Waney Squier - Full Transcript

Waney SquierConsultant Paediatric Neuropathologist at the John Radcliffe Hospital, Oxford

Interview location: John Radcliffe Hospital, Oxford
Interview date: 10th October, 2007


Profile | Transcript Summary | Full Transcript

 

SECTION 1

SA:  I suppose the very first question, since our last interview, is how have things changed in your practice since Alder Hey?

WS:  Well, that's a really interesting question, because we thought it was going to make a huge difference; that we were going to be doing many fewer autopsies and keeping far less tissue because of Alder Hey.  Margaret Esirie, my colleague, looked into some of the statistics very recently, and in fact the curve is just going down as it was before Alder Hey.  So the number of autopsies had been declining anyway.  Alder Hey did make a blip but it doesn't seem to have changed what was already a downward trend.

SA:  And what was the reason?  Who is not asking for autopsies now?

WS:  It's a good question.  I think it's the clinicians who feel they get so much good information from all our sophisticated techniques – all our MRI scans – that they don't need to do an autopsy.  And Alder Hey perhaps just sort of justified them in feeling, "Well we don't want to ask for autopsies, they're not very nice."

There's far less importance placed on autopsies in medical training, too.  Medical students aren't expected to do them, or to go and see, I think, more than one or two.  [The attitude seems to be that ] we've moved on to being able to use much more sophisticated investigation, and the autopsy is a bit of an old-fashioned, rather gruesome way of looking at pathology.

Autopsies: a mine of information

SA:  And how do you feel about that?

WS:   I think they're completely wrong.  I mean I hate doing autopsies, always have done, but the information we get is absolutely invaluable.  I'm very interested in what causes Subdural haemorrhage Occurs when a blood vessel ruptures and blood builds up between the brain and the brain's tough outer lining, the dura.s in infants at the moment, and I've been going through some papers recently... There's a huge pile of them, and if you go back to material that was written in 1905 it's fantastic, because then autopsies were done on every case, they were done in enormous detail, and they were described in great detail.  A series of maybe 700 autopsies would be written up -- that's a huge amount of information.

SA:  1905?  More than a century ago?

Old fashioned, observational pathology has such an enormous amount to offerWS:  Yes, yes.  A lot of my information on the background of what I understand about subdural haemorrhage has come from looking at the really old literature, and it's all there.

SA:  Would you not get this same kind of information from MRI and other new techniques now?

WS:  No, it's detailed anatomy.  MRI gives us so much information, but it's actually seeing the structure with the naked eye and then looking at it under the microscope that really teaches us so much.

In fact just this morning I met one of our surgeons in the corridor -- he's interested in this area as well and we've got him all wound up about it!  He is a very bright chap – keen on doing research and getting the scientific evidence for everything that we say.   I had a long meeting with him on Friday afternoon and we threw all these papers at him and showed him some sections down a microscope, and said, "Come on, you see this in the theatre – what do you think of this?"  And he said, "Well, I'm going to have to go home and read about it".  And this morning I bumped into him and he said, "You know, I went back to the literature and I've got some fantastic old papers."  All from the 1800s, and the information was there.  And it was there because good, old fashioned, observational pathology has such an enormous amount to offer.

SA:  You think it’s still the gold standard?

WS:  I think it is, yes.  And we've forgotten a lot.  We knew a lot then, but all of those papers have got buried.   I've written a review that was criticised on the basis that I'm using information from the 1930s – "We have moved on since then…"  Well, hang on, we haven't!  Because then good, observational, descriptive pathology was the absolute bedrock to what we knew.  And we've forgotten it, moved away, and we think we know better.  Well we don't, because we're missing things with some of our new investigations.  Although the imaging is so good, it doesn't give us the same amount of information.

SA:  And are you able to push that line?  Are you telling all the people who are doing the MRI and all the other scanning techniques that it's wonderful but it's not the full story?

WS:  I hope so.  My own practice is that I look at the scans whenever I can.  For instance, if I'm examining a brain, I'll talk to my colleagues and say, "Can we look at this scan together?"  And then I’ll either get them to come back here or I’ll take a section across to them and say, "Look, that's what you've got on the scan. This is what it actually looks like.  And this is what it looks like down the microscope.  So what you're seeing as a high signal there…"  

It was just seized upon by the paediatric populationWe've actually had an on-going ‘row’ about this – it's all in good spirit, but they will stand up and say, "We've got heamorrhagic necrosis of the cortex of this baby," and I'll say "No, you haven't!"  "Yes, we have, we know because this is what the signal of the blood is when it's not moving – it must be in the tissues."  And I'll say, "Well, we've actually got the slides of this baby's brain (because the baby subsequently died), and there are no haemorrhages.  It's all in the blood vessels, and because those blood vessels are full of blood that's not moving… It may be very congested, but it's not haemorrhagic."  Gradually we're getting them to modify their terminology so that they're actually reflecting what's going on.  It might sound as if I'm just nit-picking because I've seen something that they haven't, but it's important that we understand the processes, otherwise we're going to make mistakes.

Shaken baby syndrome

SA:  Tell me, where did your fascination with the subdural haemorrhage story begin, and what's the picture that's emerging?

You get into a circular argumentWS:  Well, I came into this because of the increasing number of cases of ‘shaken baby syndrome’ – which is usually identified on the basis of finding a Subdural haemorrhage Occurs when a blood vessel ruptures and blood builds up between the brain and the brain's tough outer lining, the dura. on a scan.  Our understanding of shaken baby syndrome is based on one paper that was published in 1971, where a paediatrician said, "Gosh, I bet if you shook a baby you could get a subdural haemorrhage by tearing the vessels that drain from the brain into the dura."  He based that on some animal work that had been done in road traffic accident studies of patients who had got subdural haemorrhages but hadn't had an impact -- they'd just had a whip-lash injury.  

So they did these studies on animals and they found that yes, they could get subdural haemorrhages on animals if they whip-lashed them.  But the forces were enormous, and most of those animals had broken necks as well.  This paediatrician thought, "Well, maybe if you shook a baby you could also do the same thing," and wrote the paper.  The surgeon who was involved in this research actually rang him and said, "I think you can't do this. You can't extrapolate from adult animals to human infants."  And he either didn't understand, or didn't wish to understand and went ahead and published the paper.

Then it was just seized upon by the paediatric population who said, "Hey, we've got an explanation.  Brilliant!"  Shaken baby syndrome was born, and it's still believed.

SA:  It was as flimsy as that – it really was as flimsy as that, the basis of it?

She started thinking of other possible explanationsWS:  Absolutely.  And then hundreds of papers got published.  "We've got shaken baby syndrome, because we've got a baby with a subdural haemorrhage, and retinal haemorrhages.  The parents don't know what happened, so it must have been shaken."  Or, "The parents say it fell off the bed; we know that can't harm a baby, it must have been shaken."  So then they say, "Well, we know it's shaken because it's got these features.  And we know shaking causes these features," and you get into a circular argument.  

It was Jennian Geddes who first said, "Hold on, we're not sure this is what happens.  We're not sure that these vessels are actually torn."  Because if you did tear those vessels you'd get a massive haemorrhage -- such as we see in children who fall out of trees or get involved in road traffic accidents.  You get a great big blood clot.  That's not what you see in shaken baby syndromes. She started thinking of other possible explanations.

SA:  And is she a pathologist, a doctor, or what?

WS:  She's a neuropathologist who's since retired.

Searching the old literature

This is an absolutely fascinating area to investigateNow this is where I went back into the old literature and looked at all the birth-related Subdural haemorrhage Occurs when a blood vessel ruptures and blood builds up between the brain and the brain's tough outer lining, the dura.s.  And Jeanne-Claudie Larroche, for example, who taught me a lot of the neuropathology I learned when I was first starting, had looked at 700 postmortems and she didn't describe a single torn bridging vein.  [A bridging vein is one of these veins that goes from the brain into the dura and is thought to be torn when you shake a baby.]  She didn't describe a single torn bridging vein in a birth-related subdural haemorrhage.  And Cushing, writing in 1905, operated on these babies, and then he did the autopsies if they died, and he said he'd only ever seen two torn vessels.  And when he saw them he couldn't be sure [what had happened] because they were so congested.  But all that information has got buried.  

The good observational studies haven't supported the hypothesis that these bridging veins are torn, so we've got to look for something else.  That's why I'm now very interested in looking at the structure of the dura to see if there's a reason why blood might be coming back from the dura into the subdural space in babies of about three or four months of age.  That’s a very special little age group and the one that accounts for most cases that turn up with subdural haemorrhages without fractures, without bruises, without all these other horrendous injuries that babies get when they're being beaten up by parents, or carers or babysitters or whoever.

It could be non-accidental injury without any marksThis is an absolutely fascinating area to investigate – to look into all the samples we're getting; to look down the microscope and see if we can identify abnormalities in the blood flow channels in the dura in babies up to three months of age.  And indeed there are maturational changes.  The dura changes between birth and three months, and between three months and later on. The skull changes.  In little babies the skull is soft and the bones aren't fused together.  As you become older, about nine months, your skull becomes rigid and it becomes calcified so you've got a hard box.  But before then, if you thump a baby on the head, you may not get a fracture because the skull will simply bend.  In bending it can damage the brain, it can tear blood vessels, it can cause all sorts of injuries.  But it may then go back and you've got a baby who looks perfectly normal, but has in fact been bashed on the head.  So there are a lot of things that are very different…

SA:  But that would suggest that it is non-accidental injury surely?

WS:  Well, it could be non-accidental injury without any marks.  So you can have babies who have got damage inside the head, and you can say, “This could be impact, even though we've not got fractures or bruises”, because in the young baby the whole thing is different.

SA:  But can it also happen spontaneously… Or what are you suggesting?  That it does still seem to indicate non-accidental injury, but that shaking isn't necessarily the mechanism?

It was the biggest series that had ever been published..and she started asking a few questionsWS:  I think that it can be non-accidental injury, but I think we've got to be really careful.  Babies who get haemorrhages at about the time of birth don't seem to get them as a result of torn bridging veins – it's not that sort of trauma. Something else is going on.  It's changes in the pressure in the head.  And I think the same thing can happen to babies about three months of age.  For example, if they choke on a feed they'll immediately close off their airways; they'll try and breathe against a closed airway, or someone will come and resuscitate them, and that can change the pressure in the head.  And I think then the same mechanism might be set up as we have in babies in the neonatal period.  So I think there are a whole lot of different mechanisms that might cause spontaneous (or not spontaneous) bleeding into the dura in babies in this little age group -- three or four months of age -- that do not necessarily imply that they've had trauma, and certainly not necessarily inflicted trauma.


SECTION 2

The current debate

SA:  So how did you get involved?  Because, I mean, you say it was sometime back that the original literature was written.  How did you get caught up in this big debate?

WS:  It happened because I was reading the work that Jennian Geddes had done in 2000 when she raised the issue.  Well, first of all what she did was a fantastic neuropathological study – she looked at 50 cases of children who were thought to be non-accidentally injured, and she published this.  It was the biggest series that had ever been published, and it was just a very good descriptive study showing that most of these babies don't have the markers in the brain that we would use to diagnose trauma in adult brains.  All they have is swelling and lack of blood supply to the brain, and she started asking a few questions: "Well, how many of them are trauma?  And is it the trauma that's causing just a small damage to the brain stem, which is where all the control of respiratory function is, and that causes the child to stop breathing and then the brain swells as a sort of downstream effect of that?"  

The whole basis for this syndrome was incredibly insecureShe suggested that maybe the blood's coming from the dura itself.  She was the first person to ask that question.  And she started saying, "Well, maybe we've been getting it wrong".  And I suppose we all…Well I certainly sat up and thought, "Maybe I have, too," because I had simply believed that finding subdural haemorrhage and retinal haemorrhage and a swollen brain meant shaken baby syndrome.

SA:  Had you seen quite a number of such cases yourself?

WS:  I had seen some, and I'd actually diagnosed them as shaken baby syndrome.  It rather frightened me that I'd just accepted what I was told, so I started looking at the literature, and I started reading what was actually written about this syndrome, and realised that the whole basis for this syndrome was incredibly insecure.  Then I got into discussions with Jennian and with various other people who were questioning this, including a lively and informative group of forensic pathologists, biomechanical engineers, surgeons, radiologists, predominantly in the United States.  We exchange letters and comments about cases and discuss and question everything that's been written.

Questioning the methodology

We don't ask enough questionsIt's actually rather sad to admit that at my advanced years this is the first time I’ve become absolutely stringent and rigorous in my examination of any scientific paper to see that the methodology is good enough to accept the findings.

SA:  So this is the first time you've really woken up to the fact that something can be published that isn’t rigorous?

WS:  Well, I've known it can happen, yes, and I've tried to be reasonably careful in what I read, and I was of course trained to be careful.  But now I'm so much more vigilant, and particularly in this area.  So much of what we believe we're told and we accept – somebody teaches us something and we say, "Alright, that must be true", and we don't ask enough questions.

Somebody was quoting the other day one of his lecturers at medical school who said, "Lovely to welcome you students to my lectures here.  What I'm going to tell you is that you'll be given a lot of information here – and probably 50% of it will be proved subsequently to be wrong.  The only problem is we don't which half is going to be wrong and which half is going to be right!" [We both laugh] So we all have to keep on asking questions: "Is that right?  Do I believe it?  Does it make sense?"  I certainly became aware when I started asking questions about this that, in the area of shaken baby syndrome, the whole diagnosis depends on: "We believe it; we've seen it before; we know; most people believe that; we understand…" But not: "What are the facts to support our belief?"

“It’s wrecking people’s lives”

SA:  So in the cases that you’ve actually diagnosed as shaken baby syndrome, have you ever had to meet the parents, or come up against parents and carers who say, “That’s not how it happened”?  Because it is a huge indictment on the parents and carers, isn’t it?  And if they haven’t done anything, if it has been misdiagnosed for such a long time -- or the causes of it have been misunderstood – surely there must be quite a controversy there?

There’s a huge controversy thereWS:  There’s a huge controversy there.  It frightens me because it’s not just making the wrong diagnosis – it’s actually wrecking people’s lives.  I think the worst moment in this whole saga came when John Sweeney came to interview me for a television programme he made…what was the programme called?  He did a little series on Tuesday evenings on BBC... [tries to recall].  Anyway, he came to film this programme and I was warned about five minutes before that he was going to ask about a case that I’d diagnosed a couple of years before, and I looked at my report and it said: shaken baby syndrome.  

He then set up the interview, sat me down, handed me this report and said, “Two or three years ago (whatever it was) you diagnosed shaken baby syndrome.  Lorraine Harris has been in prison for three years.  Do you still believe in shaken baby syndrome?”  And I said, “No, I don’t.”  And he said, “Well, what do you think of your part in her conviction?”  And I was on camera; I was absolutely devastated.  It was a good piece of television.  I said, “Well, I’m just horrified.  It’s awful.  Because now I’ve had a chance to rethink and I don’t think I’d ever make that diagnosis again.”  

I was on camera; I was absolutely devastatedIn fact later, as a result of that television interview, I was asked to appear in the court of appeal in 2005 when [Lorraine Harris’s] case was heard.  I was then arguing, “Well, I don’t believe in shaken baby syndrome anymore.  These are the things I think I should have thought of and these are the alternative diagnoses.”  In the court of appeal her conviction was quashed, and the situation really went home to me when her solicitor, a delightful man called Campbell Malone, had to ring her and say, “Well Lorraine, you were right, your conviction was wrong.”  

Firstly, when the baby died she was taken to prison and she wasn’t allowed to go to his funeral.  Her five-year-old daughter was taken away and adopted while she was in prison, so when she came out after three years she was only allowed access twice a year.  Her husband had left her and her parents had died… [Waney’s voice cracks as she continues] Her life has been wrecked and it’s totally irreversible – you can’t take a child out of adoption and give her back to her rightful mother.  Her baby died of a natural disease, and yet the system has wrecked her life -- about as comprehensively as it’s possible to do.

SA:  [We both ponder in silence a while.]  So how did you come to terms with that?

Her life has been wrecked and it’s totally irreversibleWS:  It was devastating.  I’ve tried to come to terms with it by saying that I’m going to look into every detail and put everything I can into each of these cases.

“It was an honest mistake at the time”

SA:  And has it frightened you about making diagnoses, or have you recognised that medicine moves on, evidence moves on, and that it was an honest mistake at the time?

WS:  Yes, it was an honest mistake at the time.  Except that, had I had more rigorous criteria for believing what I’m told, maybe I wouldn’t have made that mistake in the first place.  But, you know, I think we’ve all made mistakes and we’ve all moved on.  But it still worries me because the amount of information we have is often insufficient to be absolutely certain of a diagnosis of non-accidental injury.  We have only a very small, well-defined evidence base, so often the best you can say is, “I really don’t know.”  And that isn’t helpful to lawyers; the police hate it.  But if it’s honest and it’s the position you’re in, then it’s what we have to say.

SA:  You said on the phone to me that you’re now passionate about this issue – was it that incident that made you so passionate?

What’s made me really passionate is what’s at stake for familiesWS: What’s made me really passionate is what’s at stake for families, as the Lorraine Harris case demonstrated.  I mean, if you can get it so wrong – and I’ve since had a number of cases where families have been found not guilty eventually, but the suffering they go through in the process is just awful.  Because often a mother can turn up at hospital with a baby who’s collapsed.

In fact, I met one mother where this happened: as soon as she got to the hospital with her baby they thought, because it had a Subdural haemorrhage Occurs when a blood vessel ruptures and blood builds up between the brain and the brain's tough outer lining, the dura., that she must be guilty of harming it and she wasn’t allowed to be on her own with the baby on a ventilator.  The police had gone to her home and they taped it off – you know, a crime scene – so all the neighbours were out there, and it was on the front of the local paper: “Mother accused of murdering baby.”  Her last hours with her baby were spent with a policeman with her at all times.

There was another case that really upset me.  This baby had been in hospital for only 44 hours before he died. That is not a long time to establish guilt.  In the notes the nurse had written: “Baby E is on a ventilator.  Parents are being interviewed by the police at present.  The police have said that if his condition deteriorates they will bring them back to the hospital.”  The parents were deprived of the last 44 hours of their baby’s life -- they were in the police station being accused of injuring him.  Just imagine, as a mother, how that must feel.  And they were found innocent.  Their case was thrown out of the family court. Those parents were deprived of the last 44 hours with their dying baby, and you can’t ever give that back to them.

We get into a very difficult, adversarial situation, with the hawks and the dovesObviously you’ve got to ask the question “Is this abuse?” because you can’t have babies being injured, but you’ve got to be rational.  If the baby’s in hospital on a ventilator, the parents are not going to be able to do much to it in that environment, so do you need to have a policeman sitting with them all the time?  And can you not put the other children with a grandparent or a neighbour rather than taking them into care? It just sets in progress this machine which has to make sure everybody’s safe. 


SECTION 3

Polarisation of medical experts

SA:  So you’ve seen the implications of a diagnosis and how it can absolutely unravel people’s lives in that way?

Becoming a Dame de la Jurade de St. EmilionWS:  Yes, and it makes one almost afraid to make any diagnosis at all.  The other thing I’ve seen is the polarisation of medical experts.  There are the people who believe that babies are injured by families…Well, we all believe that babies are injured by parents and carers.  But some are so passionate to further that belief in child abuse that they won’t brook any questioning.  They know it happens, and they say, “This is another case, and we’re not going to have any questions.”  I’m regarded as off-the-wall and a bit of a maverick because I keep on asking questions.  I keep saying, “I need to see some evidence before I accept it.”  So we get into a very difficult, adversarial situation, with the hawks and the doves.

SA:  And have you found that with your own colleagues?

WS:  Oh yes.

SA: And how do you manage that?  Is it in your nature to fight for causes, or is this just something that you feel is so important you are prepared to be adversarial?  Because if you’re not a confrontational type this could be very difficult, couldn’t it?

I’m absolutely not confrontational!WS:  I’m absolutely not confrontational!  This is part of the reason I’m a pathologist – because I’m not good at dealing with dying people and clinical situations where you have to make decisions immediately: do you give this drug or that drug?  No, I’d rather go away and think about things quietly.  But this issue has actually fired me up.  A few years ago if you’d said, “Go and be a witness in court”, I’d have said, “No, no, no.  A clever lawyer will talk me into saying black is white and I couldn’t possibly stand up to that.”  

But I’ve become so involved in this whole area; I’ve read so many papers, and I’m so up to speed on the evidence that we have that I’m willing to go into the witness box because I know that this evidence has to be put before the court.  I know that it’s important that somebody asks the questions, otherwise there are going to be dreadful miscarriages of justice.

SA:  Okay, so where are you at with it.  You realised there was a very flimsy evidence base, but are you creating a stronger evidence base for alternative mechanisms for this condition now?

WS:  Oh, this is a terrible problem.  Because yes, we’ve got quite a lot of cases now that we should be writing up.  But every time I get to being just about to write up a paper another case comes… “In court next week… we need your opinion”.  It’s really hard to get the time to do it all.

Interestingly – perhaps a sign of the way this is going is I was invited to write a review on the topic of Subdural haemorrhage Occurs when a blood vessel ruptures and blood builds up between the brain and the brain's tough outer lining, the dura.s for a paediatric journal.  I wrote my paper.  It was reviewed by two referees for the journal, who rejected it because, “It depends on old literature, because it’s not the current belief, it’s not what we understand.  This is a dangerous piece of writing.”  It was, as far as I was concerned, just an analysis of what we know about subdural haemorrhage using a lot of data I got from the old literature, and questioning the standard belief.

It’s a downhill run to prison from thereI phoned the editor, and I wrote to him, and he said:  “I’ve got two referees here.  We’ve got two referees who say ‘don’t publish it’, we don’t publish it.”  And it’s back here in my briefcase, waiting for me to publish it somewhere else.  Or to try.

SA:  This is tough – it’s indicating that the orthodox view is very, very difficult to challenge.  And the orthodox view can have a very flimsy basis – is that the story you’re telling me?  And that old data are not acceptable?

WS:  It’s not as if it’s old technology that we know was faulty or has been superseded.  This is basic, old, observational pathology: just simply people describing large numbers of cases, more than we can study today.  That doesn’t change.

SA:  So how many are you seeing of these cases?  Is it a very common problem?

WS:  Oh, I probably see a new case every week.

SA:  And is it still put down to shaken baby syndrome?

WS:  Yes it is.  And it’s hard to get beyond that.  In fact just before you came this morning two policemen brought me a case. I said to them, “I don’t think it’s shaking, there’s no evidence. The baby doesn’t have a broken neck; there are no grip marks.  This baby may well have been impacted -- either dropped, or smacked across the head or thrown against something.  But they kept saying, “Yes, well if the father hadn’t done it…” and they were making this shaking gesture.  They just can’t get away from the idea that ‘this is what families do to babies’.  

Orthodox opinion is being challengedSo we’ve got a long way to go to get that out of common parlance. Because once you’ve got shaking, you’ve got ‘intentional injury’.  If you’ve got impact, it can be just as intentional, but it can also be accidental.  So you are at least putting it on a level playing field.  And then you can put your facts before the court and the jury can make their decision on the evidence that’s put before them.  But once you’ve got shaking it’s ‘intentional’ and it’s dead easy – it’s a downhill run to prison from there.

Improving the evidence base

SA:  Do these babies always die?

WS:   Almost all the ones I see have died, obviously.  But I do get asked sometimes to comment on babies who’ve had brain scans because of my interest and understanding of the pathology.

So from there – you were asking how we are trying to improve the evidence base – well, we’ve got to publish, publish, publish.  But it’s a problem to publish.  You can’t always publish, because the orthodox opinion is being challenged.

I’ve had that with two papers -- being rejected because they’re challenging what the paediatricians want to hear.  And I think one of the reasons for that is that if you’ve diagnosed shaken baby syndrome in dozens of cases in your working career and then you think, “I may have been wrong!”  How can you live with the fact that you may have broken up families, sent people to prison, and you were wrong?    I’ve been wrong.  And the best thing you can do, I think, is say, “My goodness, I might have been wrong.  Let me re-think.”  But I think there’s a sort of, “I can’t face that, so I’m just going to pretend it’s not there and carry on.”

“The detail is so important”

SA:  But as a pathologist aren’t you in a powerful position to say, “This is not shaken”?

Riding in MinnesotaWS:  I do say that.  So we have to look further, to demonstrate impact or prove that there was some other sort of neglect or abuse. The detail is so important: in some of these cases we find a huge sub dural haemorrhage during postmortem. Well, that goes with shaken baby syndrome.  Then you go back to the scan that was taken the day the baby was admitted to hospital, soon after the collapse, and there’s no subdural.  A scan two days later and there’s a bit of bleeding, and then you come to postmortem and there’s a lot of bleeding.  

The hawks will grab this and say, “Well, subdural haemorrhage -- it must have been shaken.”  But then I ask, “What about the scans?  If the baby had been shaken, the blood would have been there on day one.”  What’s happened, I think, is that the blood is coming from somewhere else and it’s oozing… the baby’s sick and it’s on a ventilator, the liver’s not working, blood clotting’s not working.  This is collecting over a period of days.  

In fact I’ve got to go to court tomorrow on a case where exactly this has happened, and the prosecution is running a diagnosis of shaken baby syndrome.  And I’m on the prosecution side!  I’m a real thorn in their flesh, because I’m saying, “You can’t say it’s shaken baby syndrome.  There’s no broken neck; there’s no bruises where the baby’s been gripped.”  This is a huge baby.  And the blood would have been there on the first scan, but it wasn’t.  All of the radiologists on both sides who’ve looked at this case have said, “There’s no blood on the first scan.”
 
SA:  And so do they agree with you that there are much bigger questions?

WS:   I don't know.   I'm saying, "I think this baby's probably had impact injury on separate occasions", but that's not very good for the police because they want the injury to have happened 'at 12 o'clock in the morning, 3rd November 2003', or whatever, because there was only one person with the baby then, and it makes it really easy for them to identify a perpetrator.

SA:  Because impact is a much more complicated story -- it could be anything?  It could have fallen off a high chair or something?

I'm willing to be as controversial as it takes – if I've got the evidenceWS:  Yup, yup, yup.  Specially if you say, "Well, I think it's been impacted on a number of occasions, because there's old bleeding as well."  Then they say, "Oh well that's really difficult because the parents have been looking after this baby, and there's a baby minder, and the aunts and uncles... and all the rest of it.  We can't pin it down on somebody.  We need a nice tight story that fits with the baby collapsing in the presence of only one person."  And that's where it becomes a very difficult place to go, because my colleagues run with the story of shaken baby syndrome, and I think we've got to look at other things.

Alternative theories

I go to meetings here at the hospital very regularly where I will be greeted with, "Is it another ‘killer milk syndrome’, Waney?"  Because I believe that some little babies choke on their feeds and die.  Especially if they've had a difficult delivery and they've had bleeding at birth. That bleeding may not have completely healed and it may re-bleed.  And if they choke they're going to raise the pressure in their heads and they'll get another subdural bleed.

SA:  So is this the first time you've been really challenging the orthodoxy in your career, or have you found that being a pathologist means you're always in a slightly challenging role?

WS:  No not challenging at all.  I mean we're quiet people who go away and work in the back room and send out the diagnoses – as Irene would say, "On their little legs to run along the corridor"!  But no, absolutely not, I'm not a confrontational person.  But I've got to the stage now where I feel so strongly about this that I think, “I've only got a few more years to go; I can be difficult; I've nothing to lose; but there is a lot to be gained if we can prevent miscarriages of justice.”  So I'm willing to be as controversial as it takes – if I've got the evidence.  I work on the facts in front of me.  I'm not willing to bend the rules on that principle.

SA:  Irene was telling me a bit about her research with Subdural haemorrhage Occurs when a blood vessel ruptures and blood builds up between the brain and the brain's tough outer lining, the dura.s perhaps happening before birth even.  Have you been working on the 'before birth' scenario as well?

We have to be really careful that we're comparing like with likeWS:  With Irene?  She's been tremendous, in fact, in sending me some material and lots of autopsy reports…

SA:  And how interesting do you find that – the idea that it could happen before birth even?

WS:  Well it's fascinating.  It's also the haemorrhages that can arise before birth but mostly around the time of birth due to the birth process itself.  I think that's something we really should be looking at, because the mechanism is probably not trauma, as when the brain moves within the head, but it's probably due to all the pressure changes that are going on.  

The most important thing -- and the thing that's really getting me excited at the moment -- is the changes that happen from birth to six months of life.  The brain is maturing, but it's not one brain at birth and something else two, three weeks later.  It's a process that takes time.  So I think that the babies that really bother me, which are the very young shaken babies, are more like the neonatal bleeds than they are like a five year old.   

When we're looking at all this literature we have to be really careful that we're comparing like with like – we're looking at what's happening in tiny babies.  So to look at what's happening at birth, and have examples of babies who've got subdural bleeding at birth and to look at where it's coming from is terribly, terribly important, because I think that's relevant to the shaken baby syndrome. I’ve recently been looking at papers on how the dura actually develops and what an immature dura will do compared with a more mature one.  We have to look at the detail of every case. To just use the sort of prosecutor-hawk standard, "Shaken baby syndrome means we've got subdural haemorrhages, retinal haemorrhages and a swollen brain, and that's all we need," is just so imprecise as to be meaningless.


SECTION 4

SA:  One of the other things you were talking about when I last saw you was cerebral palsy – have you continued being interested in that?  What's the story that's emerging there?

We don't know why they're getting these particular infectionsWS:  Well that's also very interesting.  This is the great thing about this job – there are so many fascinating things to look at, one hasn't got nearly enough time to look at them all!

SA:  Really, you remain hugely excited by it do you?

WS:  Oh yes, yes!  I'm really good at starting projects and rushing off to do them, and then not getting round to finishing the writing-up, dotting the 'i's and crossing the 't's!  

But in cerebral palsy, what's happening there?  There are two areas that really interest me.  We've got a lot more information about what may be going on in mothers who've got infections when they're pregnant – infections that get into the placenta and membranes around the fetus.  This is increasingly associated with brain damage, and we don't know why.  Of course the worrying thing is that if pregnant women think, "Gosh, if I get an infection, my baby's going to be damaged," that would be awful, because everybody gets infections all the time.  We don't know why they're getting these particular infections.  We don't know how we're going to be able to treat them.  Doing things like suppressing the inflammatory response would damage the developing baby, so we've got to be very sure about this before we leap in and start trying to treat it.  

We don't know how infection causes the brain damage – whether it's partly to do with the body's response to the infection, combined with some lack of oxygen.  A baby who's been in an infected environment will do very badly after a normal delivery; and if it's a bad delivery it will do extremely badly.  So that's one story that's interesting: trying to correlate what's going on in the placenta with what's happened in the brain. This is something we've thought about for a number of years, but the infection issue adds another little twist.

SA:  And have you pinned down exactly what type of infections they are?

WS:  Well there are a number of bacteria which are most commonly found, and I think there are people looking into whether there's something about a particular organism that causes the response in the fetal brain.  But that's not my area, and it's quite difficult for us to contribute anything because we're seeing a final common pattern of brain damage which is fairly non-specific.  But it's just trying to tie up what's happened in pregnancy with what's been found in the placenta that's important.

Learning from MRI technology

These brains are tiny, and everybody's learningThe other area that's of tremendous interest to me is trying to correlate what's being seen on brain scans of the fetus now with what's happened to the developing brain.  There are more and more fetuses now that have MRI scans in utero.  Because MRI  technology has got so much quicker, you don't need to have a fetus that's going to lie still for 40 minutes, and you can get some exceptionally beautiful scans of them.  If I receive a baby where there’s been a termination of the pregnancy because of brain malformation, I'll take the affected sections of the brain across to my colleague who does the MRI scans and say, "Well, this is the brain; that's your scan -- how can we learn?"  Because these brains are tiny, and everybody's learning.  

What we're trying to do is identify patterns of injury that we can see on scans that are associated with specific genetic problems, so that we can know a) whether a termination should take place, and b) which gene we should be looking for if we see this pattern on a scan, and what the chances are that a mother will have another baby with that same malformation.

Because the brain scans are in themselves fairly non-specific (you obviously can't see the detail of what's going on at a cellular level), we're trying to look at a lot of these cases down the microscope and then compare back to what the scans are showing.  Those two huge files of slides over there are all of a condition called poly microgyria  -- an abnormality of brain development where the cortex, instead of having the normal regular folds, has lots and lots of folds, as if they've all stuck together abnormally.  It's something that's used as a clinical diagnosis and an MRI diagnosis, but when we look down the microscope we realise that there are four or five different kinds of poly microgyria, and some are caused by infection, some are caused by lack of blood supply, and some are caused by genetic problems.  

That's what I find absolutely fascinatingWe've got all of these cases, and I'm working with a paediatric neurologist from Brussels and she's got a lot of cases from Canada, so we've got a multi-centre study.  We're looking at the microscopic appearances to see if we can group them into the various different clinical categories so that we can try to understand what's going wrong -- what the cellular process is that's leading to this happening.  

That's what I find absolutely fascinating – that we're looking at the actual mechanisms during brain development. We can look at one little group of cells that's going wrong in one form, and another group in another form, and they will have different genes.  So we may have a chance of knowing where we can intervene, or at least what the prognosis is for future pregnancies.  

SA:  What can you see down the microscope as far as genes are concerned?  Do you have to become an expert in genetics as well?  

WS:  Oh no, it's hopeless. We can't see anything. We have to get the geneticist to do the tests on the DNA stands for deoxyribonucleic acid.  This is the material inside the nucleus of the cells of living organisms that carries genetic information (see also RNA). . And now of course we've got terribly sophisticated, and we're able to sequence out genes on these great big machines that we've got.

SA:  So it's a team effort – you see the cellular things, then you've got the MRI people and the geneticists who will be correlating information at the same time?

WS:  Yes.  So I'll look at a case and say, "I think it could be this gene or that gene that's at risk".  The geneticist will then see the family, look at the family history, see if it fits in with some of these genetic abnormalities which are passed on by either mother or father, in a dominant or a recessive form.  So they look at the pattern, see if it fits, and then they can do the gene analysis. Often it's not possible to get very far with it.  Many of the cases we see that are difficult are complete one-offs – you know, you've never see that pattern of malformation.  But then from time to time we will get a case where we say, "Oh, I've seen something like this before".  And we'll find another one [in the archive], and then sometimes I'll write to the clinician, who says, "Oh, well, actually those two parents are cousins."  

It doesn't happen very often, but when it does it's really satisfyingTwo or three cases have happened where this has come together -- we've got a couple of very rare brains that we've been able to put together, often after many years, and a pattern emerges.  Then we realise that the gene has been discovered, and we can go back to the parents and we can do the gene test and we can advise them.  Now this may be far too late for that particular parent, because she's already had her children or lost her children, but her sister or her daughter or somebody else in the family may really want to know [about this problem] because they're likely to be at risk of passing on the same mutation.

SA:  Has this actually happened, have you actually been able to go back to families later?

WS:  Oh yes, yes.  Usually because new cases come up, and we've gone back to look up another case and made the link.  It doesn't happen very often, but when it does it's really satisfying.  And of course what this brings us back to again is being able to return to cases because we've got them in the archive.  And to revert back to the shaken baby syndrome, if we want to go back and say, "Well, I've looked at 20 cases in the last year, I'll get them out and look at them again," we can't do it because the police have taken the specimens away.  Or the families have wanted them and they've been buried, or whatever.  We don't keep the material so we are really restricted in what we're able to do research on.

The coroner’s role in tissue retention

SA:  So has that happened since the new legislation in the wake of Alder Hey and Bristol?  That literally you haven't been able to keep the last five years' slides? You haven't been able to build your banks and libraries?

WS:  No, we are building banks, we are managing to in some cases.  But it's much more difficult to do so in police cases.  The coroner’s remit, as always, is to diagnose the cause of death.  If we want to do any more than that they're quite good – at least our local coroner is very good – we can say, "Please can we ask the family if we can keep the brain because we need it?  Although we know the patient died of a heart attack, we know that there was some really interesting brain pathology going on here." And he'll say, "Well if you talk to the family, you can do it."  

So we often do.  I'll ring the coroner's officer and say, "Please will you ask the family to call me?" and I'll discuss it with them myself.  I'd rather do that than have a coroner's officer -- who can't explain perhaps what the benefit would be -- go and do it.  So that way we can keep tissues.

SA:  So are you doing that quite a lot now?

WS:  I am, more than ever before.

SA:  And have you got quite good at it?

WS:  Yeah, better than I used to be I think! [Laughs]


SECTION 5

SA:  Because you were saying before that one of the reasons you went into pathology was because you wanted to retreat from the grief that you had to witness.  How easy is it now to face that issue?

WS:  Well I'm actually quite impressed with myself! I thought it would be terrifying.  I think going through the whole Alder Hey thing and having very angry parents storming up to the hospital saying, "You stole my baby's brain; how could you do it?  You people…" really angry, grieving parents, even years on… And having had a few that I've sat down with and they've gone away saying, "Oh, now we understand… You learned something; his little life wasn’t in vain”, that really gave me confidence to believe that sometimes I was getting it right with families.  

We are absolutely perplexed by the whole syndromeSo now I'm quite willing to do it, and I often tell the paediatricians or the coroner's officers they don't need to worry about talking to families about autopsies and brain examination, I'll speak to them.  I don't want to phone families at home – that's not appropriate.  But I'll say, "Please ask the families to call me", so they can do it when they're ready to.  And I'll talk to them and ask about keeping tissues.

SA:  What's your success rate?

WS:  It's not bad actually.  Last night at 8.30 I had about 40 minutes on the telephone to the parents of a little three year old girl who died a couple of weeks ago.  We don't know what she died of.  We are absolutely perplexed by the whole syndrome.  She had been ill, but they didn't expect her to die, and they hadn't sorted out what was going on.  She may have a very, very rare syndrome.  But the father called me several times and I said, "Feel free.  I can't give you any answers but I'm perfectly happy to talk to you".  I told him I was going to cut the brain yesterday, so he wanted to know what we found.  In fact we found nothing that was really helpful to him.  But that meant we had to think again.  So I phoned the paediatrician yesterday afternoon to see what she was thinking, because I wanted to speak to her before I spoke to the father.  

It's still a shot in the darkThen he phoned me again last night and we had a long, long conversation in which I said, "We don't know.  But I have spent the afternoon Googling the possibilities; I've come up with some papers; I'm going to read them and see if that might help us."  We're all going to meet at the end of the month.  But after this conversation, where essentially I hadn't given him any answers but just a lot more questions, and explained where we're going and what we're thinking of, he said, "Nobody else has given us any information. You're the only person we've spoken to who actually tells us anything."  And I said, "Well I'm sorry I can't give you a diagnosis."  "No, but at least you're telling us where you're going; you're being honest; you're explaining what you're doing and what you're looking at."  And that is a huge comfort to him.  

He's going to look at all these papers as well.  It's still a shot in the dark, and I think he understands we're not giving him diagnoses.  But he's understanding the difficulty of working through this, and that what we're doing is really, really trying to come up with some answers for him.  He's got another child and he wants to know if his son's going to die in his sleep… It's a terrifying situation.

SA:  This child died in her sleep did she?

WS:  Yes, at home.  Mother went and found her in her room in the morning when he'd gone to work.  

SA:  So the coroner would call for that postmortem?

WS:  Yes.  And he's happy for us to speak to families if we do the contacting and the work.  He's not happy for his officers to be used to go and do this work for us, because it's not his remit and he hasn't a budget to do that.

SA:  Okay, that's a good question – where does the budget come from if you want to do more than the coroner's inquest requires?  Who do you have to apply to, and say "We think it's important to find out what really happened, we need money for it"?

WS:  I wish you hadn't asked that!  Because if one of our managers hears you asking  they'll say, "That's a good question, who is paying for this?"!  It's part of our remit as a diagnostic neuropathology department to make diagnoses.  We have to do what it takes.  And in neuropathology it's often not just five minutes under a microscope.  It's five days or five weeks of intense study to try and get the right answers, and that's what we're here to do.

SA:  Okay, but a coroner wants an immediate or fairly swift diagnosis – you can't say to him, "It'll take a long time for us to get a diagnosis, and you're going to have to pay quite a lot of money to do so"?

WS:  Oh no, we can.  In this case we don't know why the baby died.  He knows we have to do the investigation, so we've got his consent to keep the brain.  He usually says, "How long d'you want it for?" Three months is a kind of rough figure.  He may come back to us and say, "Right you've had your three months now."  But he would allow us to keep it if we haven't come to a diagnosis by then.  

We really have to allow families to grieve and to move onBut if we had found, say, that this baby had a very complicated syndrome but the cause of death was that, because of this syndrome, she'd choked on a feed or something, he might say, "Well that's enough.  Now you pay for the rest."  So it's a difficult issue, and the coroners have had to be strict with it because their budget is limited, and they have to work within that as well.

SA:  And do you have a second chance – if you keep the brain, say, for three months and you realise there's a lot more questions you want to answer, can you then go back to the parents and ask if you can keep it for the archive, for research, for teaching?

WS:  As far as the coroner's concerned we can, I think.  I personally think that's a terrible thing to have to do, because at three months the parents have probably moved on quite a long way in trying to get over the loss of a child.  So if we possibly can, I like to talk to the parents at the time of the autopsy, to say then, "Ideally this is what we'd like to do, because it may come in useful; it may be that we need to go back to the brain.  

It may be that we can make a diagnosis in three weeks, but it's always helpful to have this sort of material in our archive."  If we ask the questions then, although they're very raw at that stage and it's really hard for them to contemplate it, I think it's better than coming back to parents later on, because we really have to allow families to grieve and to move on.

SA:  You once said to me that you didn't think asking for consent was really the job of the pathologist, that you weren't trained for it, and that there was going to have to be a new cadre of people, counsellors or something.  Has that happened, and do you think it's necessary?

Most pathologists won't get involvedWS:  Mm, I do.  Because most pathologists won't get involved.  I think I'm sort of unusual in wanting to speak to families, but I really do – it's important. What's happened is that we've got a superb bereavement team now.  These are people who have been trained in what we need to do: what sort of materials we need, what's involved in a postmortem, why we need to keep things, how long we need to keep them.  So they understand our side of it and they're also extremely good counsellors, as it were.  They know how to talk to people who are bereaved; they know what sort of information families want and how much information to give them.  That's actually been a tremendously successful innovation since Alder Hey.  

The bereavement team is taking responsibility for asking for consent, because clinicians didn't want to do it and weren't necessarily terribly good at doing it.  And pathologists weren't either.  So [the bereavement counsellors] have stepped right into that area where they're available to families and they can be a link between us, the coroners and the families. That's worked extremely successfully in this trust.  I'm not sure if it works as well elsewhere.


SECTION 6

Family life

SA:  Okay, Waney, let’s hear a little bit about your own personal path into pathology.   What kind of family did you grow up in – what's your family background?

WS:  My family was completely non-medical.  And non-university, but they hoped my two brothers and I would do well at school and go to university.  I had two older brothers.  At school I really enjoyed biology and learning how tissues work in animals and plants -- you know, “What are the mechanisms of living things?”  So I wanted to do zoology and do research.  And I wanted to do psychology, of course -- we all want to know what makes people tick when we're 18!  

I couldn't possible scrape people up off the M40 and put them back together againMy brother, who is seven years older than I am, helped me [decide what course to take].  He was doing zoology and he used to make me revise with him, ask him questions and test his knowledge when he was doing ‘A’ levels.  He did natural sciences at Cambridge and then went into research in a dental school in London, and he soon realised that there's a very real disadvantage to being a pure scientist as opposed to being a dentist.  If you're a dentist you can go out on a Saturday morning, do a few fillings and buy yourself a nice smart car.  But if you're a scientist in this country you're on a very different salary and you're on this constant… You know, every three years you've got to write a grant, you've got to apply for your funding and you don't have tenure.  

So he fairly soon ended up going to the States, where it's much easier to work as an academic scientist in a clinical environment.  Anyway the upshot was, he said when I was applying for university, "You're going to do medicine."  And I said, "No I'm not.  I'm absolutely not.  I couldn't possible scrape people up off the M40 and put them back together again.  I'm just not that kind of person."

SA:  Really?  That's what you felt?

WS:  Really, yes.  I was just not cut out to be a doctor.  And he said, "Do it, because you'll find that when you go through medical school you'll have all the opportunities to do a huge range of things.  You can go and do research, but just get yourself qualified in medicine.  And so I did."

SA:  And did you enjoy it?

I'm better off not making rapid decisionsWS:  Oh I loved it.  I had a ball at medical school; I thought it was tremendous fun.  I was in Leeds.  It was a great place, because we had a huge number of patients per student.  Being relatively few medical students in Yorkshire we had lots and lots of opportunities to go to small peripheral hospitals -- to do paediatrics in Bradford,  psychiatry out in Killingbeck, or wherever.  We got sent off on little postings, two or three of us at a time, to go and live in little cottage hospitals and we saw lots and lots of patients.  Compared with what my friends had in London I think we were very lucky because we got tremendous clinical experience.  

At the end of that I decided I was either going to do paediatrics or pathology.   I was still fascinated by what goes on at the tissue level, but I wanted to try paediatrics because I really enjoyed it.  I thought kids were tremendous fun. You couldn't have a stuffy old professor shambling around in paediatric wards because the kids wouldn't allow it.  I enjoyed paediatrics and did that for a few years.  But then I found that I'm better off not making rapid decisions and not having to deal with the sort of emotional environment you get with sick and dying children.

SA:  You found that really quite harrowing, did you?

WS:  Yes, yes I did.  I always had to take a deep breath before I walked into casualty, not knowing what one's going to see.  Running around being told to do something… Nursing staff saying, "Right doctor, here's a child having seizures – do something", and you have to do it.  I'm not that sort of person.  Even now I never make a diagnosis at once.  I always look at a case, think about it, go home, come back next day and write a diagnosis only when I've had time to reflect.  Although I really enjoyed paediatrics, I need time to think and I get a bit crabby when I've been up all night [Laughs].  So I ended up going into pathology.

SA:  And did you know about pathology already?  Where did you first come into contact with pathology?

I wanted to know what the mechanisms were, why things happenWS:  At medical school.

SA:  Was it well taught?

WS:  Yes, I think it was.  Leeds actually had a very good pathology school. I started off the first two years at medical school doing anatomy, physiology and chemistry, and I really enjoyed anatomy. I did a BSc in anatomy – had an extra year, which was looking at tissues and things down a microscope, and I really enjoyed that.  I realised also that I liked asking questions; I wanted to know what the mechanisms were, why things happen.

SA:  So this is a very natural niche for you in the medical sciences?

Every day I'm being sent things to look at which we don’t understand,..It's always fascinatingWS:  Yes it is.  And the great thing is, if I'd gone into pure research, you've got to come in on a Monday morning and think, “Right what am I going to do today?  Let's set up a project and do it.”  You have to think of it, design it, and set it all up and then pursue your research, whereas in pathology, if I walk in on Monday morning, somebody will say, "Right, here's a case for you to look at."  And there's the question: why? What's happening in this case? Why is it different from the last one?  Every day I'm being sent things to look at which we don’t understand, which we have to look at.  So there are always lots of things to ask questions about, to read about, to do research on.  It's always fascinating.

The thrill of detective work

SA:  And how did you go into neuropathology and paediatric neuropathology?

WS:  In general pathology you can spend your life looking at, you know, prostatic chippings, little bits of skin, hundreds and hundreds of very similar samples.  In neuropathology the brain is so complicated that each case is always a very long, involved study.  I was fascinated by the brain and brain development when I was a student as well, and found neurology quite interesting.  But you never get any answers in neurology, you do a few tests and then you sort of guess, whereas in neuropathology you've got a really complex organ and a lot of very difficult questions to answer.  I think it was that that interested me.  And having been keen to do paediatrics, I thought that looking at the developing brain would be interesting.

In development every week the brain is differentAnd of course it's completely fascinating. Much of adult neuropathology has to do with dementia and Alzheimer's disease and strokes and things that really are on the way downhill, whereas in development every week the brain is different.  It's like putting a puzzle together. When you see a brain scan of a child who's got cerebral palsy who's six years old or something, you can look at the scan and say, "How can we tell what happened?"  Well, we know that this structure has formed, and we know it forms between 11 and 17 weeks of gestation, so the event must have happened after 17 weeks.

Okay, we know that neuronal migration has been interfered with as well because there's malformation there in the cortex, and that happens before 23 weeks, therefore this must have been between 17 and 23 weeks gestation. So you start asking questions: "What happened then to cause this pathology?"  Nobody knows.  So you go back into the notes and you find, hey, this mother was admitted to hospital because she'd been involved in a road traffic accident, she was kept in a couple of nights, and there was a lot of abdominal bruising.  Wow!  That might be your answer.

You're doing this detective work which you can really only do on the developing brain, so it's absolutely fascinating, to me.

SA:  You said the other day that you go home thinking how lucky you are to be doing this.

Wow! That might be your answerWS:  Absolutely.  In fact I've got a trainee with me now, a neuropathologist visiting us from Sweden for three months, and on Friday we were working together and when we finished the day we both went, "Wow!"  We had so many interesting cases.  We saw a case of a woman who had something called fat Embolism The obstruction of a blood vessel by a foreign substance or a blood clot. to the brain.  She'd had an operation on her leg and obviously some bone marrow had got into the blood and had dispersed through the circulation and blocked one of the vessels in her brain.  It's only the second case I've ever seen in my life.  Very, very unusual.  I showed it all around the department and nobody else had seen such a good case.  When you see something that's really rare and you've spotted it and you've made the diagnosis, it's really satisfying.

Then we had the afternoon talking to the neurosurgeon about my ideas of what's happening in the dura with these babies, and we sent him home saying, "My wife's going to kill me, because I'm going to spend the whole weekend reading these papers and asking questions now.  You've set me up for this!"  But that's really stimulating, when you've got somebody else who wants to ask the questions… These cases come through every day, I don't have to go out looking for them.  It's just our everyday work.

Balancing motherhood and career

SA:  What about home life – do you take your work home or are you quite good about dividing off?

I would never advise any woman to go part timeWS:  Oh that's got worse and worse!  I've got two daughters who have now left home, so I've got lots of time to work if I need to.  And the medico-legal cases of course are done outside my NHS hours, so they tend to take over at home.  There's an awful lot of paper work so the dining room is a bit stacked up with papers.

SA:  What did the kids feel when they were still at home?  How did you manage motherhood and the job?

WS:  [Laughs] That's quite interesting, because when my daughters were little I was just starting off in my consultant job in neuropathology.  They were at the 18 months and just-born stage, and I was driving into Oxford each day and dropping them off at nursery and driving back home… I was working part time then, and I would never advise any woman to go part time because when you're not there the work just gets plonked on your desk.  You get to do the same amount of work as everybody else but in your reduced hours -- and with reduced pay.

So at that stage I was just fraught most of the time.  If I wanted to write a paper it would probably be one o'clock in the morning that I was writing it, and going to bed to get up at 6.30 am to get the children up for nursery again.  They have said to me in recent years, "Those years were absolute hell, it was awful, you were so busy all the time.  And you were always bad tempered"!  But they actually now are incredibly proud that I've got a job that keeps me stimulated and keeps me busy.  Also, I'm doing things that I think they regard as very valuable.

SA:  Did you feel guilty at the time?

WS:  Oh yes!  Constantly guilty.  Even though one's paid half time I was aware that I would be leaving at 3.30 pm when the nursery closed and my colleagues would be looking at the clock as I left.  They probably just thought, "Oh, it must be tea time, she's off."  But I was thinking, "They're noting that I'm going, and they're staying."  So you compensate for that by working harder and doing more than anybody else, and trying to write the papers and so on.  And you're guilty because you're not always there for your children.  And at weekends you know you should be doing things with them but you just actually have to prepare for a lecture.

But on balance, looking back… I find the work so fulfilling, and it is lovely occasionally when you look at something and think, "I know what it is because I've seen it before".  One of the compensations of getting old is that you do gain experience.  Also now I find I'm confident enough to take on the battles of the shaken baby syndrome, and think, "I'm tough enough to deal with this". I don’t think I could have done that if I'd stopped, given up my career and then come back to it. So it has been immensely rewarding.  And I do think that, for all the girls feeling they had a rough few years, they're very pleased to know now that they've left me with a  fulfilling life rather than a huge empty nest and a less-than-satisfying career.

Family  influences

SA: Going back to your own family, what sort of home did you grow up in?

WS:  My father went to an excellent school and wanted to be a farmer.  But his father was killed in the first world war, and he had two brothers and his mother said, "You have to go and work. Your uncle can get you a job in the bank."  So he became a bank manager, and he really didn't enjoy it very much.  But he retired when he was about 58 and he bought a smallholding – a house in the Cotswolds, a cow and a calf.  He acquired a dog, a stray cat, some ducks and some chickens, and he was so happy for 20 years, it was absolutely lovely.

SA:  But this was after you'd grown up?  He was a bank manager to put you and your brothers through school and things?

WS:  Mm.  My mother had been a secretary, and she was full-time at home and was terribly ambitious on my behalf.  She didn't want me to be stuck at home not having a career.  So she was very keen for me to go to university and get a decent job.

SA:  Was she an influence on you, an inspiration in pushing you?

They know what it's like to be really roughed up in courtWS:  I think so.  There were times when I thought her approach wasn't quite balanced… When I was expecting my first baby, it was, "Isn't this going to interfere with your career?"  And when I told her I was pregnant the second time, "Oh not another baby!" As if, "this is going to stop you shooting on with your career".  I desperately wanted to have children and I thought, "Well I'm going to do both," and fortunately I did.  That's another reason for being a pathologist – it's much easier to be flexible about your time if you’re in pathology, and not having to do long nights and weekends on call and so on.
So yes, I think my mother was influential in making me want to do well, and making me want to pass exams.  My father was much more laid back -- he wanted me to do what was right for me.  I think the biggest influence was this older brother of mine.

SA:  Did he take an interest in your career?

WS:  Oh yes, very much so.  And he still does.  He helped me to get there and be inspired and get through medical school.  And again, he expected me to do well. You don't fail exams, you pass exams, and you pass them well.

SA:  In the big moments in your life, like that awful case you were telling me about when you realised you'd been accepting things too readily, who have been the people you've turned to for inspiration, comfort, support in your career?

That was his tactic – to get the jury to believe that whatever I said was not to be taken seriouslyWS:  That's an interesting question.  My daughters have always been very supportive.  But I’m always terribly careful about not making them feel that I’m depending on them.  Other colleagues; other people making these diagnoses.  Some of the lawyers I've worked with, who do a lot of defence work, will be really supportive in saying,    "Yes, you've got to say what you think".  So too are other professionals who think as I do, particularly in the States.  They know what it's like to be really roughed up in court, as it were, and if you've had a bad day in court you can always email them, and they'll say, "Yeah, tough…"


SECTION 7

Being an expert witness

SA:  Is it very rough in court?  Are they fairly cruel?

WS:  Oh yes, very much so.  I don't think we get nearly the maltreatment that they get in the United States – personal character assassination is very much on the cards there.  It's not yet as bad over here.  But I was in a case just recently in Chester, and I have since read the transcripts of one of my colleagues being cross examined in the witness box and being asked, "D'you agree with Dr Squier or not?"  He said, "Well yes I do."  And they said, "But she's out on her own; she's a lone voice; she's going against all the orthodox opinion, isn't she?".

I wasn't asked those questions, but my colleagues were, and this was clearly the prosecution building up a case to set me aside as being completely off the wall.  There are lots of people who believe what I believe, but in this case that was his tactic – to get the jury to believe that whatever I said was not to be taken seriously.

SA:  You'd already been cross examined had you?

Making me out to be a complete maverickWS:  I had been cross examined, yes.  And in fact it was one of those cross examinations where the prosecution barrister was really trying to get to me by bringing out paper after paper from the literature.  But every case he brought out I'd actually read and knew in great detail, so when he quoted a paragraph at me I could say, "Yes that's all very well, but look at the next paragraph, where he qualified that…"  This selective quotation from the literature is terribly dangerous.  I thought, "Well, I've managed to counter everything he's come at me with".  But the sort of character assassination of making me out to be a complete maverick…

SA:  So what happened?  What was the jury's verdict?

WS:  It was really interesting, because the man was convicted and the judge allowed him to go home and spend three or four days with his family before going to prison – which is unheard of.  So the judge was clearly very upset with the way the case had gone, with the jury's decision.  Normally, if you're convicted you just go straight to jail.  Do not pass go!  The lawyers in the case said they thought the judge was unhappy with the way the verdict had gone, because he felt there was enough evidence to make conviction very uncertain.  But you've got a jury…

SA:  So are you getting more and more caught up in court cases?

{audio}/mp3/Waney Squier_clip2.mp3{/audio}

It's very easy to be pushed from the middle ground into taking a stanceWS:  Oh yes, yes. And it's very recent.  I really didn't want to go to court at all when I started in pathology.  I remember when I first came into neuropathology, going to inquests was terrifying.  But now I do it with a lot more confidence than I had in the past.  Even so, it's still very frightening.  Because in the adversarial situations of the court it's very easy to be pushed from the middle ground into taking a stance and one has to guard against that the whole time.

To get it right in court… One of the things that's so important is the way you come across to a jury, which is bad news really because a jury will look at you as an actor, and will like the way you are or not like the way you are, and that will probably be more important than what you're saying.  So it's not only the content.  It's all very well to go into court and say, "Look, we have evidence that shows this, this and this, and they only have belief".

That's not actually going to be terribly important with the jury.  If you say you've got evidence but you can’t give a definitive answer, [jury members] are not going to be nearly as impressed with that as with somebody who says, "We know... We see it all the time.  I'm a neurosurgeon, I know what happens with babies".  They believe that.  But if you go and say, “Well actually you might say that, but the facts are...This is what’s written up in the literature...This is what we see as pathologists...This is the mechanism...”, that’s not as important to jurors.

So one has to realise that one's playing to lawyers and playing to juries:  this isn't pure science; this is theatre as well .  If you go into court and you are incredibly confident and your body language is: "I know this, I've read all the papers", that can be wrong as well.  And if you go in feeling really certain that a person is innocent or you're on the right side, that's wrong, because you're supposed to be unbiased.  You're supposed to be in the middle, and you're supposed to be providing information that is for the court.

So it's a whole new game, to try and go in and give unbiased information without taking sides.  And of course your legal team – the people you're there with, the people who instruct you, the people who are sitting by you in court -- are there to win.  So you're with a team who want you on board… I mean, even to say you're with a team is perhaps wrong as well.  You're supposed to be there as an independent witness to the court, but you're automatically on one side or the other.  So it's quite tough.

SA: So this is a skill you've learned, is it?

WS:  Well I don't know if I've learned it, I'm having to experience it.  Whether I'm getting better at it or not, I don't know.

“Scientific fact is lost”

The other ridiculous thing is that what I can take to court is what I see down the microscope, what my findings are in a particular case, which is really intensely complicated, detailed pathology.  But that has to be translated into: "Did this person do it or not?"  The way in which my very complex neuropathological report gets translated to the jury is via lawyers who ask me questions.  Now they don't understand the pathology either, and you're allowed to answer, “Yes” or “No”. You never get the opportunity in court to say, "Well can I just give you a 20 minute run down on what a Subdural haemorrhage Occurs when a blood vessel ruptures and blood builds up between the brain and the brain's tough outer lining, the dura. is?  Can I explain what we think about this?"  The judges won't want to know; the lawyers won't understand it, and they haven't got time.  So you're really having to answer the questions put to you by a lawyer based on what his understanding is.

That's the problem with court: scientific fact is lostIn 2005 the court of appeal looked at four cases of shaken baby syndrome, and they judged the new hypothesis proposed by Jennian Geddes on the alternative source of subdural bleeding – from the dura itself rather than from the torn blood vessels.  It was a complete and utter farce to see lawyers struggling to understand incredibly complex physiological explanations for what's happening in baby brains.  It's hard enough for us to understand and we've been doing it for years, we've been through medical school.  But for lawyers to try and understand it, and then to say, "Well the court of appeal found that the hypothesis didn't stand up to scrutiny" is a nonsense.

SA:  Is that what they said?

WS:  Oh yes! To have judges addressing and reviewing and assessing the scientific value of a complicated hypothesis is absolute nonsense.  It's like me trying to comment on aspects of the law.  I know nothing about the law, I can't know whether a law is a good one or a bad one or how it should be used.  So to have scientific hypotheses judged in court is equally stupid, and yet that's what happened.  And that's the problem with court: scientific fact is lost.  The lawyers are there to win the case, and that's all they want to do.

SA:  So do you find it very frustrating, the legal work?

WS:  Very frustrating, yes.
 
SA:  And not fulfilling?

WS:  Well the great thing about it, and the reason I'm really grateful for doing this – and not only criminal cases, but civil cases too (for instance where parents are bringing a case against a Trust because their baby got damaged at birth) – is that it makes you think in a completely new way. You don't just write down, “This is another case of birth-related hypoxic-ischaemic brain damage."  You have to say why you're saying that, what your evidence is, what else it could be -- and not simply a list of 17 other differential diagnoses, but which are the likely ones, the ones you really need to consider.

Certainly in civil cases the lawyers are often very, very clued up and they know the literature at least as well as I do – certainly in birth injury cases, the lawyers are very high-powered people, and it's very stimulating to work with them because you have to be right.  Or at least you have to be as accurate as you possibly can.  They do demand evidence; they do demand that you have all the papers there to back your opinion, which isn't what's happening in the criminal courts.  But in either situation you know that you can't just write a sloppy report, because you're likely to be in the witness box and somebody will read it to you and every single typo, every comma in the wrong place, every misuse of English, will be glaring at you when everybody is focussing on you.  It makes you very careful about the way you write reports, the way you use language.  You can't write things that are open to misinterpretation, so it's made me approach my diagnosis in a very different way.  And that actually is quite stimulating.

It's such a privilegeI think when we get to the end of a career… You know, you've been 20 years doing a subject, you can't just go on doing the same old things.  This has actually brought me to a new way of looking at what I'm doing, and being intellectually very rigorous about the way I write up cases.


SECTION 8

Being a pathologist is a “privilege”

SA: What would you say, looking back over your career, have been the main motivations?  Is it the puzzles of the science, or working for the families or what?

Every case has something new to offerWS:  Working for the families.  If you do something that actually makes a family feel better when a child has died; if you can come up with a diagnosis or an explanation and a family writes to you and says, "Thank you, you gave us a lot of help", that is tremendous.  Because as pathologists we don't meet families.  We don't get bottles of sherry at Christmas!  So the odd letter from a family is hugely gratifying.  But what I think really motivates me is having all of this material to look at.  It's such a privilege to have all of this pathology that we don't understand, so many questions to answer.

We don't need to do nasty things to rats and to monkeys in cages, because we've got so much material that comes to us as part of our diagnostic work that we don't understand.  And we can use that to learn.  Every case that somebody sends me, if I think, "Oh gosh, have I got time to look at another brain?"  But I know that there's going to be something that I'll learn from it.  Every case has something new to offer.  So that's what keeps me stimulated, and keeps me going.

SA:  When you're retired and sitting in your arm chair with a rug over your knees, what will you remember as the highlights of your career?

WS:  I'd love to say it was all those papers I wrote up, all those ideas I had.  Because I've got lots of ideas that I've never actually got round to writing up.  Then somebody else writes them up and you think, "Ooh, I thought of that!"

I think it'll be regrets that I didn't write up more stuff.  But I'm terribly bad at finding the time for it because there's always something new to look at.  And I'm awfully bad at the last minute bits – I've got a paper coming out in January and there's one table in it that's been sent back to me about four times because it's not the right format – "We can't deal with it in Power Point, we want it as…" -- and I think, "This is the part I can't deal with".  The ideas at the front are wonderful, and I wish I just simply had the stamina to take them right the way through so I could say, "Look, these are all the papers I've written, and these are all the ideas I had."  But it hasn't happened that way...

The high points will have been the parents who've been gracious enough to say “Thank you” having lost a baby, because I can't imagine what it's like to lose a baby.  It must be the worst thing that can happen to you.  And if you can turn around to a pathologist who's actually looked at your baby's brain and be grateful to them (oh gosh, I'm getting emotional at this point!), I think that's a pretty super thing for parents to do.

Mentors

SA:  In your career who have been your mentors? Have you had people out there who've inspired you?

She was a tremendous inspiration to meWS:  Yes.  First of all I really do have to thank my brother for putting me here and making me do medicine, because he was great at setting me off.  My other brother, who was completely non-medical but a great party animal, used to say, "This is my sister; she cuts up dead babies!"  [Laughs] So I had to deal with that.  But you learn to defend yourself, and perhaps it set me up for when we had the organ retention problems.

Then when I started to do paediatric pathology, one of the reasons I chose paediatric neuropathology was that nobody else had done it.  Joe Smith in London was the only person in this country who had done any real work on baby brains, as far as pathology was concerned.  At that time even stillborn babies didn't often get postmortems -- they were not regarded as terribly important.  Of course now we regard them as incredibly important for understanding what's going on and how we're going to stop bad things happening again.

So there weren't many people to turn to, and the person who helped me most of all was Jeanne-Claudie Larroche in Paris.  She was a paediatric pathologist who had written a lot about baby brains, and a lot of the early papers on damage to the developing brain.  I went and spent a few days with her, and then sent her cases and  went back to see her again.  She is absolutely superb – she's a diminutive little woman, full of energy.  She was awarded the Legion d'Honeur for her work in neuropathology.  She was just so warm and friendly.  She always took me home for dinner and her mother, who she lived with, cooked for us.  She was fantastic -- I still see her sometimes, and write to ask her questions sometimes, though she's long retired.  If I'm in Paris I go and visit her. So even though it wasn't a long, close working relationship, she was a tremendous inspiration to me.

The other person who was superb in helping me start my career in Oxford was Jean Keeling, who was the paediatric pathologist here when I first came.  She was really grateful to have somebody to do all her brain pathology for her, but she was extremely knowledgeable and had been in paediatric pathology for so long that she taught me a great deal.  Just by giving me confidence with lots of work, being there with me, and writing those reports -- she wrote my first big paper with me -- she was a great inspiration at that time.

SA:  Irene was saying paediatric pathology is completely different from adult pathology – children are not just little adults.

We're all passionate about wineWS:  That's right.  And that's what we really need to get people to understand.  Talking about Subdural haemorrhage Occurs when a blood vessel ruptures and blood builds up between the brain and the brain's tough outer lining, the dura.s again, you can't apply what we know in adults to babies.  Because subdural haemorrhages occur in babies and they occur in adults people sometimes say, "Well you know, at the extremes of life the same thing happens."  But it's not the same thing, it's totally different.  Irene's absolutely right.

The pleasures of music and fine wine

SA:  Okay, one final question: how do you relax? How do you switch off?

WS: I go and listen to music, I go to lots and lots of concerts. And I drink! [Laughs]

I'm very interested in wine and do a lot of wine tasting, and organise wine tastings and wine tasting dinners.  I have a nice circle of friends in Oxford and we're all passionate about wine, so we're always running round to each other's houses and saying, "Ooh, try a bottle of this," and, "Oh I've got something, let's have mine as well".  So it's not just a question of blotting it all out, it's a reasonably academic pursuit of wine.  That's what I really love to do, and it really takes you away from your day's work if you can just sink a few bottles of wine with good friends.

SA:  Where did you get this interest in wine?

Wine appreciation is a serious business. Becoming a Chevalier de la Sabre d’OrWS:  I don't know.  At home we didn't drink wine – wine cost at least 50 pence a bottle!  You couldn't possibly have wine except at Christmas.  And my parents didn't really care about it.  When I was a student I realised that wine was... It defied analysis.  You can't just say, "This red wine from this vineyard is going to taste like this."  It's going to be different every year.  It's going to depend on who made it, and how they made it, and the wine from this vineyard is going to be different from that.  And that's immediately fascinating: why?  I wanted to know why.

I was doing my BSc in anatomy in Leeds, and Bob Holmes, who was the professor of anatomy, was keen on wine and he said, "Join the wine society".  So I did, as a student, and I just thought, “I want to know about it”.  I didn't want to be taken out for dinner and told, "You'll like this, it's Blue Nun, girls always drink Blue Nun".  I wanted to say, "No actually I'd really rather have a '73 Saint Emilion please"!

SA:  And learning about it, has it increased the appreciation?

WS:  Oh yes!  I do like to know about things.  I like to know about music.  I get no greater pleasure than going to a concert with a musician who will say, "Did you hear that key change?  And listen to this."  That really enhances the pleasure enormously.  It's the same with wine: learning about it you just get to new levels, you understand why this wine is older and that one is younger.  Having blind tastings and guessing where a wine has come from is fun.

SA:  So it's the way your mind works, really, wanting to understand?

WS: Yes.

ENDS


Copyright © 2020 | Conversations with Pathologists. All Rights Reserved. Design by MK Digital

Please publish modules in offcanvas position.