Reviews

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 - had 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.

(Credit: PHIL NOBLE/PA) View larger version (74K): [in this window] [in a new window]   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 by proxy - 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.

Trevor Jackson. 

BMJ tjackson@bmj.com