BMJ 2001;323:347 ( 11 August )
Cot death confusion: explaining the unexplainable
Ever since solicitor Sally Clark was
convicted in November 1999 of murdering two of her children, she has
maintained her innocence. In the face of an initially hostile press,
Clark's family stuck by her and insisted that the deaths of her two
baby boys were cot deaths or instances of sudden infant death syndrome
(SIDS). Gradually their campaign gathered momentum (it now has its own website, http://www.sallyclark.org.uk/), and even when Clark
lost her appeal against her conviction, last October, it was clear that
this case was not going to go away.
From the start, many people
including prominent doctors
serious misgivings about the safety of the original verdict,
particularly about one piece of evidence from a key prosecution
witness, the paediatrician Professor Sir Roy Meadow. These concerns
have ensured that the Clark case, and the debate over what we know and
don't know about cot death, has remained a media issue.
In the past three months there have been several articles about
Clark in which her transformation from media bête noire to media
cause célèbre, the victim of a major miscarriage of justice, can be
seen to be complete. On 6 May the Sunday Telegraph ran a
detailed article titled "Against the odds," in which it argued that
much of the medical evidence brought against Clark was flawed. She was
found guilty by a 10:2 majority verdict of murdering her first child,
Christopher, in 1996 when he was 11 weeks old, and, just over a year
later, her second child, Harry, when he was 11 weeks old. (Clark now
has a third son, born before her case came to trial.)
Christopher's death had initially been attributed to a
respiratory infection, but after the death of Harry
said by the
prosecution to be a victim of shaken baby syndrome
it was claimed that
both babies had been subject to abuse.
The chronology of how and when suspicions were aroused and the
pathological evidence itself seem complex. Post-trial newspaper reports paint a picture of pathological mayhem, with medical experts disagreeing and changing their opinions. The Sunday
Telegraph article said: "For long periods in the Chester
courtroom, the case consisted of erudite discussion of intra-alveolar
haemorrhages, haemosiderin-laden macrophages and other such abstruse
medical arcana." As Sally Clark's husband, Stephen, also a
solicitor, told BBC's Woman's Hour on 26 July 2001, "It
has taken me three years to understand some of the medical evidence."
Later in May there were a range of media reports on the Law
Society's decision not to strike Clark off, but to suspend her. This
was an unusual decision given that Clark is a convicted murderer and
was widely held to indicate deep unease among many in the legal
profession about the convictions.
On 15 July in a joint investigation, Radio 5 Live and the
Observer took as their starting point new research claiming
that there was a genetic cause of SIDS, thereby calling into question probably the most famous piece of evidence presented at Clark's trial.
The new research was the discovery of a so called cot death gene by
researchers at Manchester University in February.
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Convicted by a soundbite statistic? Sally Clark and her husband
arrive at court
One voice missing from these reports was that of Professor Meadow
himself, the man responsible for this famous piece of evidence or, as
the Observer put it, this "crude aphorism." He had told the trial jury that in an affluent family like that of Sally and Stephen Clark, where both parents were non-smokers, the probability of
two babies dying of SIDS was one in 73 million. (Meadow has since said
the statistic came from a government report and was not his own.) In a
case in which jury members were subjected to several weeks of complex
and conflicting medical evidence it is Meadow's soundbite statistic
that the Clark campaign and the media have subsequently credited with
clinching a conviction. Professor Meadow, no stranger to controversy
(he was the first to observe and give a name to Munchausen's syndrome
see editorial on p 296), acquired a reputation as the man who
sent Sally Clark to jail. His statistic was the subject of a
BMJ editorial, "Conviction by mathematical error?"
(BMJ 2000;320:2-3), which said that the 1 in 73 million
figure was seriously flawed and that the odds on the same family having
two cases of cot death were much lower, at 1 in 8500. The
Observer's 15 July article claimed the gene discovery meant
that the odds for a second cot death could be as low as one in four.
The difficulty for anyone trying to make sense of this case is
that, by its very definition, cot death is something that remains unexplained. The Foundation for the Study of Infant Deaths says that
cot death is "the sudden and unexpected death of a baby for no
obvious reason" (www.sids.org.uk/fsid/).
Speaking to the BMJ this week, Professor Meadow said he had
had concerns about the terms on which he was prepared to join the media
debate over the Clark case and over cot death itself. Radio 5 Live and
the Observer both said they had put a series of questions to
him, "but he declined to talk to us." Professor Meadow said he
would have been happy to appear on a live debate, but Radio 5 Live, he
was told, was not live. He was worried that if his responses were taped
and inserted into a documentary programme he would be in danger of
being "stitched up."
On 29 July, according to the Sunday Times, Meadow "broke
his silence." But even here, in an article largely sympathetic to him, the point he had most wanted to get across had been missed, or
again, maybe just misunderstood, he told the BMJ this week. This point, he said, concerned the importance to the trial of the 1 in
73 million statistic. He said: "There's been a lot of talk from the
Clark campaign and the media about the fact that the recurrence of
death from SIDS was incorrectly discussed at the trial by me. What the
papers have missed is that the reason the court never explored any of
this is that no expert in the whole case considered either death to be
an example of SIDS. No one on either side deemed either death a cot
death." Instead, he said, there were obvious signs of trauma on both
children (a fact disputed by some pathologists according to some
reports), "so the whole issue of cot death recurring was an irrelevance."
He added: "The media tend to present it as a disease, as if a baby
died from SIDS, but all it is is a `Don't know.' Some medical colleagues use the term as if it's a disease. There's a tremendous amount of confusion."
Why did Meadow think the media is so bent on seeking the "cause" of
cot death, and why had he received such a hostile press? "The public
is very uncomfortable about the issue of child abuse, and they tend to
shoot the messenger. And those of us who write about it and speak about
it and point it out, we are unpopular messengers."
And where does this leave Sally Clark? With so much divided
opinion about her case, the probability is that whatever you believe about it, you could be wrong, and that sounds worryingly like reasonable doubt.
© BMJ 2001