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9 PUBLIC INQUIRY INTO THE DEATH OF
10 ROBERT HAMILL
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13
14
15 Held at:
16 Interpoint
17 20-24 York Street
18 Belfast
19
20 on Friday, 16th January 2009
21 commencing at 10.00 am
22
23 Day 4
24
25
1
1 Friday, 16th January 2009
2 (10.00 am)
3 MR UNDERWOOD: I will call Dr Lawler, if I may.
4 DR WILLIAM LAWLER (sworn)
5 Examination by MR UNDERWOOD
6 MR UNDERWOOD: Doctor, please take a seat.
7 A. Thank you very much indeed, sir.
8 Q. Can you give the Panel your full names, please?
9 A. My full name is William Lawler.
10 Q. Your professional address?
11 A. I work from home and my address is my home address.
12 Q. You need not give us that.
13 A. No, I understand.
14 Q. Can I ask you just to identify the documents you have
15 produced for us, please? On screen, first of all,
16 I would like to see [72226].
17 A. Yes. That is my first report.
18 Q. I think that is your first report.
19 A. It is, sir, yes.
20 Q. Then if we look to page [72270].
21 A. Yes. That is my -- I was asked to produce a glossary of
22 terms and I so did.
23 Q. Thank you very much. Finally, if we go to [72809],
24 please --
25 A. Yes.
2
1 Q. -- that's a further letter, is it?
2 A. It is, yes.
3 Q. Thank you very much. I would like to ask you, please,
4 about the physical injuries that you could establish
5 from the materials you saw. Before I do that, can I ask
6 you something about the time-lapse between the assault
7 and the post mortem and what effect that might have had
8 on the physical science?
9 A. Yes. It is quite obvious that there was a gap of
10 10 or 11 days between the incident, during which the
11 deceased sustained his injuries and his subsequent
12 death. In young individuals like this, the normal
13 reparative processes, the normal healing processes, will
14 continue throughout that time. Therefore, there will
15 always be the body's attempt to heal and, therefore, to
16 remove relatively minor injuries.
17 Indeed, in that length of time, injuries which are
18 perhaps not quite so minor may also have dissipated and
19 may be difficult, if not impossible, to see on external
20 examination.
21 Q. If I were to, for example, take being struck by
22 a cricket ball at some speed, giving you a bruise, how
23 long would you expect the bruise to last?
24 A. Well, I can say from my own personal experience that
25 bruises like that in fit, young, healthy individuals, as
3
1 I once was, would have disappeared within a week.
2 I would be playing cricket the following Saturday and
3 the bruises that I had obtained from playing the
4 previous Saturday would have disappeared or at least
5 they would not have been visible externally.
6 Q. Right. With that context then, can we have a look at
7 your page [72238]?
8 A. Yes.
9 Q. We here see analysis of the injuries as you saw them.
10 Can I highlight the paragraph which starts:
11 "(1). Injuries sustained on 27.04.97".
12 A. Yes.
13 Q. You put in that warning that it was more difficult than
14 you anticipated partly due to the inadequacy of the
15 notes made on 27th April.
16 A. Yes. I think that is a fair use of the word
17 "inadequacy". I know that it implies criticism, but
18 I think you have to bear in mind that people who look at
19 patients who have been admitted unconscious tend to have
20 different priorities than people like me, who look at
21 bodies at a later stage.
22 They are out to treat whatever it was that was
23 responsible for the problems that brought them into
24 hospital in the first instance, and so they may well not
25 describe injuries which they consider to be trivial or
4
1 inconsequential, but which actually may be relevant when
2 trying to interpret the overall context of what may have
3 happened.
4 Q. Thank you. If we go down to, "(a). Sides of the head",
5 you say:
6 "Clearly, there was a bruise on each side", of the
7 head. You get the CT scan.
8 Can you give us some idea of the size and severity
9 of those bruises?
10 A. As far as the size of the bruises is concerned, they
11 were measured by Professor Crane in his autopsy report,
12 and I --
13 Q. In which case, we can find that.
14 A. Yes, they were. One side was larger than the other,
15 but, nevertheless, they clearly reflected the local
16 application of sufficient force to cause bruising and,
17 as I have said somewhere there, there may well have been
18 more than one impact to these areas, bearing in mind
19 that the bruising will start to heal and will start to
20 diffuse, and you can end up with a bruise which looks as
21 if it is a single bruise, but which, in fact, was
22 derived from more than one impact, but it has fused
23 together in the interim.
24 Q. If we go to the third paragraph there:
25 "I note references in the nursing notes to
5
1 an abrasion on the left side. This suggests possible
2 contact with a rough surface ..."
3 Of course, one is doing one's best here with other
4 people's notes a long time after the event, but can you
5 give us any idea how strongly you feel about that
6 possibility?
7 A. It appears that the deceased's head may well have been
8 moving around during the time that he was lying on the
9 ground, and at some stage there has been a graze on the
10 left side, if one accepts what it says in the nursing
11 notes.
12 It doesn't give any clue as to the size of the
13 abrasion and it doesn't give much of a clue as to its
14 exact location. It is actually quite difficult to be
15 sure, therefore, what it is that it has been due to.
16 I have suggested a possibility and I don't think I dare
17 put it any stronger than that, because I don't know the
18 details of the injury other than what I had read, but,
19 under those circumstances, and if I apply my own
20 background experience to cases like this, where one sees
21 bruising on both sides of the head, it is not uncommon
22 for the head to be moving around and at some stage for
23 a blow or a stamp or a kick to be applied with the head
24 on a rough surface.
25 If that causes the head to jar or to move in any
6
1 way, then you may get an abrasion at the site of contact
2 with the roadway. That was what was implicit in what
3 I have written here.
4 Q. Thank you. If we jump to page [72240], you there deal
5 with the question of an impact with the roadway. You
6 say:
7 "There is a constellation of four findings in this
8 case, all of which ... could have resulted from
9 a forceful impact with the roadway - as in, for example,
10 a fall over backwards following a punch or a push."
11 You list them: occipital scalp injury; left orbital
12 roof fracture; left eyelid bruising; and bilateral
13 frontal lobe contusions.
14 Now, I know you have seen the result of those
15 conclusions being put to Professor Crane and his
16 comments on that. Do you stand by those?
17 A. Yes. I think that all of those findings could have
18 occurred in that way. I don't say that they must have
19 occurred. I am suggesting that they could have
20 occurred, because it is a way in which you can explain
21 the various findings, and, in particular, it is a way
22 that you can explain the left orbital roof fracture,
23 which is somewhat difficult to explain in any other way.
24 It is not impossible that it could have been caused
25 in another way, but I think that when you take that into
7
1 the context of the rest of them, then I think that that
2 is a reasonable and realistic possibility to put
3 forward.
4 Q. Again, I press you as hard as I can on this. Can you
5 give us any idea how strongly you feel about that
6 possibility?
7 A. Well, in answer to that question, may I pick up the last
8 point that I have made at the bottom of that page,
9 because I think I have to be fair upon myself.
10 Q. Of course.
11 A. I have said:
12 "I am aware that no deep scalp bruising was found in
13 the occipital region, at autopsy, by Professor Crane."
14 Had he identified deep bruising in this area, then
15 I would have felt much happier and I would have felt
16 more able to be more strong in my suggestion as to this
17 being a reasonable and likely possibility.
18 I am hampered by that negative finding. I don't
19 think that it excludes the possibility at all, but it
20 does make it somewhat less likely than it would have
21 been had that bruising been found.
22 Q. All right. Bearing in mind everything you have seen and
23 read, can you offer a likely scenario for the way in
24 which the injuries which you have seen were sustained?
25 A. I think that we have evidence externally and internally
8
1 of significant blunt force injury to the deceased's
2 head. I have seen cases where there has been far more
3 than there is here. Of course I have, but,
4 nevertheless, there is evidence that there has been
5 significant blunt force trauma.
6 I think that we have to look very closely at the
7 neuropathological findings in this context also, because
8 I think that the extent of the diffuse axonal injury
9 described by all those who have examined the microscope
10 sections from the deceased's brain I think also reflects
11 the fact that there have been multiple impacts to the
12 deceased's head.
13 Q. Right. So it is less than likely then that this was one
14 blow or one accelerated fall. Would that be the
15 consequence of that?
16 A. I think -- I think that's correct. I think that the
17 extent and severity of the diffuse axonal injury
18 described here is extremely unlikely to have arisen
19 simply from a single accelerated fall.
20 Q. Now that we are on the axonal injury question, can I ask
21 you something about the relationship between the
22 location of axonal injury and the extent of the
23 acceleration?
24 I think it is fair to say we had two competing
25 answers from the experts we have heard from so far.
9
1 Professor Crane, when I asked him about this -- I think
2 this is fair -- essentially said he knew of no
3 relationship between the severity of the acceleration
4 and the location of the axonal injury, whilst Dr Herron
5 said, where you find axonal injury deep in the
6 brainstem, that suggests a higher degree of acceleration
7 than if you find it at the higher levels of the brain.
8 Where do you stand on this?
9 A. I think that my understanding is that I would be more
10 supportive of Dr Herron, but I have to say that these
11 are areas to which I defer as far as neuropathologists
12 are concerned. That is their area.
13 That is why, in this particular case, I felt it
14 appropriate to invite the Inquiry to instruct
15 a neuropathologist to review the neuropathology in this
16 case. That's why, when dealing with criminal matters
17 back home, where I do just that, I involve
18 neuropathologists to deal with questions like that.
19 Q. Thank you.
20 We have also heard, particularly from Dr Herron,
21 about there being no explanation for the actual
22 mechanism by which the axonal injury killed Mr Hamill.
23 Have you any explanation for how the axonal injury might
24 actually have led to the death?
25 A. It is my view, and it has been my view all along, that
10
1 I think the mechanism for the deceased's death here was
2 that uncommon entity known as the Neuroleptic Malignant
3 Syndrome. I think it would explain a range of clinical
4 and pathological findings -- I mean laboratory findings,
5 not histopathological or morbid and anatomical
6 laboratory findings -- and I think it would explain the
7 way in which he died when he did.
8 Q. Moving on to that, if Neuroleptic Malignant Syndrome was
9 the actual, eventual cause of the death, I think you say
10 that it is entirely understandable that Chlorpromazine
11 was administered. So there is no suggestion of
12 negligence on the part of the doctors?
13 A. No. Again, I am not a clinician. I understand full
14 well why it was felt appropriate, and indeed necessary,
15 to administer Chlorpromazine in this case, yes.
16 Q. If the Neuroleptic Malignant Syndrome did develop from
17 that administration of Chlorpromazine, how would that
18 have killed Mr Hamill?
19 A. Again, this is an area where this is still subject to
20 some degree of speculation, and it is getting outwith my
21 own field of expertise, but my understanding is that it
22 develops as a so-called idiosyncratic reaction. It is
23 something that a very small number of individuals
24 develop when exposed to these types of drugs. It is not
25 a predictable mechanism. You can't anticipate who is
11
1 going to get it. It affects far less than 1% of people
2 who are given these types of drugs, and it may take
3 a little while for it to develop .
4 Once it develops, it seems somehow to interfere with
5 the normal conduction of impulses between nerves.
6 Dopamine is one of the substances which is involved
7 under these circumstances and there is -- Dopamine
8 blockade is said to be the mechanism together with
9 sympathoadrenal dysfunction.
10 I quote those because I am getting outwith my depth
11 and I am the first one to admit it.
12 Q. We have obviously asked Dr Herron and Professor Crane
13 about NMS. Dr Herron, in particular, said he had some
14 personal experience of treating patients with NMS and
15 that he -- in his experience, the NMS was associated
16 with things like lead pipe rigidity, liver damage,
17 massively elevated CK levels, which, as both he and
18 Professor Crane point out, were not present here.
19 Can you cover an explanation for why those might not
20 have been present in this case?
21 A. Well, I think -- may I invite you to go through them
22 again? I am sorry.
23 Q. Of course.
24 A. The lead pipe rigidity, I think it is worth remembering
25 that the deceased had significant neurological problems
12
1 as a consequence of his diffuse axonal injury. If I can
2 quote -- I know I am quoting from my own report, which
3 in turn is quoting from what the --
4 Q. Is this page 18 of your report?
5 A. Well, I was actually looking at page 6 of my report,
6 which is [72231].
7 Q. Perhaps we could have that up on screen there?
8 A. It is there. Somebody has beaten me to it. The
9 important point --
10 Q. A lot faster than I am.
11 A. Yes, indeed, and me, that's for sure.
12 The important point there is in the centre where
13 I have referred to the clinical assessment of the
14 deceased on the 29th. This is, of course, at
15 a relatively early stage during his hospital stay. The
16 neurological assessment at this stage was severe
17 weakness in arms and mild weakness in legs. In other
18 words, he already had significant neurological problems
19 at that time.
20 Now, if there is the interruption in the normal
21 nerve supply from the brain down to the arms and the
22 legs, it therefore means that, when it comes to
23 developing the Neuroleptic Malignant Syndrome, those
24 connections are still not intact, and so, therefore,
25 I think it reasonable to presume that he will not
13
1 necessarily develop the sorts of problems which
2 characterise the Neuroleptic Malignant Syndrome as far
3 as the rigidity is concerned, because he already has
4 problems within his central nervous system due to his
5 pre-existing, as it is there, traumatic axonal damage.
6 Q. Right.
7 A. As far as the other parameters are concerned, he did
8 have a significantly raised creatinine kinase level. It
9 was about six and a half times the upper level of
10 normality for that particular laboratory. That is
11 significant. I can't think of an alternative
12 explanation for that other than the Neuroleptic
13 Malignant Syndrome.
14 Q. Uh-huh.
15 A. He had one or two other features. He had renal
16 problems. Again, they are seen clinically about
17 24 hours prior to his death. Again -- forgive me for
18 flicking around -- if I were to invite you to go to,
19 first of all, page [72232] --
20 Q. Please?
21 A. -- you will see that the third paragraph under the
22 heading of "07.05.97".
23 Q. Uh-huh.
24 A. You will see that the nursing notes refer to pyrexia.
25 So he is already starting to develop a very abnormal
14
1 high temperature at this stage. Again, I don't think
2 Professor Crane or Dr Herron could offer a reasonable
3 alternative explanation for the high temperature in this
4 case. He is sweating profusely, which is another
5 feature you get in the Neuroleptic Malignant Syndrome.
6 You can see that his urine output was falling and that
7 the ward testing of the urine showed marked proteinuria
8 and a moderate amount of blood.
9 These I think are pointers towards his developing
10 renal function impairment. The proteinuria, or that
11 which he has picked up as proteinuria, a moderate amount
12 of blood, may well be from the damage to the muscles,
13 which is part of the Neuroleptic Malignant Syndrome and
14 which is the source for the elevated creatinine kinase.
15 If I can turn over the page, 72233, I have put
16 down a series of reasons here why I think that the
17 Neuroleptic Malignant Syndrome is realistic and
18 I personally think it is the only reasonable explanation
19 as to why the deceased died at the time that he did.
20 You can see at the top I refer to a very marked
21 pyrexia. He has a temperature above 40 degrees.
22 Somebody refers to 42 degrees. His blood pressure has
23 started to drop, having been elevated on the previous
24 day. He has all these abnormalities which I have
25 listed, including some things which are normal, which
15
1 I think are relevant, because they exclude some possible
2 explanations for his deterioration at that time.
3 The blood cultures, for example, were negative.
4 I think that's an important negative finding, because it
5 argues very strongly that he has not died a septic or
6 a bacteraemic death.
7 The catheter specimen of urine grows something
8 which I think is a non-specific contaminant. He does
9 not have a urinary tract infection.
10 The chest X-ray is normal. He does not have any
11 pneumonia and, indeed, Professor Crane did not find any
12 at post mortem examination. He has problems with his
13 white cell count. He has some evidence, I think, of
14 renal function impairment again. He has the elevated
15 serum creatinine kinase. At 924, it is about six and
16 a half times the upper limit for the normal adult range
17 for that laboratory, and he has an elevated aspartate
18 aminotransferase enzyme, some of which could have come
19 from muscle and some of which may have come from liver.
20 So I think there are several pointers here which
21 I consider to be relevant and I think they point to this
22 particular entity as explaining why the deceased died
23 when he did.
24 Q. Can I just put one factor that has been suggested in
25 relation to the high temperature and that is that there
16
1 was axonal damage in the hypothalamus?
2 A. Yes. I am aware of that. I think my answer to that
3 would be that, of course, there was damage to his
4 hypothalamus from the time of the assault. Had that
5 been what I consider to be a realistic explanation for
6 his hyperpyrexia at this stage, I would have expected it
7 to have occurred earlier.
8 I can't understand why, if that had been the
9 mechanism, it should have occurred at this particular
10 time and certainly in the context of these other
11 findings that are here on the screen.
12 Q. Thank you very much.
13 One other thing I need to ask you about on the
14 medical side of it, as it were, is hypoxia. Everybody
15 else has ruled that out. Do you have any opinion to
16 offer on that?
17 A. I am dependent upon those who have examined the
18 deceased's brain microscopically, and I understand that
19 both Dr Herron and -- and I know Dr Reid, felt there was
20 a relatively small amount, but that they both felt it
21 was non-contributory in the overall scheme of the
22 deceased's brain problems.
23 Q. Thank you. One other matter I would ask you to comment
24 about, if I may, and that's the way in which the post
25 mortem report, the incident case, was created and the
17
1 time it took and the system by which it emerged.
2 We know that about three months was taken before
3 slides were produced for the neuropathologist,
4 Dr Herron, to work on, and then he roughly took another
5 three months for research and analysis and reporting,
6 and that a factor in the period that he took was that
7 he, together with one other neuropathologist in Northern
8 Ireland, does this work voluntarily, on top of, as it
9 were, his day job, to the rate of currently about
10 700 hours a year per neuropathologist.
11 I wonder if you can help us with what the system is
12 in England? Are there neuropathologists who do this out
13 of the goodness of their heart, or is this done, if
14 I might put it this way, more professionally?
15 A. If I put it this way: I think both applies.
16 In England and Wales and Scotland, to the best of my
17 knowledge, there are three neuropathologists who are
18 prepared to take on cases which have criminal
19 implications. There is a much larger number of
20 neuropathologists, but the vast majority of them feel
21 unable or unwilling to get involved in cases which have
22 medical/legal importance and which may result in their
23 having to appear in court to give evidence. I can't
24 criticise them for that. That is not the normal
25 requirement of a neuropathologist who is appointed
18
1 within the National Health Service.
2 However, there are three who do the majority, almost
3 all, of the neuropathology within England, Wales and
4 Scotland. They do it over and above the National Health
5 Service commitments which they have, and there is
6 payment associated with it. Some of that payment goes
7 to the hospitals where they work for the use of the
8 facilities in those hospitals and some of it going to
9 them, as experts, for their expert neuropathological
10 opinion.
11 Q. Are there any proposals to get more neuropathologists or
12 streamline the system or anything of that nature?
13 A. Not to my knowledge. I think a few of us have been
14 trying very hard over the last few years to put forensic
15 neuropathology on to a much sounder and stronger footing
16 than it is at the moment.
17 It is not quite ad hoc, but it is almost that,
18 because these people emerge. They don't have a formal
19 training programme. They don't have the quality
20 assurance procedures, which, these days, I think are
21 pretty well mandatory in all areas.
22 I think they are trying to develop these, but
23 I think they need quite a lot of encouragement, and
24 I think that quite a few of us would like to see some
25 sort of recognition for forensic neuropathology, because
19
1 I think they have an incredibly important role to play
2 in some types of cases that we, as forensic
3 pathologists, get involved with and the sorts of things
4 that are outwith our field of expertise, given our
5 background.
6 MR UNDERWOOD: I see. Thank you.
7 THE CHAIRMAN: Can I just ask you this: we gather already
8 that, leaving aside whether there is someone available
9 to do it -- that is assuming he is there straightaway --
10 it takes at least a number of weeks before the brain
11 will be ready to be examined.
12 A. That's absolutely correct, sir, yes.
13 THE CHAIRMAN: Now, does the fact that in England you have
14 only three neuropathologists, generally speaking, doing
15 this work lead to delays beyond that; in other words,
16 there is a queue of cases waiting to be dealt with?
17 A. There is a bit of a queue. There certainly is with
18 regard to the neuropathologist to whom I send my own
19 cases. He is very good and I think he works very hard.
20 He does have a queue.
21 It is not -- I don't think it is one that is
22 unacceptable, because I think at the end of the day --
23 I am sorry; that's a cliche -- what we are looking for
24 is a good, reliable neuropathological opinion. Again,
25 I think that's almost a cliche, but it is terribly
20
1 important.
2 THE CHAIRMAN: In fact, you are saying it is worth waiting
3 for.
4 A. Yes. That's just the point I was going to make.
5 I think it is worth waiting for. The criminal justice
6 system, I try to persuade them it is worth waiting for
7 because you have the expertise these people have which
8 I haven't and could never have.
9 THE CHAIRMAN: If you had more properly qualified
10 neuropathologists, you could reduce the waiting time,
11 could you?
12 A. Yes, I think we could. I think we could do that without
13 diluting the pool of expertise that each one of them
14 will get. I think each of the new recruits, under
15 circumstances like that, would soon develop the
16 experience and expertise which is necessary in order to
17 do the job properly.
18 THE CHAIRMAN: However unavoidable the delay is, it may have
19 a knock-on effect of other parts of the procedures which
20 have to be followed following the death.
21 A. I accept that, and there is the delay for the family and
22 the repatriation of the brain on occasions. Yes,
23 I understand all of that, and I think that we have to
24 persuade those who are adversely affected by the delay
25 of the importance of that delay in order to come up with
21
1 a good, reliable expert opinion as to what is there or
2 what is not there, dependent upon the nature of the
3 case.
4 THE CHAIRMAN: The pressure you have spoken of, which is
5 rather on an ad hoc basis, on the whole, does it receive
6 a very sympathetic understanding or simply, "Well, we
7 see the difficulty, but we can't really do anything
8 about it"?
9 A. I fear there is somewhat more than element of the latter
10 than there is of the former.
11 THE CHAIRMAN: Thank you very much.
12 MR UNDERWOOD: I have finished my questions. I don't know
13 whether my friends have anything arising out of that.
14 MR ADAIR: Just a couple of brief matters, if I may be
15 permitted, Mr Chairman?
16 THE CHAIRMAN: Yes.
17 Cross-examination by MR ADAIR
18 MR ADAIR: Dr Lawler, I just want to confirm -- I think it
19 is your evidence, but I just want to confirm that you
20 still believe, dealing with the external head injuries,
21 that the most likely explanation for the four areas you
22 have described, the occipital scalp injury, the
23 bilateral contusions, the fracture and the left eyelid
24 bruising --
25 A. Yes.
22
1 Q. -- do you still believe that the most likely explanation
2 for those injuries is as a result of a fall, as you say
3 in your report?
4 A. Yes. I think I was a bit more cagey than that. I said
5 it was "possibly, perhaps probably". I think those were
6 the words that I used. I tried to be very careful
7 because, as I said in answer to the previous questions,
8 I was a bit disadvantaged by the lack of any bruising in
9 the scalp at the back of the head.
10 Q. I understand. Could you turn up page 15, please,
11 [72240], of Dr Lawler's report. If you could just
12 highlight the bottom paragraph.
13 A. Yes, I accept that. I can see exactly what it is that
14 you --
15 Q. Dr Lawler --
16 A. I accept that.
17 Q. -- I am not trying to keep you to words. So we know
18 where we are now, do you still accept what you said,
19 that the most likely explanation for those four injuries
20 is a result of a fall?
21 A. Yes, I do, and that is the side of the mid-line that
22 I would wish to go. I was trying to emphasise how
23 little I am beyond the mid-line in that context for the
24 reasons I think I have tried to explain.
25 Q. I understand.
23
1 A. Thank you.
2 Q. Now, the other external injuries to the head were the
3 bruises, one on either side of the head, which you have
4 told us, and my understanding is what you are telling us
5 is that could be one blow or could be a number of blows.
6 A. Yes.
7 Q. It is impossible to say?
8 A. Yes.
9 Q. Could one of those bruises, if you are right that the
10 most likely explanation for the other four injuries is
11 as a result of a fall to the ground, be as a result of
12 a blow to the head, for example, by a fist?
13 A. Yes.
14 Q. Could both those blows be blows to the head with a fist?
15 A. Yes.
16 Q. I suppose, so we are all clear about it, they equally
17 could be, could they, as a result of kicks?
18 A. Of course.
19 Q. Now, I am not going into the issue as to the direct
20 cause of death as between your opinion and
21 Professor Crane's opinion, but I wonder, can you help us
22 in relation to diffuse axonal injury? If you feel you
23 are unable to answer or you feel there is debate, please
24 say so.
25 The effect of the evidence, as I understand it, to
24
1 date has been, for example, from Professor Crane, that
2 his belief is that you can sustain diffuse axonal injury
3 such as this from an accelerated fall. By
4 an "accelerated fall", I mean falling down the stairs,
5 a punch, accelerating the fall. Do you agree with that
6 proposition?
7 A. I accept you can get some diffuse axonal injury under
8 those circumstances. I don't think there is very much
9 evidence to indicate that you can get diffuse axonal
10 injury as extensive as has been described here as the
11 consequence of a single accelerated fall.
12 Q. Is it more likely, therefore, dealing with this case in
13 particular, that the diffuse axonal injury was caused by
14 a combination of a blow to the head causing
15 an accelerated fall combined with a kick or kicks?
16 A. Yes. I think, given all the findings that we have,
17 I would venture to suggest that that is the most likely
18 explanation for the totality of what was found, yes.
19 Q. Dr Herron, the neuropathologist, had told us there is
20 still some debate going on in the medical profession as
21 to whether a kick or kicks can cause diffuse axonal
22 injury --
23 A. Uh-huh.
24 Q. -- but taking everything into account, do you still
25 believe that the most likely explanation in this case is
25
1 a combination of a blow or blows to the head and
2 accelerated fall and kick or kicks?
3 A. Yes. If I may say so, with respect, you have moved
4 along from a fall to an accelerated fall --
5 Q. Yes.
6 A. -- for which, I think -- once you get on to
7 an accelerated fall, then I think I am stepping back
8 from what I said before. I hope you don't think I am
9 being pedantic, but I think an accelerated fall is one,
10 as I understand it, where the individual is punched or
11 pushed and the force generated by the punch or the push
12 contributes to his falling over.
13 I think if it had been an accelerated fall, we may
14 have seen more in the way of bruising associated with
15 the occipital scalp injury and we may even have seen
16 an occipital skull fracture; not necessarily, but
17 I think we may have done.
18 So I think the comment I make, that you kindly
19 pointed out to me at the bottom of my page 15, [72240],
20 which is still on the screen, does not -- I was not
21 referring to an accelerated fall. I was referring to
22 a non-accelerated fall. Forgive me, if you think I am
23 being pedantic. I think I would wish to draw the
24 distinction between the two.
25 Q. Again, I am not, equally, being pedantic, but can we
26
1 distinguish between the two with any degree of
2 certainty? I assume a punch can cause a fall which is
3 similar to an accidental fall.
4 A. Yes, I accept that. I think that I -- it depends how
5 accelerated the acceleration is for the accelerated
6 fall. Again, I realise that we are in the danger of
7 becoming terribly pedantic.
8 Q. Yes.
9 A. The difference I associate is that you can push somebody
10 over and, if they lose their balance, they will go over.
11 I don't call that an accelerated fall. What I call
12 an accelerated fall is where there is a considerable
13 amount of force involved, whether it be from a punch or
14 a push, and that force contributes significantly to the
15 total amount of force which is transferred to the head
16 when the head impacts with the roadway or whatever it
17 is.
18 MR ADAIR: Thank you, Dr Lawler.
19 MR McGRORY: If you please, Mr Chairman, I have some
20 questions.
21 THE CHAIRMAN: Yes.
22 Cross-examination by MR MCGRORY
23 MR McGRORY: Professor, just arising from the questions
24 Mr Adair was asking you, with particular reference to
25 the issues on page 15, [72240], of your report --
27
1
2 A. Yes.
3 Q. -- is it a correct interpretation of your report that
4 what you are talking about there is really the
5 contre-coup injury as it concerns the occipital area of
6 the lower part of the back of the skull?
7 A. I am actually talking about all four of the separate
8 findings that I have listed on that page 15, [72240]; in
9 other words, I will go through them briefly, if I may,
10 if that helps.
11 Q. No, just --
12 A. It is the combination of all those four findings which
13 have been documented at some stage. I accept
14 Professor Crane did not document an occipital scalp
15 injury, but I think there is extremely good evidence
16 that it was documented by those who saw the deceased in
17 hospital in the earlier stages, and, obviously, before
18 he died. So I am accepting that there was one.
19 We know that there was a left orbital roof fracture,
20 because Professor Crane identified that. It had not
21 been diagnosed during life, but it was there and is
22 present on the post mortem photographs. The left eyelid
23 bruising is seen on the photographs and documented by
24 Professor Crane, and he does refer to bilateral frontal
25 lobe contusions.
28
1 So when you add all of those four together, it is
2 that combination which I think is attributable to a fall
3 backwards, striking the back of the head on the ground
4 and the forces being transferred through to the frontal
5 lobe contusions, which is contre-coup, and to the left
6 orbital roof fracture, which is, in effect,
7 a contre-coup, as the forces are transmitted through the
8 base of the skull and cause fracturing at the front
9 Q. Thank you. I just wanted clarification that we were
10 dealing largely with the contre-coup issue.
11 A. Yes.
12 Q. Can I ask you, Dr Lawler, to go back to the beginning of
13 your issue and on the issue of the physical
14 manifestation of injuries in the context of possibly
15 being kicked to the head?
16 A. Yes.
17 Q. You were talking about the bruising possibly having
18 faded by the time of death in this particular case?
19 A. Yes, and I think you give me the opportunity, if I may,
20 to make the point that I think it may be that injuries
21 to the upper part of the trunk may also fall into that
22 category as well --
23 Q. Yes.
24 A. -- because they, too, could affect the sort of rotating
25 and appropriate movement of the head such as to give
29
1 rise to the diffuse axonal injury which we have been
2 talking about.
3 Q. Yes. Would you agree that at the time of admission,
4 which was within a very short time after the assault,
5 bruising at that point would not have developed?
6 A. I think the answer to that is probably.
7 Again, without wishing to be pedantic, you may see
8 bruising almost immediately, and I think we all
9 experience instances where that happens, but it is not
10 at all uncommon, particularly when you are dealing with
11 head injuries, for these bruises to evolve, to develop
12 over a few hours. So I think that's quite likely, yes.
13 Q. You also noted in your report, Dr Lawler, that the scalp
14 had not been shaved at the time of the post mortem?
15 A. I think that's the case. There was no evidence to
16 suggest it had been. I don't think Professor Crane has
17 disagreed with that observation, other than a small
18 amount at the front on the left side where he found
19 an abrasion within a healing scar, but I am talking
20 about the rest of it.
21 Q. If a victim had been kicked to the area of the head
22 normally covered by hair, do you accept that that might
23 have masked the obvious development of bruising and even
24 the fading of that bruising?
25 A. Well, I think it might have done two things. The first
30
1 is it might have served to absorb some of the forces of
2 the kick, although it would not have prevented the head
3 from moving around as a consequence of the kick, and the
4 second thing, of course, is that there may have been
5 some bruising on the outer surface of the scalp, which
6 was not present on the deep surface of the scalp, so
7 that, when you look at the inside of the scalp during
8 the post mortem examination, you don't see that
9 bruising, but, in fact, it is within the substance of
10 the scalp on the outside. We do see that from time to
11 time.
12 If the scalp is not shaved or if it is not dealt
13 with in -- or the hair cut short such as to be able to
14 see the scalp below the hair where the hair was, then
15 you may miss these sorts of bruises and it may cause
16 some interpretational difficulties.
17 Q. I would just like to draw to your attention two of the
18 aspects of Dr Herron's evidence, if I may, on the issue
19 of the Neuroleptic Malignant Syndrome.
20 A. Yes.
21 Q. Dr Herron said yesterday that on the issue of the CK --
22 to shorten the creatinine kinase enzyme issue --
23 A. Yes.
24 Q. -- that in his personal experience the enzyme level in
25 the blood where he had encountered this syndrome had
31
1 gone up to 50,000 to 60,000, but in the case of
2 Mr Hamill was in the region of 900, which is very
3 considerably lower.
4 A. Yes.
5 Q. Now, Dr Herron felt that that, as a neuropathologist,
6 was a significant indication that the neuroleptic
7 syndrome was less likely to have been the cause of
8 death.
9 Do you accept that to be a valid observation on his
10 part?
11 A. I don't, no. There is -- one of the papers that
12 I quoted in my report says that the creatinine
13 phosphokinase elevation is present in 92% and implies
14 that it may not attain such high levels.
15 In other words, it is somewhat variable and I think
16 the fact it is as high as it is means I can't think of
17 any realistic alternative explanation for it.
18 Q. Can I ask you about the issue of the temperature? Now,
19 that, again, was one of the factors which you attributed
20 to your eventual conclusion that Neuroleptic Malignant
21 Syndrome was the ultimate cause of death.
22 Dr Herron yesterday suggested that the extent of the
23 injury to the hypothalamus was a significant indicator
24 that there was an alternative reason for the raise in
25 temperature.
32
1 Have you any reason for disagreeing with him in that
2 regard?
3 A. I think -- I tried to answer that question earlier in
4 response to your colleague.
5 Q. Yes.
6 A. My answer to that is that the damage to the
7 hypothalamus, which is traumatic axonal injury, occurred
8 during the assault, and, therefore, was present from the
9 time of admission to hospital onwards.
10 I find it very difficult to imagine why it should
11 have taken ten days for the temperature to rise as much
12 as it did, bearing in mind that prior to that it had
13 been reasonably normal.
14 I would also put the rise in the temperature into
15 the context of the other findings as well.
16 Q. Dr Herron yesterday commented that the brain injuries,
17 as severe as they were, had a dynamic nature to them --
18 A. I accept that, of course.
19 Q. -- and that this could have caused -- may have caused --
20 perhaps this is me putting an interpretation on it --
21 injury to the hypothalamus to develop in the intervening
22 period between the assault and the death.
23 Would you accept that that was a possibility?
24 A. Experience has taught me that you never say never in
25 forensic pathology. Having said that, I find that
33
1 rather difficult to understand the concept thereof, that
2 here you have an individual who has clearly sustained
3 traumatic axonal damage to his hypothalamus during
4 an incident and yet it takes ten days for
5 a manifestation of that to develop.
6 When it does develop, it develops very acutely and
7 very markedly, with a temperature that goes up to as
8 high as 42 degrees C, it appears from the clinical
9 notes, and it all occurs at and around the same time
10 that he develops other problems, all of which I think,
11 including the raised temperature, can be explained by
12 the Neuroleptic Malignant Syndrome.
13 Q. One final question, Dr Lawler. Would you accept that
14 the dynamic nature of the brain injury may have caused
15 complications in other respects in terms of cardiac
16 effect and so forth that might have contributed to
17 death?
18 A. Again, I think that I never say never, but in the
19 context of everything else, I would ask, firstly, why
20 should it have occurred at this particular time and not
21 earlier? Why didn't the cardiac effects manifest
22 themselves in some form of arrhythmia in the intervening
23 ten days from admission to hospital until his
24 deterioration over the last 24 hours or so of his life?
25 Secondly, I think that we need to look at the
34
1 totality of the clinical and laboratory findings over
2 the last 24 hours of the deceased's life, and I think my
3 own personal view is I think they add up to the
4 Neuroleptic Malignant Syndrome, which I think will
5 explain all of these findings.
6 MR McGRORY: Those are my questions.
7 MS DINSMORE: If I might, Mr Chairman?
8 THE CHAIRMAN: Yes.
9 Cross-examination by MS DINSMORE
10 MS DINSMORE: Good morning, Dr Lawler.
11 Dr Lawler, in relation to the suggestion about the
12 blow to the head, my friend Mr Adair put to you the
13 suggestion of that being struck by a fist. There is
14 a suggestion that the deceased may have been struck by
15 a bottle. Would the striking by a bottle fall within
16 the ambit of a possible causation of the blow to the
17 head which is absorbed?
18 A. I'd see no reason why it could not.
19 MS DINSMORE: I am very much obliged. Thank you.
20 Re-examination by MR UNDERWOOD
21 MR UNDERWOOD: Can I just come back on one matter?
22 On the issue of the possible impact with the roadway
23 by which Mr Hamill hit the back of his head -- we still
24 have your page 15 up, [72240].
25 A. Yes, indeed.
35
1 Q. Do I understand your evidence to be this: that, had that
2 been an accelerated fall, you would have expected a more
3 serious physical injury to the back of the head?
4 A. Yes, I think I would, and, indeed, I think I would have
5 expected there perhaps to have been more severe
6 bilateral frontal lobe contusions, as is documented down
7 here as well.
8 MR UNDERWOOD: That's helpful. Thank you.
9 Sir, that's my questioning.
10 Questions from THE CHAIRMAN
11 THE CHAIRMAN: One or two matters.
12 First of all, a punch on the ground, in other words,
13 his head is on the ground and there is a punch then.
14 Are you able to muster as much force into that blow
15 generally as a kick?
16 A. I think in purely general terms it is always going to be
17 difficult to generate the same amount of force with
18 a punch as you can with a kick, regardless as to where
19 the victim is.
20 Q. Especially if you have to stoop to do it?
21 A. Yes. I think that's fair comment.
22 Q. Now, we were told that the diffuse axonal injury causes
23 the axons to stretch and become porous --
24 A. Yes.
25 Q. -- and that the harm to the system is done when fluid
36
1 seeps into the axonal tissue --
2 A. Uh-huh.
3 Q. -- and destroys its ability to conduct signals.
4 A. Yes.
5 Q. How long does that sort of process take to develop so
6 that the signalling system is injured? Are we speaking
7 of minutes or longer?
8 A. No. I think we are speaking of a very short period of
9 time. The delay may be in the identification of it by
10 the neuropathologists, because of the techniques that
11 they have available to them. It may be that they cannot
12 identify it down the microscope for -- well, some would
13 say an hour and a half, some would say a little longer
14 than that, but that's purely a technical issue. I think
15 that the damage is caused very rapidly indeed; once the
16 injury has been inflicted, the damage occurs. It either
17 occurs or it doesn't. When it occurs, that is it, in
18 the sense it is irreversible.
19 Q. So it could not take days to manifest itself in terms of
20 managing the system?
21 A. No, I don't think it could. I think it is an almost
22 immediate phenomenon in the area where those nerves have
23 been irreversibly damaged.
24 Q. Now, you say in your report he received a brain injury.
25 It was appropriate, as you understand it, to dose him
37
1 with Chlorpromazine.
2 A. Yes.
3 Q. And death was attributable to the unusual effect of that
4 drug?
5 A. Yes. I think that caused him to die when he did.
6 Q. But you say the initial incident, the brain damage, was
7 the beginning of the chain leading to death --
8 A. Undoubtedly.
9 Q. -- and that the law would see it, since the
10 administration of the drug was appropriate, as
11 a significant cause of the death?
12 A. Yes.
13 Q. Leaving aside the way a lawyer looks at it, supposing
14 there had been no NMS?
15 A. Yes.
16 Q. Was this man going to have survived? He was in a bad
17 way, wasn't he?
18 A. Well, I think he -- first -- my first answer to that is
19 I think he would have survived longer than he did.
20 Q. Yes.
21 A. My second answer to that is that I think that, given the
22 extent of the axonal injury as identified by the
23 neuropathologists, I think he would have always had
24 a considerable degree of disability. Again, I wouldn't
25 wish to put it any stronger than that, because I am not
38
1 a clinician, but from my own personal experience of
2 cases not dissimilar to this, I think that there would
3 have been -- bearing in mind that the neurological
4 damage, the traumatic axonal injury is irreversible,
5 then all the symptoms that he had prior to his
6 developing what I would argue is the Neuroleptic
7 Malignant Syndrome, those would have continued, because
8 they were a reflection of the diffuse axonal injury that
9 he had suffered.
10 As to how long he would then have survived, these
11 people can, in theory, survive a long time. They can
12 survive weeks, months or years, but they do so with
13 considerable neurological impairment
14 Q. But certainly his life was at risk and he might or might
15 not have survived?
16 A. That is undoubtedly true. There is a well-recognised
17 increased risk to these people of developing chest
18 infections, urinary tract infections, septicaemia
19 arising from those, all of which are as a direct
20 consequence of the neurological problems which they
21 have.
22 Questions from REV. BARONESS KATHLEEN RICHARDSON
23 REV. BARONESS KATHLEEN RICHARDSON: Dr Lawler, the NMS
24 reaction to the drug, is that an immediate reaction like
25 an allergic response or is it cumulative and would it
39
1 matter how many doses he had had and at what length of
2 time?
3 A. I think the answer is it is neither of those two.
4 Q. Right.
5 A. It is what is known as an idiosyncratic reaction. It is
6 not an allergic reaction in the pathological sense.
7 The second thing is that it develops after a period
8 of time. That period of time will vary. About 16% of
9 Neuroleptic Malignant Syndrome cases develop within
10 24 hours after the initiation of the drug and 66% within
11 the first week, and virtually all within 30 days.
12 I quote from a reference that I have here, because
13 I'm in danger of getting outwith my field of expertise,
14 but I think that's a fair summary of the timescale
15 involved. It is not related to the amount that they
16 get. It is not dose related. It is purely an abnormal
17 reaction that these individuals develop to these drugs.
18 REV. BARONESS KATHLEEN RICHARDSON: Thank you very much.
19 MR UNDERWOOD: Unless there is anything else arising, that
20 concludes the evidence of Dr Lawler.
21 Doctor, thank you very much for coming over and
22 giving your evidence.
23 A. You are welcome.
24 (The witness withdrew)
25 MR UNDERWOOD: Sir, I have the next witness here, who is
40
1 Miss Hagan, but I have been asked for a break for
2 fifteen minutes before I call her. So may I invite you
3 to rise for that period.
4 THE CHAIRMAN: Very well.
5 (11.00 am)
6 (A short break)
7 (11.15 am)
8 MR UNDERWOOD: I call Maureen Hagan, please.
9 MRS MAUREEN HAGAN (sworn)
10 Examination by MR UNDERWOOD
11 MR UNDERWOOD: Would you like to tell us your full names,
12 please?
13 A. Maureen Hagan.
14 Q. Do you like to be called Miss, Mrs or Ms?
15 A. Mrs.
16 Q. Mrs Hagan?
17 A. Yes.
18 Q. I will be asking most of the questions on behalf of the
19 Inquiry and the three Panel members are going to be the
20 ones interested in hearing the answers. In fact,
21 everybody is interested in hearing the answers, but they
22 are the ones whose job it is.
23 You have signed a witness statement for us, I know.
24 Can I just put up on screen page [80339]? This is
25 a draft witness statement and I think over the last few
41
1 days you have signed one that we have not managed to get
2 on to our electronic system yet which has a few changes
3 to it. Is that right?
4 A. Yes.
5 Q. Can I just get you to tell me that where you have signed
6 it, the signed version which we will see later on,
7 that signed version is true?
8 A. Yes.
9 Q. I just want to ask you about your recollection, first of
10 all, about Mr Hamill arriving at the Craigavon Area
11 Hospital. How clear is your recollection of that?
12 A. My recollection is quite clear.
13 Q. We know you were on duty in the A&E department. Who
14 else was on duty in terms of nursing?
15 A. I can't remember.
16 Q. All right. Do you know Maureen Millar?
17 A. I do, yes.
18 Q. Was she also a nurse employed at the Craigavon Area
19 Hospital at the time?
20 A. She was employed at the time, yes, but I don't remember
21 if she was there.
22 Q. Do you recall what her role was compared with yours?
23 A. She was a staff nurse.
24 Q. Is that the same level as you were then?
25 A. Yes.
42
1 Q. Okay. What I particularly want you to do, if you would
2 be so kind, is to have a look at some forms which were
3 filled in when Mr Hamill came in, but, before I do that,
4 can I ask you what you can remember of his state when he
5 arrived at the hospital?
6 A. I just remember the ambulance people bringing him into
7 the resuscitation room. I am not sure if I met the
8 ambulance at the door before we went in or if I was in
9 the resuscitation room. I have a feeling I was in the
10 resuscitation room whenever he came in and he was put on
11 to the trolley and -- you know, as is usual with
12 anybody, the ambulance people give you a history and you
13 have a look and start to do some observations, like take
14 his blood pressure and that.
15 Q. We know he was unconscious --
16 A. Yes.
17 Q. -- do you remember if there was any blood on him or
18 anything of that nature?
19 A. Can I have a look at my statement? I know there was
20 blood on his face.
21 Q. By all means, if you want to look at your statement, we
22 can. Can I take you to the forms that you filled in at
23 the time?
24 A. Yes.
25 Q. Let's have a look at those. Can we start with
43
1 page [38972]? What sort of form is this?
2 A. That's known as a Triage Form.
3 Q. Ordinarily, who would fill in the Triage Form?
4 A. Ordinarily, it would be the triage nurse and there is
5 a room specifically for triage, but in Robert's case,
6 because he was so ill, he was just brought straight into
7 the resuscitation room. So the Triage Form was filled
8 in at his bedside.
9 Q. I see. Is that your signature at the bottom left-hand
10 side of this form?
11 A. It is, yes.
12 Q. Can I just ask you a few things about the entry? If we
13 look at the top right-hand, we see:
14 "Date: 27/4/97. Time seen at triage:
15 02.05."
16 Can you help us with whether you would have filled
17 that in as soon as you saw him or whether you would have
18 looked at him first and then come back to fill in the
19 form a few minutes later?
20 A. I just couldn't answer that. I may have had it in my
21 hand. I don't know.
22 Q. Right. Just underneath that, what we see is:
23 "? Involved in fracas in Portadown.
24 "? Hit on head by bottle.
25 "Unconscious.
44
1 "Breathing noisily.
2 "Wound to back of head."
3 Is that accurate?
4 A. Yes.
5 Q. Can I just take you to the first two lines of that where
6 you have:
7 "? Involved in fracas in Portadown.
8 "? Hit on head by bottle."
9 Can you help us with where you would have got that
10 information from?
11 A. That would have been given to me by the ambulance
12 personnel.
13 Q. I am pausing because people are writing it down. Then
14 the lines underneath that:
15 "Unconscious.
16 "Breathing noisily.
17 "Wound to back of head."
18 Is that your observation or is that what somebody
19 would have told you?
20 A. No, that would be my observation.
21 Q. I want to ask you about the entry:
22 "Wound to back of head."
23 How serious would a wound like that have had to have
24 been for you to have written it down?
25 A. I don't know. I don't know if that -- I don't know
45
1 if --
2 THE CHAIRMAN: What would have led you to consider there was
3 a wound to the back of his head?
4 A. I might have been told that. You know, at that stage,
5 I wouldn't have examined the back of his head.
6 THE CHAIRMAN: Is that because of his condition?
7 A. Yes.
8 MR UNDERWOOD: All right. Can I go to page [38973], please?
9 Can you help us with what sort of form this is?
10 A. That's known as a Casualty Card.
11 Q. I think you tell us in your statement that this comes
12 with two carbon copies, this top copy and two carbons?
13 A. Top copy and two copies beneath it.
14 Q. You also tell us that there is sometimes a continuation
15 sheet, which is essentially blank, just more room for
16 notes?
17 A. Yes, blank, just with a name at the top of it.
18 Q. You believe, I think, that there probably would have
19 been a continuation sheet, which we have not been able
20 to manage to find. Is that right?
21 A. Yes. I imagine there should have been one.
22 Q. Can we have the split-screen facility and have that on
23 one side of the screen and have, on the other side,
24 [38677], please? What we have here, if I have this
25 right, is two copies of the same thing. Unless anything
46
1 else is going to be pointed out to me, the only
2 difference I can see between them is the one on the
3 left hand, just below halfway down on the right-hand
4 side of it there is a box marked out. I wonder if we
5 could highlight that? That's it. I think you tell us
6 in your statement that's your writing on one of these
7 copies. Is that right?
8 A. Yes.
9 Q. Can you tell us what it says?
10 A. It is:
11 "U&E, FBP, group and hold, chest, skull and cervical
12 spine."
13 Q. What does that mean?
14 A. That means the bloods that he had done, some of the
15 bloods, electrolytes and urea, full blood picture and
16 blood for grouping and holding in case he would need
17 a blood transfusion --
18 Q. I see.
19 A. -- and he was X-rayed, chest, skull and cervical spine.
20 Q. Thank you. Then, if I may, I would ask you to look,
21 again with split screen, at [38665] and [38666]. Can
22 you tell us what -- this is two pages of one document
23 I think. Is that right?
24 A. Yes.
25 Q. I think we see on the right-hand side at the bottom your
47
1 signature again. Is that right?
2 A. Yes.
3 Q. It calls itself a nursing care plan.
4 A. Yes.
5 Q. Can you describe how this document comes about?
6 A. This would be a document, if a patient was being
7 transferred elsewhere, would be filled in to facilitate
8 the nursing staff to the ward that he was going to, to
9 facilitate them, to let them know, you know, quickly,
10 you know -- you know, that he had X-rays done or how he
11 was whenever he came in or just basically information
12 for them.
13 Q. All right. Can I just ask you to help us with the way
14 these three forms mesh with each other? The Triage Form
15 you have told us is the first document that's completed
16 and here it would have been completed when you saw
17 Mr Hamill, but ordinarily it would be completed before
18 anybody was actually seen by nurses?
19 A. Yes, but it can be completed at any time during the ...
20 Q. All right. The Casualty Card slip we saw after that,
21 when is that normally compiled in comparison with the
22 Triage Form?
23 A. That would be after the Triage Form usually.
24 Q. Right. The form we are looking at, the Nursing Care
25 Plan, compared with the other two, when would that
48
1 normally be compiled?
2 A. Whenever the treatment would be finished and the patient
3 would be going to a different ward.
4 Q. Does it follow then that the information on the Nursing
5 Care Plan is compiled from other documents?
6 A. Sorry, just ask me that again.
7 Q. If what you tell us is that the Nursing Care Plan is the
8 last document to be completed, because you complete it
9 in order to tell the next department that somebody goes
10 to what has happened --
11 A. Yes.
12 Q. -- would you expect it all to be completed in one go?
13 A. No, no.
14 Q. Right. So if it is completed as you go along, is it
15 completed when someone is given some drugs or given some
16 treatment of some other description or what?
17 A. No, usually the person would have had maybe the
18 treatment and the drugs, and X-rays before this would be
19 completed. It is completed partially from other
20 documents, but sometimes just from your own observations
21 that are not written down.
22 THE CHAIRMAN: Is it a running record that is filled in as
23 things happen?
24 A. No. That wouldn't be possible in a situation like that.
25 THE CHAIRMAN: I see.
49
1 MR UNDERWOOD: So partly this could come from what's in your
2 head?
3 A. Yes.
4 Q. With that in mind, can we have a look at these pages?
5 What I want to ask you about is: in respect of a lot of
6 these entries, firstly, who made them, and, secondly,
7 whether they definitely relate to Mr Hamill? Because
8 there is a suggestion that might be made that
9 observations in respect of another patient have
10 inadvertently been put, not by you, but by somebody else
11 on to this form. I want to get your assistance on that,
12 if I can.
13 If we pick up the top line:
14 "27/4/97.
15 "Time of Arrival: 0200.
16 "Mode of Transport: ambulance."
17 Can you tell us whose handwriting that is?
18 A. I don't know whose handwriting that is.
19 Q. Right. Below that, we have Mr Hamill's name and
20 something has been blanked out. That's his address.
21 Over to the right-hand side you have:
22 "Family alerted."
23 A. "Family attended by R/C chaplain."
24 Q. Is that your writing?
25 A. That's my writing, yes.
50
1 Q. Then we have a series of boxes, one of which is ticked:
2 "Civil Assault."
3 It may be a curious question to ask you, but does
4 that look like your tick?
5 A. It is not my tick, no.
6 Q. Right. If I might say so, it seems larger in scale than
7 any of your writings. Below that, we see:
8 "Conscious/unconscious."
9 "Unconscious" is ticked. Again, is that your tick?
10 A. No.
11 Q. Then we see:
12 "Appearance of skin: bloody ++ head + face".
13 Is that your writing?
14 A. No.
15 Q. "Respiration: Inadequate", has been ticked.
16 Same question: is that you?
17 A. No.
18 Q. Right. Now, in relation to those, the civil assault,
19 unconscious, appearance of the skin and inadequate
20 respiration, from your memory and from what you have
21 seen, would those have been accurate in relation to
22 Mr Hamill?
23 A. The civil assault was -- the time of arrival is not
24 accurate. It was 2.05, time of arrival. "Civil
25 assault" is accurate. "Unconscious" is accurate.
51
1 I believe -- in my statement --
2 Q. If it helps you, yes.
3 A. Oh, no, it is here. His face was not covered in blood
4 or his head was not covered in blood. He had a graze on
5 his head, but, at that stage, he would not have been
6 covered in blood. This document was --
7 THE CHAIRMAN: When you say "at that stage", that means on
8 admission to the resuscitation room, does it?
9 A. Yes. He had a graze on his head, but, by this stage,
10 where Robert has been ventilated and this must have been
11 filled in while he was in X-ray or whatever, if he
12 had -- if his face had been bloody, it would have been
13 cleaned at that stage and something put on it. You
14 know, you wouldn't -- somebody's face wouldn't be
15 covered in blood.
16 Q. Did you see him at any stage where he could have been
17 described as we see there:
18 "Bloody ++ head + face".
19 A. No.
20 Q. If we go further down the form we see "Head" and that's
21 ticked. I take it that it is not one of your ticks?
22 A. It is not, no.
23 Q. Then we see:
24 "Lacerations: Yes.
25 "Site: left side of head.
52
1 "Blood loss: Yes.
2 "Site: from above", which I take to mean the left
3 side of the head. Again, not your writing?
4 A. No.
5 Q. Can you help us with how a nurse would have filled that
6 in? If there was a graze, could somebody have said
7 "yes" to a laceration, because it does not offer you
8 a graze box, does it?
9 A. Sorry, ask me that again.
10 Q. You have told us that Mr Hamill had a graze on the side
11 of his head. Here it doesn't offer you the option of
12 whether there is a graze. It just gives you the choice
13 of saying whether there is a laceration or not.
14 If you had been faced with doing this -- I know you
15 didn't fill this part in, but if you had been asked the
16 question, "Has he got a laceration or not?", would you
17 have said "yes"?
18 A. Going by what I have written here I would have probably
19 written "no" and written where it says, "Site" just
20 written, "Graze on the side of his head".
21 Q. Then:
22 "Other relevant information: attacked by gang", does
23 that say?
24 A. "Attacked by gang", yes.
25 Q. Can you read the rest of it for us?
53
1 A. "... and hit on head by ?? bottle".
2 Q. Is that your writing?
3 A. That's my writing, yes.
4 Q. Again, that would have come from the information given
5 to you by --
6 A. By ambulance staff.
7 Q. Thank you. If we go down under the "Immediate Care"
8 section, we see:
9 "Time commenced. Left arm. 1-litre Hartmann", is
10 that?
11 A. Yes.
12 Q. That is at 0245. Hartmann solution is something that
13 comes in intravenously, is it?
14 A. Yes.
15 Q. I take it that's not your writing. Is it?
16 A. No.
17 Q. This is roughly 40 minutes after Mr Hamill came in. Can
18 you give us any help about who might have been writing
19 that in and in what circumstances?
20 A. Who wrote in the "Hartmann's"?
21 Q. Yes.
22 A. This Nursing Care Plan can be filled in at any time.
23 The patient was in Intensive Care before this bit here
24 was filled in. The reason that it would have been
25 a litre of Hartmann's was erected at 2.45 is on the
54
1 Casualty Card itself. It was copied from that.
2 Q. I see. It was just copied in from the Casualty Card.
3 A. Yes.
4 Q. Again, you accept that's, of course, accurate for
5 Mr Hamill. He was actually given that Hartmann's?
6 A. Yes.
7 Q. If we go further down we see:
8 "Units cross-matched. Hold."
9 That's something you told us you'd written on the
10 form we just looked at, I think.
11 A. Yes.
12 Q. Is that your writing below there?
13 A. Yes. "Alcohol level" -- "others", that's the blood
14 investigation, and skull, cervical spine and chest were
15 X-rayed.
16 Q. In case it helps, are any of those ticks yours, do you
17 think?
18 A. Those are not my ticks, no.
19 Q. Then if we go to the right-hand side of the page, you
20 have various drugs --
21 A. Yes.
22 Q. -- and "Dr Gormley" written against. Again, not your
23 writing, I take it?
24 A. No.
25 Q. Then you have -- is that:
55
1 "Large graze left side of head."
2 That's your writing, is it?
3 A. Yes.
4 Q. It was a large graze, was it?
5 A. Yes, from what I can recall.
6 Q. Can you give us any sort of impression as to what, in
7 1997, you would have regarded as large? The size of
8 a 50p piece, bigger than that?
9 A. It would have been bigger than that. You know, I just
10 cannot tell you, but thinking of what -- as you say,
11 coming back to what I would have written for large, it
12 would have been quite big. I would have said, you know,
13 quite big an area.
14 Q. So 3 or 4 inches in diameter, something like that?
15 A. Yes, yes.
16 Q. Then we get some writing further down that page. Is all
17 of that your writing?
18 A. There is another bit:
19 "Any other care: please specify. Catheterised."
20 That's my writing, and:
21 "Relatives: father and his sisters were present."
22 That's my writing, and under "Clothing:"
23 "taken by father."
24 That's my writing:
25 "Condition on leaving: patient ventilated -
56
1 sedated."
2 That's not my writing
3 Q. Where is that?
4 A. The very bottom of that right-hand page. It says:
5 "Condition on leaving."
6 THE CHAIRMAN: You say the answer to that is not your
7 writing?
8 A. "Patient ventilated" is my writing but the "- sedated",
9 is not my writing.
10 THE CHAIRMAN: Underneath?
11 A. "X-ray to ICU", is my writing.
12 THE CHAIRMAN: In other words, all of that, except the word
13 "- sedated" --
14 A. Is my writing, yes.
15 MR UNDERWOOD: Mrs Hagan, you have been very helpful.
16 I think you understand that what the Inquiry is
17 attempting to do is to find every piece of evidence
18 there is about the condition that Robert Hamill was in
19 when he came to hospital in order to assist the Panel to
20 determine what happened to him before that.
21 Is there anything else I have not asked you which
22 you think might help from your memory or from anything
23 I have looked at here in the documents?
24 A. I can't any of anything.
25 MR UNDERWOOD: All right. It is possible other people might
57
1 want some questions to be asked of you, but that's all
2 I have to ask. Thank you very much.
3 MR ADAIR: I wonder if I might ask one matter?
4 THE CHAIRMAN: Yes.
5 Cross-examination by MR ADAIR
6 MR ADAIR: Is it normal that the clothing is taken by the
7 family in these circumstances? Why was the clothing
8 taken? Was he put into a gown or something? How did
9 that happen?
10 A. Robert Hamill's clothes were taken off him whenever he
11 came in to assess his injuries.
12 Q. In accident and emergency?
13 A. Oh, yes. Probably part of it would have been cut off,
14 you know. The clothing would have been through there
15 and maybe put in a plastic bag. Usually clothes are
16 kept, but Mr Hamill's father came in and took the
17 clothes home with him.
18 Q. Right. Can you remember, were they actually in
19 a plastic bag or, I think you said, just thrown there?
20 A. Yes.
21 Q. I understand. In an emergency, obviously you are just
22 going to get the clothes off as quickly as possible.
23 A. That's right, yes.
24 Q. If you can't remember, say so.
25 A. I can't remember.
58
1 Q. Can you remember whether they were put in a bag?
2 A. I can't remember. Everything was done very quickly, so
3 possibly they were just thrown in a pile on the floor.
4 Q. Was it you that he asked for the clothing or --
5 A. It was, yes.
6 Q. Were Robert's sisters there at the time as well?
7 A. I couldn't say for sure if they were there at that time
8 or not. I know his sister had been there.
9 I wouldn't -- you know, obviously, you know, I didn't
10 know his -- I wouldn't have known his sisters to see or
11 anything like that. They could have been there.
12 Q. Did he take away all his clothing, as far as you know?
13 A. As far as I know, yes.
14 MR ADAIR: Thank you very much.
15 Cross-examination by MR MCKENNA
16 MR McKENNA: One matter of clarification. If we could go to
17 the Nursing Care Plan at page [38665]. Is that in front
18 of you?
19 A. It is, yes.
20 Q. We have already been referred to writing on it which
21 I know is not yours:
22 "Bloody ++ head + face".
23 Can you see that?
24 A. Yes, I can.
25 Q. Am I right in thinking that the plus symbol is used to
59
1 describe the degrees to which something is present?
2 Would that be correct?
3 A. That's correct, yes.
4 Q. Does that go from one plus to three pluses, obviously
5 being an increase?
6 A. I don't know if there is any limit of pluses.
7 Q. But normally, would you expect to see somewhere in the
8 range of one to perhaps three or four?
9 A. Yes.
10 Q. Now can you clarify, Mrs Hagan, the way that that is
11 written there we see:
12 "Bloody ++ head"?
13 A. Yes.
14 Q. That would indicate obviously a degree of blood to the
15 head more than one plus but less than three, if I can
16 put it in that way?
17 A. Sorry. Say that again.
18 Q. We see there the word "bloody"?
19 A. Yes.
20 Q. Then we have two plus symbols?
21 A. Yes.
22 Q. Then the word "head"?
23 A. Yes.
24 Q. Does that indicate to you the presence of blood in the
25 head? Can I establish that for a start?
60
1 A. I thought that was:
2 "Bloody ++ head and face".
3 So that would be your interpretation of it?
4 A. Yes.
5 Q. Could it also mean:
6 "Bloody ++ head + face".
7 Indicating there is also blood to the face. Could
8 that be one interpretation of it?
9 A. I suppose it could be. I don't know.
10 Q. What I am trying to get at here is there is a presence
11 of blood about the head and face, but the way that that
12 is written, that may indicate there is more blood to the
13 head area than in particular the face area.
14 A. I don't know. I just took it to say it was:
15 "Bloody ++ head and face".
16 MR McKENNA: Okay. Thank you, Mrs Hagan.
17 MR UNDERWOOD: I have no questions arising from that.
18 THE CHAIRMAN: Thank you, Mrs Hagan.
19 MR UNDERWOOD: Mrs Hagan, thank you very much for coming.
20 A. Thank you.
21 (The witness withdrew)
22 MR UNDERWOOD: We have one more witness today who is not
23 able to attend, unfortunately, until 1.30. May
24 I suggest we rise until then? I would anticipate she
25 will be about half an hour to three-quarters of an hour
61
1 when she does attend.
2 THE CHAIRMAN: Thank you.
3 (11.55 am)
4 (The luncheon adjournment)
5 (1.30 pm)
6 MR UNDERWOOD: I propose to call Maureen Millar.
7 MRS MAUREEN LETITIA MILLAR (sworn)
8 Examination by MR UNDERWOOD
9 MR UNDERWOOD: Mrs Miller, could you tell us your full name,
10 please?
11 A. My name is Maureen Letitia Miller.
12 Q. Thank you very much. If you would be so kind, I think
13 we can get on to the screen a statement at page [80966].
14 If you would have a look at that for me, please.
15 If we flick through that statement on the screen,
16 please, through to page [80972], is that your witness
17 statement made for the purpose of the Inquiry?
18 A. Yes, it is.
19 Q. Is it true?
20 A. Yes, it is true.
21 Q. Thank you very much. If we could go back to the first
22 page, please, [80966], in paragraph 2 you tell us that
23 you were a staff nurse at Craigavon Area Hospital on the
24 nights of 26th and 27th April 1997.
25 A. That is correct.
62
1 Q. Can you tell us, before I ask you any more detail, how
2 good your memory is of that night?
3 A. It's not totally clear. It's almost 12 years ago. So,
4 with extreme clarity, I may not be able to recall
5 everything in detail.
6 Q. All right. Can we have a look at paragraphs 3 and 4,
7 please? You tell us that you were in charge of the A&E
8 department, having been there for 11 years by then:
9 "Being in charge meant that I assumed overall
10 responsibility for the care and treatment of patients."
11 We have heard from another nurse who was present on
12 the night, Maureen Hagan. Do you recall her?
13 A. Yes.
14 Q. What was her status in relation to you in the hospital?
15 A. She was also a staff nurse, but with the rotas, the
16 off-duty rotas that were done, I was in charge that
17 night.
18 Q. Right. It follows then, when you say in paragraph 4:
19 "In my role I allocated tasks to the staff nurses
20 under my charge ..."
21 Is that because the rota system gave you that
22 responsibility on that night?
23 A. Yes. There were different areas within the department
24 so you allocated somebody to take the resus room or the
25 observation ward, whatever.
63
1 Q. I see. If we go over the page, please, to [80967], you
2 tell us at the bottom, paragraphs 8 and 9, that you
3 recall Robert Hamill coming in:
4 "I recall that his complexion was quite red but
5 do not remember if he had any bruising ..."
6 Do you recall if there was any blood on him?
7 A. It is hard to say. I remember his face being very, very
8 ruddy on arrival. He may have had some blood as well,
9 but I'm not totally clear about that.
10 Q. Very well. You then go on, in paragraph 9, and we don't
11 need to go into the detail of it here, to talk about the
12 resuscitation room?
13 A. Uh-huh.
14 Q. Now, if somebody came in unconscious by ambulance, what
15 was the system for dealing with them?
16 A. An unconscious patient was taken immediately into the
17 resuscitation room. He would have been given oxygen
18 straight away. Observations would have been commenced
19 on him. His -- he would be immediately triaged on
20 arrival in the resus room, and, as well as that, the
21 appropriate medical staff would be fast bleeped, that
22 being the anaesthetist or the SHO. The A&E SHO would be
23 present as well. That was the routine for ill patients
24 taken into resus.
25 Q. On this occasion in respect of Robert Hamill, do you
64
1 have any recollection of where you were? Were you in
2 the resuscitation room or outside or what?
3 A. I can't recall.
4 Q. Okay. We are going to come in a moment to a Nursing
5 Care Plan. Can I ask you, before we look at one in
6 detail how the documentation worked?
7 You have an unconscious patient, whom you need to
8 attend to urgently.
9 A. Yes.
10 Q. We know that paperwork has to be created so that there
11 is a record tracked.
12 A. Uh-huh.
13 Q. How does it work? Is somebody standing over your
14 shoulder with a pen and paper or do you make a note as
15 soon as you have done something, or what?
16 A. Because there are maybe two nurses in the resus room,
17 one is actually doing the hands-on, the blood pressure,
18 putting monitors on, putting oxygen on, reading off the
19 observations and can be calling to the other nurse,
20 "Blood pressure is 160/100", whatever it may be.
21 The documentation is started immediately on arrival
22 for the purposes of ensuring that all interventions are
23 recorded.
24 Q. So the records are pretty much contemporaneous with the
25 things being recorded, are they?
65
1 A. Yes, they are ongoing.
2 Q. So, having said that, can we have a look at pages -- and
3 split the screen at pages [38665] and [38666], please?
4 We have, I think, by agreement here got the Nursing Care
5 Plan for Robert Hamill. What I want to do is take you
6 through the entries on it, please, and get you to
7 identify for us which, if any, of these entries are
8 yours, and whether, from what you know, these entries
9 definitely relate to Robert Hamill.
10 Taking it from the top:
11 "Date: 27/4/97.
12 "Time of arrival: 0200.
13 "Mode of Transport: ambulance."
14 Do you recognise that handwriting?
15 A. Yes, that's my writing.
16 Q. Underneath that, we have an alert, "Roman Catholic
17 chaplain". Maureen Hagan has told us that's her
18 writing. Do you actually recognise her writing?
19 A. Yes, I do.
20 Q. Then we have boxes, one of which is ticked "Civil
21 Assault". Can you say whether that was your mark on
22 there?
23 A. I can't say, no.
24 Q. All right. Does the fact that that box is ticked chime
25 with your recollection and your understanding of what
66
1 had happened?
2 A. It does.
3 Q. Do you recall speaking to the ambulance crew at all?
4 A. I recall with the other nurse receiving -- bringing the
5 patient from the ambulance trolley to the resus trolley.
6 The two trolleys would be level with one another.
7 I can't recall who the ambulance men were, but the story
8 that we were given, it was an alleged assault in the
9 middle of Portadown.
10 Q. Let me try my luck. Do you happen to remember any more
11 about what they told you?
12 A. There was a large group of people and this gentleman had
13 been badly assaulted in the middle of it.
14 Q. If we then go down the next set of boxes,
15 "Conscious/Unconscious", again there is a mark.
16 Will your answer be the same for all these marks,
17 that you cannot say whether they were yours or not?
18 A. Yes.
19 Q. Obviously, he was unconscious.
20 A. He was unconscious, yes.
21 Q. Then you have:
22 "Bloody ++ head + face."
23 Whose writing is that, do you think?
24 A. That's mine.
25 Q. Can you help us with when you might have written that in
67
1 relation to him being brought into the resuscitation
2 room?
3 A. That may have been written shortly after he was put on
4 the trolleys where you had actually assessed his face or
5 his head and his body and you had found whatever
6 injuries were there to be found.
7 Q. Can you help us with your notation and what it meant:
8 "Bloody ++ head + face."
9 A. That means there was a lot of blood around his head and
10 face. The "++" would be a sign for a lot, you know,
11 much bleeding.
12 Q. Do the two pluses relate to the head and one plus relate
13 to the face or --
14 A. I think that's "head and face".
15 Q. Then you have, "Respiration:" is "inadequate".
16 Can you help us with any recollection you have about
17 that?
18 A. His breathing, I recall, was quite snorty, loud and
19 inadequate. He wasn't breathing properly, which meant
20 that his oxygen levels wouldn't be very good. So he
21 would have oxygen applied immediately.
22 Q. Then we go down under "Apparent Injuries". There is
23 a set of boxes. "head" is ticked:
24 "Lacerations: Yes.
25 "Blood loss: Yes.
68
1 "Sites: left side of head.
2 "Sites: from above."
3 I know I can't press you on whether these are your
4 ticks, but when somebody completes a form like this, are
5 they likely to complete the tick box at the same time as
6 the text we are looking at or is it likely that these
7 were completed by different people at different times
8 A. Well, my writing is the laceration on the left side of
9 the head and the blood loss from the above laceration.
10 So when I discovered that, it had to be written down
11 and documented on the care plan.
12 Q. Do you think somebody might have ticked these boxes and
13 then left it for you later to have written in later, for
14 example:
15 "Left side of head.
16 "From above."
17 A. Well, his apparent injuries on arrival appeared to be
18 a head injury. So that would be the first thing. On
19 thorough examination afterwards if you found more
20 injuries, you would apply.
21 Q. All right. Then if we go down the page -- sorry.
22 I should stop you at the laceration there.
23 We heard some evidence that there was a large graze
24 on the side of Mr Hamill's head when he came in.
25 Obviously there is not a box there for "graze". You get
69
1 a choice of "laceration" or not. If you had seen
2 someone with a large graze that may or may not have been
3 bleeding a reasonable amount, would you have ticked the
4 laceration box, as it were, or circled the laceration?
5 A. If I had found an abrasion, it would probably be an
6 abrasion on left side of face. I may not necessarily
7 tick "laceration", but whatever injury was found, be it
8 a bruise to the left side of face or a graze on the
9 cheek or laceration, that would be documented.
10 Q. All right. Then we have:
11 "Other relevant information: attacked by gang", etc.
12 We heard from Mrs Hagan that that's her writing.
13 A. Yes.
14 Q. You confirm that, do you?
15 A. Yes.
16 Q. Then we go down to "Immediate Care". What we have on
17 the right-hand side there is:
18 "Left arm, 1 litre Hartmann at 0245."
19 Whose writing is that?
20 A. That's my writing. That was his intravenous fluids.
21 All trauma patients would have intravenous fluids. They
22 would have venous access gained straight away to ensure
23 they had an immediate line in for the insertion of
24 fluids or for the administration of drugs, and he had
25 Hartmann's solution set up.
70
1 Q. Then we know from Miss Hagan that the investigations
2 part is in her writing. Again, that's what you think,
3 is it?
4 A. Uh-huh.
5 Q. Is there any possibility that somebody else's findings
6 could have been recorded on to this form by mistake?
7 A. No. Absolutely not. Those were relevant.
8 Q. Let me put it to you specifically that another gentleman
9 who was brought in in the same ambulance and from the
10 same sort of group as Mr Hamill was being treated, who
11 had a head injury.
12 Is it at all possible that observations on his head
13 injury might, by mistake, in the heat of the moment in
14 a busy A&E, have been recorded here?
15 A. No. Those were all relevant to Mr Hamill.
16 THE CHAIRMAN: How many patients would you be able to have
17 in the resuscitation room at a time?
18 A. At that time, you could have four patients.
19 THE CHAIRMAN: I see.
20 MR UNDERWOOD: Do you have any recollection of another
21 gentleman?
22 A. Not in resus, no.
23 Q. Then if we go to [38666], we see in the box for what is
24 obviously administration of drugs an intravenous route
25 marked for three separate and ordered by Dr Gormley.
71
1 A. Uh-huh.
2 Q. Whose writing is that?
3 A. That's my writing.
4 Q. Then we see:
5 "Large graze left side of head."
6 That's Mrs Hagan's, according to her. Again, can
7 you confirm that?
8 A. Yes, that's right.
9 Q. Can you give us any sort of explanation why we might see
10 that on page 2?
11 A. I can't. I'm sorry.
12 Q. Then I think the rest of the writing, but for one
13 matter, is accepted by Mrs Hagan to be hers.
14 A. Uh-huh.
15 Q. Let me just put that one part of it to you. If we look
16 right down to the bottom:
17 "Condition on leaving".
18
19 A. Yes.
20 Q. "Patient ventilated ..."
21 Then we have"... - sedated."
22 Mrs Hagan said the "- sedated" wasn't her writing.
23 Can you help us with whose that might have been?
24 A. I have no idea whose writing that is. I wasn't aware
25 that there would be other people adding information to
72
1 the form. "Sedated" is in relation to the drugs that he
2 was given when he was ventilated, which would be the
3 Scoline, the Intraval Sodium and the Deprivan.
4 THE CHAIRMAN: So that's not your writing?
5 A. No, it is not my writing.
6 MR UNDERWOOD: I think you understand that the purpose of
7 this investigation is to find out all that can be found
8 out about how Mr Hamill died and, in particular, the
9 nature, the duration and the extent of the assault on
10 him, and how any of the medical findings could possibly
11 assist us on that.
12 A. Uh-huh.
13 Q. Is there anything else you know, either from
14 recollection or from documents, that you think might
15 assist in that?
16 A. Sorry.
17 Q. Is there anything I have not asked you about which you
18 think might be helpful for the Panel to know?
19 A. All the interventions that were done for Mr Hamill were
20 appropriate to an ill patient being brought into resus
21 where he would have an anaesthetist present and be tubed
22 and ventilated to assist his breathing.
23 Where there was -- he had X-rays done. He had
24 trauma X-rays; skull, cervical spine and chest. They
25 would be automatically ordered. I don't feel that there
73
1 is anything missing from that care plan.
2 Q. Is there anything else you think the Panel might be
3 assisted by from your recollection of what you saw of
4 Mr Hamill?
5 A. I have given as much as I can recall about the night.
6 MR UNDERWOOD: That's very kind. Thank you very much.
7 Those are the questions I have. It may be that others
8 might wish to raise some questions.
9 MR ADAIR: Might I raise just two brief matters,
10 Mr Chairman, please?
11 THE CHAIRMAN: Yes.
12 Cross-examination by MR ADAIR
13 MR ADAIR: I understand this is a number of years ago and it
14 is difficult to actually remember, but do I understand
15 you have a memory of when Mr Hamill came into A&E or
16 into the resuscitation room that his face was ruddy?
17 A. I have a vague recollection of that. It was
18 discoloured, ruddy, which could be partly due to the
19 fact that his respirations were so poor as well. I am
20 sorry I can't give extreme clarity on it.
21 Q. Subject to the Panel, it is a long time ago. If I may
22 say so, as far as I am concerned, it is perfectly
23 understandable.
24 Have you any actual recollection of blood on his
25 face; actual recollection, as opposed to what we read on
74
1 the document?
2 A. Not on his face. I can't recall any blood on his face
3 at the time, but obviously we found a laceration.
4 The face and the head are very well supplied with
5 blood vessels. So if somebody is lying flat and they
6 have a laceration, the blood can actually flow further
7 away from the wound as well. It is quite difficult
8 sometimes to ascertain where the actual site is. You do
9 have to examine the head or the face and see where the
10 actual wound is.
11 Q. So stating the obvious, the blood can flow from the
12 laceration on the side of the head onto the face?
13 A. Yes.
14 Q. Your description of the laceration being on the left
15 side of the head --
16 A. Left side.
17 Q. -- have you any further recollection? Was that at the
18 back of the head or the left back or was it simply the
19 left, or have you any recollection of that?
20 A. I have no recollection. I am sorry.
21 MR ADAIR: Thank you very much. That's all I wish to ask.
22 Cross-examination by MR WOLFE
23 MR WOLFE: Just one brief question, if I may.
24 Do you have any recollection of how many nursing
25 staff would have been on duty that night in the A&E?
75
1 A. There were three of us, three nurses.
2 Q. That covers resuscitation and the A&E department in
3 general?
4 A. Yes, yes.
5 Q. Apart from yourself and Mrs Hagan, who was the other
6 one?
7 A. I think it was Nurse xxxxxxxxxx.
8 Q. I am obliged. Thank you.
9 A. I do have to say when somebody as ill as this is brought
10 into the resus room, we have to contact the Night Sister
11 as well, who is in charge overall of the hospital, and
12 make her aware of how ill this patient is and that he is
13 being treated in the resuscitation room.
14 Q. Have you any recollection of whether she came down to
15 A&E?
16 A. I can't recall straightaway, but the Night Sister would
17 always attend the department as soon as she gets
18 information of such an event.
19 Q. Of a serious incident?
20 A. Yes.
21 MR WOLFE: Thank you.
22 Cross-examination by MS DINSMORE
23 MR DINSMORE: I wonder, could you outline what treatment
24 Mr Hamill received in relation to the laceration that
25 you located?
76
1 A. I can't recall what treatment he had.
2 Q. You can't recall whether it was sutured or dressed?
3 A. No, I can't recall.
4 MS DINSMORE: Thank you.
5 MR UNDERWOOD: I have nothing arising out of any of that.
6 THE CHAIRMAN: Thank you very much.
7 MR UNDERWOOD: Thank you very much, Mrs Millar. It is very
8 kind of you to come.
9 A. Thank you very much.
10 (The witness withdrew)
11 MR UNDERWOOD: That concludes the evidence of this section.
12 We have done all the evidence we intended to do this
13 week with a couple of hours to spare, so rather better
14 than on schedule.
15 I am proposing, therefore, to start next week with
16 a short opening of the next group of witnesses, who will
17 deal with how the violence broke out.
18 THE CHAIRMAN: 10.30 on Tuesday.
19 (1.55 pm)
20 (The hearing adjourned until 10.30 am
21 on Tuesday, 20th January 2009)
22
23 --ooOoo--
24
25
77
1 I N D E X
2
3
3 DR WILLIAM LAWLER (sworn) ........................ 1
4 Examination by MR UNDERWOOD ............... 1
4 Cross-examination by MR ADAIR ............. 21
5 Cross-examination by MR MCGRORY ........... 26
5 Cross-examination by MS DINSMORE .......... 34
6 Re-examination by MR UNDERWOOD ............ 34
6 Questions from THE CHAIRMAN ............... 35
7 Questions from REV. BARONESS KATHLEEN ..... 38
7 RICHARDSON
8
8 MRS MAUREEN HAGAN (sworn) ........................ 40
9 Examination by MR UNDERWOOD ............... 40
9 Cross-examination by MR ADAIR ............. 57
10 Cross-examination by MR MCKENNA ........... 58
10
11 MRS MAUREEN LETITIA MILLAR (sworn) ............... 61
11 Examination by MR UNDERWOOD ............... 61
12 Cross-examination by MR ADAIR ............. 73
12 Cross-examination by MR WOLFE ............. 74
13 Cross-examination by MS DINSMORE .......... 75
14
15
16
17
18
19
20
21
22
23
24
25