by John Askill
‘But Bev was so upset. There were tears rolling down her face.’ The truth was very different. Sue Peck had not asked Dr Porter to prove Claire was dead. Neither had the doctor pointed to the straight line on the monitor to prove there was no sign of life. But at the time, Sue Phillips had no reason to doubt the nurse she trusted as a friend. Nurse Allitt should have gone off duty, but she told Sue Phillips that her pal and housemate Tracy Jobson was working and she could not face going home to an empty house.
While Allitt was in tears in the cubicle with Sue Phillips, Claire’s heartbroken parents collapsed, sobbing, in the TV lounge nearby. It was around 8.15pm. Ten minutes later Dr Porter, soaking wet with perspiration from the effort of trying to save Claire, appeared and told them he was terribly sorry but their little girl was dead. There was nothing more he could do.
The couple walked back to the treatment room to be with Claire. Asthma had killed their little girl, or so they thought. Yet when they met Dr Porter he seemed utterly bewildered by the tragedy.
Sue Peck remembers: ‘He was just sitting there with his head in his hands, and he said: “This should never have happened.”’ He told the Pecks that Claire’s death was a million to one chance, a freak occurrence he could not explain. ‘He told us that children die from asthma when they are untreated. In his opinion the chances were a million to one that a child could die while actually being treated in hospital. He was very distraught.’
It was Sue Peck’s parents who began to ask questions about Claire’s death. Why had the doctor said Claire shouldn’t have died? What had he meant by that? They didn’t understand. Sue and David were confused, too, but the specialist had told them it had been a million to one chance. ‘We simply thought we had been very unlucky,’ said Sue.
Still reeling from the shock of it all the Pecks were asked to stay at the hospital to meet the coroner’s officer.
The hospital chaplain, the Rev. Shelton, who had conducted Liam Taylor’s funeral service at the crematorium and buried Becky Phillips in his churchyard at Manthorpe, arrived and tried to comfort them.
Sue’s father and brother went to the chapel of rest and identified Claire’s body to the police. It was 11pm before Sue’s father was able to drive the couple back home.
As he was leaving the hospital Sue’s father overheard two nurses talking about the tragedy. He was within earshot when one nurse said: ‘Not another one …’ It was a throwaway comment that made no sense at the time. Sue and David had no idea that three other children had already died.
The next day Sue’s father, Eric, returned to Grantham to collect a copy of the death certificate from the coroner’s office. Once more an odd comment made him wonder about Claire’s death. As he waited for the certificate a woman at reception remarked: ‘Crikey, not another one. There’s been a lot at Grantham hospital recently …’
A post mortem was held on Wednesday, 24 April, when the pathologist reported that asthma was the cause of Claire’s death, which David and Sue accepted. For the fourth time the pathologist had decided that death was due to ‘natural causes’. There would be no need, once again, for an inquest to be held.
Dr Porter, however, had taken a blood sample as Claire clung to life by a thread. It was a sample that was later analysed as doubt increased about the real cause of the children’s deaths.
Sue said: ‘We only found out about the blood sample a long time later. If he hadn’t done that then they would never have known the answers. I am sure that Dr Porter suspected there was something wrong.’
Claire’s funeral took place on 26 April. David and Sue still found it hard to believe that Claire was dead. All the time they kept remembering what the doctor had said about Claire’s death being a chance in a million.
Claire’s death had a profound effect on Sue and Peter Phillips. They had no way of knowing that Timothy Hardwick had died, but they did know that Liam Taylor, Becky and now Claire had all lost their lives on Ward Four – and they were determined to ask questions. They demanded a meeting with the hospital’s general manager, Martin Gibson, wanting to know why the ward was still open, still taking in more sick children, despite all that had happened. They had heard suggestions that there was a virus on the ward causing children to have heart attacks. Peter recalls: ‘It was a few days after Claire had died and we heard people talking on the ward about this virus, saying it was causing the kids to have heart attacks, and we had even heard some of the staff mention the rumour. If that was the case we wanted to know why they’d not shut the ward straight away.
‘I told Martin Gibson: “There are kids dying on that ward …” But he said they couldn’t close the place unless there was concrete evidence of something like Legionnaires Disease or meningitis, and they’d swabbed the walls, done all the checks and found absolutely nothing.’
Sue and Peter lost their tempers. It was the first time they had come face to face with Mr Gibson and they were in no mood for his assurances that the ward was free from disease. Sue remembers: ‘We went at him like a bull in a china shop. He was trying to be nice, like a caring, considerate person, but we weren’t in the mood. He said he could understand why I was mad, he’d have been mad if his daughter had died. He was trying to pacify us and he said he’d not heard talk of any heart virus. We were no happier when we left his office.’
The job of carrying out the first investigation into the deaths of babies on the Children’s Ward at the Grantham and Kesteven Hospital fell on the shoulders of a former policeman. Tall, grey-haired Maurice Stonebridge-Foster was the coroner’s officer, always the first person to be informed of any ‘sudden death’.
He had been coroner’s officer for six years after he retired from the Lincolnshire police force. He was a ‘bobby’ through and through. He’d never wanted the exalted heights and had never progressed from the ranks of police constable, spending most of his twenty-six years in the force in uniform, pounding the beat as a ‘village copper’, or at police stations in the bigger towns of Boston and Grantham, before landing the job assisting the coroner.
His three children were grown up; a son and one daughter were in the navy and another daughter was training to be a radiographer. His hobby was breeding King Charles spaniels; these had won him numerous prizes at dog shows all over the country, including Crufts, and he proudly carried a picture of his dogs in his wallet.
But, as coroner’s officer in Grantham, dead bodies were his life and as much a routine to him as speeding drivers were to the traffic cops.
And when he ‘put in his ticket’ to leave the force, in October 1990, he continued life with the dead, staying in his old job as a civilian coroner’s officer, working from the same office, with the same daily routine, investigating all of the 400-plus sudden deaths in and around Grantham each year.
His job, on behalf of the coroner, Mr John Pert, was to examine any sudden death – road-crash victims, suicides, falls, factory accidents, air crashes, electrocutions – the list was endless – and inform the coroner of his findings. He found himself most days in the mortuary at the Grantham and Kesteven Hospital where he would witness the clinical, sometimes grisly, job of post mortem examinations carried out by the pathologist and his mortuary staff. If the medical experts decided that death was from natural causes and there was nothing suspicious, then there would be no need for the coroner to hold an inquest.
If there was any death that was not natural, the coroner would hold a public inquest to establish the basic three points – when, where and how the unfortunate victim died.
Maurice Stonebridge-Foster, like coroner’s officers all over the country, would prepare the evidence for the coming inquest, organise the witnesses and medical experts, and comfort relatives in their grief. It was not everyone’s idea of a great job, but the former policeman liked it as much as any job he’d done in the force. ‘It’s the most useful job I have ever done,’ was his view.
At the age of fifty he had never been a detective but, in April 1991, six months after he had ‘retired’ as a poli
ceman, Stonebridge-Foster found himself the first to be called to Ward Four at the Grantham and Kesteven Hospital – never once suspecting that he was in the front line of what was to be the biggest murder investigation ever carried out at a hospital in Britain.
One ‘sudden death’ after another from the Children’s Ward piled on to his desk but nothing he heard raised his suspicions. The regular pathologist was off sick so the routine post mortems were carried out by stand-in pathologists Dr Klaus Chen and Dr Terry Marshall. In all cases, they stated that, in their opinion, each of the children had died from natural causes.
No inquest, the coroner decided, was needed.
Mr Stonebridge-Foster later defended the decision. He said: ‘I don’t think I missed anything. As far as I was concerned they were just sudden deaths of sick children in hospital. There was nothing suspicious. Other children died naturally in the hospital at the same time, and there was nothing suspicious about their deaths either. There was nothing abnormal.
‘It wasn’t a case of a baby having a knife in its back or being covered in bruises. They were in hospital because they were sick and, unfortunately, sick children die. Some of the parents said they couldn’t understand what was happening. They said they thought something was wrong. But that is a normal reaction from a parent at a time when they are so upset at losing their child.
‘The worst cases for me were those parents who had lost their baby. But we look at between 400 and 500 deaths a year and there’s usually about eighty inquests.
‘I realised the deaths all came within a short period at the hospital but sometimes it happens like that; there may be a run of deaths in one place. But when the cause of the deaths was natural causes, I accepted it. There were no unnatural deaths, so there was no need for the coroner to hold inquests.’
Much later, after the new evidence on the causes of death emerged, inquests into all four cases were held.
Coroner Mr Pert sat in front of the parents of Liam Taylor, Timothy Hardwick, Becky Phillips and Claire Peck at Grantham Guildhall and said: ‘In forty years, I have never had such tragic circumstances brought before me.’
7. Secret Cameras
When twelve policemen move in to begin a major investigation at a hospital one might suppose that everyone from the cleaner to the kitchen cat would know about it; that there would be the clump of size 11 shoes in the corridors, and white cars with red stripes and blue lights in the car park announcing: ‘The police are here.’
But when the team of detectives moved in to the Grantham and Kesteven General Hospital on 1 May 1991 they were so discreet that their arrival passed almost without notice. Most people in the hospital had no idea for several weeks that there was any police investigation under way and even when, much later, some nurses and hospital staff did begin to realise it, many of them thought it was because one of the nurses had had some money stolen – such was the lack of awareness of criminal activities on Ward Four.
Detective Superintendent Stuart Clifton, the man leading the police enquiry team, is quietly spoken with an easy smile and a reputation for tenacity. He is also a ‘thinking’ policeman who found time to gain a BA in social sciences from the Open University.
Married with two sons, he had joined the police out of boredom in February 1966 after first qualifying as a quantity surveyor in the construction industry. His training had given him an eye for detail that was to become invaluable in his new job.
He was stationed at Boston, then transferred all over Lincolnshire. Promotions took him right to the top as operational head of Lincolnshire CID.
At the hospital Supt Clifton and his team first sought the opinions of the two chief paediatricians, Dr Nelson Porter and Dr Charith Sena Nanayakkara. He met them hoping for answers, perhaps even clues, but he went away with more questions than answers from the two doctors who didn’t agree with each other.
Dr Porter told Supt Clifton that something untoward was going on and Dr Nanayakkara was not so sure. The detectives hadn’t expected such a conflict of opinion, right at the beginning of the enquiry, between the two experts on whom they had hoped to rely. As he listened to the technical medical jargon, Stuart Clifton had instant misgivings about his new task and was overheard to remark in a whisper: ‘I wish I was on leave!’
One detective said: ‘Dr Porter just had this feeling that something had been going on but he didn’t know what.’
He added: ‘The hospital authorities had already done checks, swabbed the ward, wondering whether it was Legionnaires Disease. They hadn’t thought there was anything criminal happening, that’s not what they were looking for.
‘But Dr Porter seemed to have already made up his mind that he didn’t like the look of what had been happening on his ward. He had been to a British Paediatric Association conference where they had talked about children being tampered with in hospital, usually by their parents. Something must have clicked because after he got back to Grantham he phoned the hospital manager, Mr Gibson, at home. He was so worried about the number of children collapsing on his ward that he wanted to suggest to Mr Gibson that the hospital install video surveillance cameras to monitor what was happening in each and every cubicle.’
Similar ‘spy on the ward’ cameras had been hidden at a London hospital where a child had been suffering from unexplained fits. The secret cameras later filmed the mother deliberately putting a pillow over her child’s face, until the youngster went into a fit. Then the mother could be seen building herself up into a frenzy before screaming for help.
Dr Porter had made the call to Mr Gibson on the Friday evening, three days before Claire Peck was to die on Ward Four. But Mr Gibson was not at home and he could only leave a message. Still worried, Dr Porter drew up his own action-list during the weekend, cataloguing what he would do ‘when we had the next one’. But on Monday teatime Claire had collapsed before any of his suggestions could be initiated.
When the police arrived, Dr Porter asked again for Ward Four to be put under surveillance. Detectives installed one of the closed-circuit video spy cameras over the main entrance to the ward in a position where they could monitor round-the-clock who might be slipping in unnoticed on to Ward Four.
The complexity of the medical evidence now convinced Supt Clifton that he needed a medical adviser to consult and interpret the opinions he was being given. He called in David Hull, a distinguished consultant paediatrician from Nottingham who had been chairman at the conference which had been attended by Dr Porter a few days earlier. Supt Clifton asked him to begin by carrying out a new medical review of nineteen cases, including all children who had died at the hospital or within forty-eight hours of leaving.
By now he had set up an incident room at Grantham Police Station, manned by a detective sergeant and eleven other officers, and set about looking for evidence. The enquiry was to be the most difficult case any of the officers had ever encountered. It was different because they would normally have started with a murder weapon – knife or a bullet in the back of the victim – and there would be a motive – love, jealousy, greed or whatever.
But here, all the post mortems had already been done and all the children had been found by pathologists to have died from natural causes.
Supt Clifton had to turn the clock back and reinvestigate everything that had been done before. It took him into a new world of medical science where policemen were not expected to be particularly knowledgeable. Hoping for assistance from parents who were already emotionally torn apart by what had happened to their children, he called in the force’s Family Support Unit, a group of experienced policemen and women normally used in delicate child-abuse cases.
They spent ten days interviewing parents of the children who had died or been lucky to survive, asking them if they suspected anything. The results were disappointing. In the main, parents believed their children had been extremely well looked after on Ward Four; many were full of praise for the nurses and doctors who had worked so hard to save their children. They didn’t welcom
e police officers asking them to recall upsetting times, no matter how delicately they probed.
For three weeks the police scoured the hospital records, checked the case histories of every child who had passed through the ward and analysed every single emergency in the hospital’s ‘bad run’.
Discussions sometimes went on into the night during ‘debriefing’ sessions at the Blue Pig, the squad’s adopted pub – a sixteenth-century inn which served Whitbread bitter and an array of four real ales, Castle Eden, Flowers, Boddingtons and Websters.
There had been twenty-four separate incidents in the space of sixty days when children had suffered cardiac arrests, respiratory failures and heart attacks. The casualty ‘crash team’ hadn’t been summoned every time but, even so, the sheer volume was astonishing when, normally, the detectives were told, the crash team might expect one call-out to the children’s ward in a year, twice at the most.
How could that be simply a ‘bad run’? The way the police saw it, this must be more than bad luck.
But suspicion was not enough and evidence was nowhere to be found.
Mr Hull produced his initial report into the nineteen cases he had examined and his conclusions were also far from encouraging. He reported that, in his view, there were no more than three incidents worthy of further investigation, and two of those might be questionable.
After three weeks they had got nowhere and every avenue had turned into a cul-de-sac. There was so little progress that they almost gave in and walked away from Ward Four, empty-handed.
There was a feeling that the case was going nowhere. Where, after all, was the evidence?
Only the persistence of Supt Clifton kept the investigation going. He was convinced that something just didn’t add up. It was the sort of instinctive feeling that detectives cannot always explain. A colleague remarked later: ‘He just wouldn’t let go. He just kept saying he knew something wasn’t right. He had a gut feeling about it.’
