 90.  100 would be in
 3       the high side and basically shows there is a bit of
 4       tachycardia, as we call it.  The pulse was up for
 5       whatever reason.
 6           The blood pressure is raised as well, 160/103.
 7       Usually what happens is, if you do lose a lot of blood,
 8       initially you may have a slight -- I will say that
 9       again.
10           If you lose some blood, or there is fear, anxiety,
11       you might increase your blood pressure.  As you lose
12       some blood, perhaps maybe a litre or so, you can
13       maintain your systolic pressure, which is your 160.
14       Your diastolic may even go up as the body compensates
15       for it by squeezing the artery -- the vessels, but your
16       pulse can go up as well in that case.
17           So, in essence, that blood pressure is slightly on
18       the high side, but it doesn't speak anything in
19       particular.
20           Now, there is also -- what I look out for is if the
21       blood pressure is high and the pulse is very low, there
22       is a certain reflex that you can follow if there are
23       signs of raised pressure in the brain.  Obviously this
24       is not the case, because the pulse is not low.
25   Q.  Right.  If we can then go on to the -- sorry.
    38
 1       I shouldn't have said that.
 2           Still in this part, moving to the part of it that
 3       was your handwriting, again, can you help us with what
 4       you have written there?
 5   A.  Yes.  The first bit says:
 6           "Unresponsive.
 7           "Airway: breathing with upper airway obstruction.
 8       Will not open jaw to introduce Guedel airway.
 9           "02 saturation 75%.  [Patient was] bagged.  No open
10       injury.  Abdomen soft.  No limb fractures.
11           "Pupils equal and reacting.
12           "Plantars both downwards reacting.
13           "Left knee reflexes decreased."
14           It is very poor for a copy of that.  Below that is
15       "areas", "breathing" -- it must be "circulation stable".
16   Q.  Again, can I get you to help us with the meaning of some
17       of these things?
18   A.  Sure.
19   Q.  Where you say:
20           "Upper airway obstruction.  Will not open jaw."
21           Is that the same thing?  Has he got an obstruction
22       which is, in fact, that he wouldn't open his jaw, or
23       were they two separate things?
24   A.  What happens is that, to assess upper airway
25       obstruction, the first sign of it is obviously you can
    39
 1       hear sounds, a bit like snoring.  So there are signs of
 2       upper airway obstruction.  I felt in this patient there
 3       were signs of upper airway obstruction.  The next thing
 4       I did was try to open his airway -- open his mouth to
 5       put what we call a Guedel airway to try to lift out the
 6       tongue, because quite often it is the tongue that falls
 7       down and obstructs the upper airway.
 8   Q.  The oxygenation of 75 --
 9   A.  Uh-huh.
10   Q.  -- can you tell us the significance of that?
11   A.  Well, I mean, anyone with oxygen saturation of 75%,
12       that's very low.  Normal person's oxygen saturation
13       is -- well, it is 95% to 100%.
14           For example, patients with COPDI, people who have
15       chronic lung disease and are very used to a low level of
16       oxygen, you know, about 88%, 89%, 90%.  75%, if anybody
17       has oxygen of 75%, they would be very, very -- well,
18       they wouldn't be conscious, would they?  So something is
19       very wrong there.
20   Q.  Is that associated with airway obstruction?
21   A.  I believe so, yes.
22   Q.  By "bagged", I think you explain in your witness
23       statement at a later point that this is a bag over to
24       introduce oxygen?
25   A.  Yes.  We put a mask over the face and then this mask is
    40
 1       attached to a bag which is filled with an oxygen
 2       reservoir.  Then we squeeze the bag to blow the oxygen
 3       into the lungs to try to bypass the airway.
 4   Q.  Can I ask how the degree of saturation, the 75%, for
 5       example, that we have measured here is actually
 6       measured?
 7   A.  That's measured on the 02 saturation probe, which is
 8       a probe which is put on the finger usually.
 9   Q.  Then if we could move further down the page, please,
10       under "Investigation", you have got, I think, the
11       remains of the Glasgow Coma Score figuring --
12   A.  Yes.
13   Q.  -- 5/15.  I know you have dealt with this in your
14       statement.  Can you just help us on that?
15   A.  Normal person's GCS score is 15/15.  Anybody who is --
16       has a GCS of less than 8 is considered quite obtunded
17       and certainly at risk of losing the airway.
18           When you have a GCS of 5, it is basically
19       semi-comatose.  The patient would not be responding.  It
20       is made up of three elements: the GCS, the eye opening,
21       verbal and motor response.
22           Essentially, the eye opening is 1 out of -- is 1,
23       which is -- basically, his eyes are closed and he is not
24       doing anything.  Verbal is also 1, which means he is not
25       making any sound at all even to any stimulus.  I think
    41
 1       the "M" is the motor response, which is 3, which is
 2       essentially making abnormal flexion posturing whenever
 3       he has been stimulated.
 4   Q.  Sorry.  I should have asked you before.  We need not go
 5       back to it.  You explained that under the examination
 6       part you also put "no open injury".
 7   A.  Uh-huh.
 8   Q.  The Inquiry may need to consider at some point whether
 9       there was a head injury that was open from which
10       Mr Hamill was bleeding at some point.
11   A.  Uh-huh.
12   Q.  Can you help us with how you would have dealt with that?
13       If, for example, he had been presented to you with
14       either fresh bleeding from the scalp or there had been
15       bleeding which had recently ceased --
16   A.  Okay.
17   Q.  -- would you have noted that?
18   A.  Yes.  If there was bleeding from the scalp to cause --
19       enough anyway to cause him to be -- what we call
20       haemorrhagic shock, then there would have to be a huge
21       amount of bleeding and there would have been --
22       obviously have been blood elsewhere.
23           There may be a small little contusion, as you call
24       it here, or abrasion on the scalp.  I wouldn't call
25       those open wounds.  They certainly would not bleed
    42
 1       enough.  Bruising, contusion to the scalp itself, you
 2       cannot really lose enough blood in the scalp itself to
 3       cause you to go into haemorrhagic shock.
 4   Q.  All I am interested in at the moment is how significant
 5       an open injury must have been for you to have noted it
 6       at a time like this.
 7           It would have to be very significant, would it?
 8   A.  It would have to be, yes, blood and a cut obviously.
 9   Q.  I understand.  Then under investigation on the
10       right-hand side you have a signature which you say in
11       your statement is yours.  That's true, is it?
12   A.  On this beside the time of 0215?
13   Q.  Yes.
14   A.  Yes.  That's mine.
15   Q.  Help us with the time relative to you seeing and giving
16       your diagnosis and setting out treatment and management.
17       When would you sign off and time one of these forms?
18   A.  Signing and putting the time, that would be the time
19       whenever I have written the top bit.  I have seen the
20       patient, examined the patient and started the
21       preliminary investigation and that's when I would time
22       that.
23   Q.  Okay.  It is difficult to know now at this stage of the
24       Inquiry how significant timings in hospital may turn out
25       to be.  Let me see if I can --
    43
 1   A.  There is a time at the top of that sheet which is stated
 2       time of arrival.  That's 0206.  I presume that's the
 3       time whenever he is booked into the computer, which
 4       should be very close to the time when he actually
 5       arrived in the department.
 6   Q.  So is this fair, that assuming he arrived at 0206, and
 7       assuming your watch was accurate when you noted the 2.15
 8       time, in that time he had been dealt with in triage?
 9       You have seen him, investigated, given your provisional
10       diagnosis, set out the treatment and management and then
11       gone to write up the form.  Is that right?
12   A.  Yes.  I mean, he -- when I say it is very close to the
13       time, it is possible in nine minutes I could have made
14       that assessment, written it and timed it, because,
15       I mean, there is really no time spent getting the
16       history from the patient, because that's not available.
17       The writing doesn't take a huge amount of writing.  It
18       is quite obvious that the problem was airway and that's
19       the one I was trying to resolve --
20   Q.  So be it.
21   A.  -- at that time.
22   Q.  Finally on this form, under the "Treatment/Management"
23       heading, is that your writing?
24   A.  Yes.
25   Q.  Can you help us with what it says?
    44
 1   A.  "Cervical collar.
 2           "Anaesthetist for intubation.
 3           "Brown Venflon", which is a large IV cannula.
 4   Q.  Was the cervical collar precautionary or did you have
 5       reason to believe there might be a neck injury?
 6   A.  This is a patient who is unconscious with some injury to
 7       the brain.  You always have to be cautious about the
 8       neck.  That's what has been taught to us in BTLS
 9       courses.
10   Q.  Very well.  Can we then go back to your statement at
11       page [80693], please?  In paragraph 9, if I could
12       highlight that, please, you say:
13           "I gave a statement to the police investigating the
14       attack on Mr Hamill which is ... contained at page 673."
15           In that statement you added you attended to somebody
16       we now call D who had a scalp laceration and a small cut
17       in his scalp.
18           Referring to your notes, you see you have noted in
19       the first part of your history that he had been walking
20       down the road, etc.  I want to take you to those notes,
21       if I may --
22   A.  Okay.
23   Q.  -- which we see at page [38950].  A similar form.  We
24       know that D went in the same ambulance or we believe D
25       went in the same ambulance as Mr Hamill to the Craigavon
    45
 1       Area Hospital.
 2           If we look at this, and again, if we can pick up
 3       down to the second line, the second break, here we have
 4       a date and time of arrival of 2.07, so within a minute.
 5           Again, you have age, etc.  Different acuity and
 6       revised acuity to Mr Hamill.  Perhaps I should have
 7       asked you this on the other form.  What does acuity
 8       signify?
 9   A.  I think that's for the triage, category 1, 2, 3, 4, 5.
10       So that's -- 4 would be not that acute.
11   Q.  Okay.  So if we then look at the next box under
12       "History", please, again, is this your writing?
13   A.  Yes, it is.
14   Q.  Can you help us with what that says?
15   A.  "Had 7 pints beer tonight.
16           "Walking down road with wife.
17           "Attacked by 30 people.
18           "Punched and kicked.
19           "Next thing remembered was in ambulance."
20           According to wife, "Wife: D was unconscious for
21       about 10 minutes."
22   Q.  Does the way you have constructed that help us with who
23       gave you the information contained in the various parts
24       of it?
25   A.  Yes.  I mean, the first bit of it about the pints was,
    46
 1       I presume, from the patient himself and the last bit,
 2       the wife had said that the patient was unconscious for
 3       ten minutes.
 4   Q.  Were you aware that D and Mr Hamill were, as it were,
 5       together?
 6   A.  I mean, I think this was about an hour after the --
 7       after I seen Mr Hamill.
 8   Q.  3.05 we see later further down the form.
 9   A.  Yes.  I certainly was aware it was the same incident,
10       but I am not sure whether they were related or know each
11       other.
12   Q.  All right.  Can I take you further down this page to the
13       examination section, please?
14   A.  Uh-huh.
15   THE CHAIRMAN:  Just before you do, does "acuity" mean
16       general awareness, alertness?
17   A.  No.  That's a triage acuity as in how serious the
18       patient potentially is.  It is the job of the triage
19       nurse to assess the severity of the patients as they
20       present.  Those with the highest acuity, it would be 1.
21       That basically means they need to be seen immediately.
22       I can't remember what Mr Hamill's acuity was.  Was it 1
23       or 2?
24   THE CHAIRMAN:  2.
25   A.  2 would be very high acuity as well.  Certainly the
    47
 1       guideline is seen within ten minutes.
 2   THE CHAIRMAN:  Thank you.
 3   MR UNDERWOOD:  So, looking at the examination, again some
 4       different writing for the pulse, etc.  I will not
 5       trouble you with that.  Is the rest of that your
 6       writing?
 7   A.  Yes.
 8   Q.  Again, can you help us with what that says?
 9   A.  "Alert and orientated.  Glasgow Coma Scale 15/15.
10           "ABC, 3 ticks", which means airway breathing,
11       circulation is fine:
12           "No neurological deficit.
13           "Small laceration in scalp.  Tender plus" -- I think
14       that's "haematoma of scalp".  Then:
15           "Tender right temporal mandibular joint -- teeth..."
16           I can't read that
17   Q.  Don't worry.  If you can't, you can't.
18   A.  "Nose bruised plus.  No tender chest, abdomen, pelvis
19       limbs or back.
20           "Good air entry.  No crepitus or bronchi.  Heart
21       sounds 1 and 2.  No heart sounds, no murmurs.  Abdomen
22       soft, not tender.  Bowel sound is soft."
23   Q.  Very well.
24   A.  Sorry "teeth aligned", I think is what it is.
25   Q.  There may be some question about whether, in the nursing
    48
 1       notes, the notes for Mr Hamill and the notes for D got
 2       confused.  Therefore, I want to ask you about whether
 3       any of this signifies that D was bleeding from the scalp
 4       or might have been bleeding from the scalp.
 5   A.  Well, he has a small laceration on his scalp, so he must
 6       be bleeding if he has a cut.
 7   Q.  If he had been very bloody as a result of that
 8       laceration, would you have had a different entry or
 9       would that have covered it?
10   A.  I think if he was very -- I wouldn't expect a lot -- it
11       is a small laceration of the scalp so it wouldn't be
12       very bloody.
13   Q.  That's helpful.  Thank you.
14   THE CHAIRMAN:  Basing it on what you tell us, by the time
15       you wrote up these notes on D, you had already about
16       three-quarters of an hour before writing up the notes on
17       Robert Hamill?
18   A.  That's right, yes.
19   THE CHAIRMAN:  Each form having the patient's name?
20   A.  Yes.  If I can refer back to Robert Hamill's notes.
21   THE CHAIRMAN:  Please do.
22   A.  Can you put it up on the thing?
23   MR UNDERWOOD:  I am trying to find the page number for you.
24       [38677].
25   A.  Certainly from the history, examination and
    49
 1       investigation, I would have written it at 0215, and if
 2       we go a bit further down, certainly the -- sorry -- yes,
 3       the cervical collar and, if this -- you know, the tick
 4       that is in for intubated would have been after the
 5       patient has been intubated.  So it would be later than
 6       0215 that the tick would go in.  So the 0215 would be
 7       for the first bit.  The bottom bit would be later than
 8       0215.
 9   Q.  So you would have revisited the form after signing it
10       and dating it at that point?
11   A.  Yes.  You could not intubate a patient within
12       nine minutes of arrival.
13   Q.  Very well.  There is one other document I would like you
14       to look at, please.  That is [38673].  It is
15       an emergency telephoned lab report on Mr Hamill.
16   A.  Uh-huh.
17   Q.  We see from the top right-hand corner the date of
18       specimen is 27/4/97.  What I want to highlight, if
19       I may, is the haematology section.
20   A.  Yes.
21   Q.  This tells you that his white cell count was 13.9, his
22       haemoglobin was 16.2.  Platelets were 198.
23           Can you assist us with what that tells us, if
24       anything, about injuries which Mr Hamill sustained?
25   A.  That's basically normal.
    50
 1   Q.  Right.
 2   A.  If you were going to lose a lot of blood, say, for
 3       example, the circulating blood volume is 5 litres.  If
 4       you lose 2 litres of blood -- and really depends -- this
 5       is a concentration, so if you lose 2 litres of blood,
 6       the first thing that happens is you will find there will
 7       be some changes in the blood pressure and pulse and
 8       things.  What we do is we give them the fluid in.
 9           At that stage, you will find that the haemoglobin
10       will drop.  However, in the acute situation, for
11       example, you can lose 2 litres of blood.  If you don't
12       replace the blood, the haemoglobin will still be high
13       like that.
14   Q.  Okay.
15   A.  So it doesn't help you, I am afraid.
16   Q.  So it gives you no assistance?
17   A.  No.
18   Q.  Sir, those are the questions I was proposing to ask the
19       doctor, unless anybody has anything that has emerged
20       from the process over the last three-quarters of
21       an hour.
22   MR ADAIR:  No thank you.
23   MR McGRORY:  No, sir.
24   MS DINSMORE:  No, thank you.
25   MR UNDERWOOD:  Doctor, thank you very much indeed for
    51
 1       coming.
 2   THE CHAIRMAN:  Thank you, Dr Low.
 3   A.  Can I leave?
 4   THE CHAIRMAN:  Yes, of course.
 5   DR LOW:  Thank you.
 6                      (The witness withdrew)
 7   MR UNDERWOOD:  Can I just make good an omission of mine from
 8       this morning?  I was asked, when dealing with the
 9       witness statement that I read of Mr Patel, to take you
10       to some passages and I entirely forgot to do it.  Can I
11       go back to that, please?  The page number that we need
12       is [81081].  What I was asked to take you to is
13       paragraph 20.  I am happy do that now:
14           "I was also asked at the murder trial, 'Was it
15       shortly after 10 past 3 that the alert was raised as to the
16       man's condition?'."
17           This is 8th May 1997:
18           "I replied, 'I think my recollection would be
19       perhaps about 3.30 or something like that when I was
20       first called'.  I was then asked, 'We know that at 10 past 3
21       he had been given 100 mg of chlorpromazine.  Is
22       that correct?'.  I replied, 'That's right'.  I refer
23       to the extract from the transcript of the trial produced
24       and shown to me...  I now know that Robert Hamill was
25       given Chlorpromazine at 3.10 am on 8 May 1997, so some
    52
 1       12 hours before his", over the page [81082], "condition
 2       deteriorated and not half an hour before."
 3           Then he refers back to a drugs chart.  I understand
 4       the purpose of that is just in case, when we hear more
 5       evidence, there is any confusion about the sequence and
 6       timing of the prescription of chlorpromazine.
 7           Sir, that leaves us with the end of the evidence
 8       that's available for today.  What I am proposing to do
 9       next is to call Professor Crane and Dr Herron tomorrow,
10       then Dr Lawler, Miss Hagan and Miss Millar on Friday to
11       conclude the medical evidence.
12           Unless there is anything else I can assist with
13       today, I have no more to present.
14   THE CHAIRMAN:  No.  Thank you.  Yes, Mr ...?
15   MR ADAIR:  No, sir.  I have no ...
16   THE CHAIRMAN:  I thought you were standing up to tell us
17       something.
18   MR ADAIR:  I was getting ready to leave, sir.
19   THE CHAIRMAN:  Just anxious to get away.  Very well.  10.30
20       tomorrow morning.
21   (3.55 pm)
22       (The hearing adjourned until 10.30 tomorrow morning)
23                            --oo0oo--
24
25
    53
 1                            I N D E X
 2
 2   Extracts of medical witness ......................    1
 3             statements and post mortem
 3             read by MR UNDERWOOD
 4
 4   DR BOON KEE LOW (sworn) ..........................   31
 5          Examination by MR UNDERWOOD ...............   31
 5
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