185. Request for an Inquest into the Death of Dr David Kelly; Schedule of Responses to Issues Raised

8/6/2019 185. Request for an Inquest into the Death of Dr David Kelly; Schedule of Responses to Issues Raised.

1/60

9 th June 2011

1

Request for an Inquest into the Death of Dr David Kelly

Schedule of responses to issues raised in the course of theconsideration as to whether to make an application unders.13 of the Coroners Act 1988

9 th June 2011


2/60

9 th June 2011

2

1. A failure to pursue available lines of inquiry atthe Inquiry and the existence now of newevidence means that a full Inquest is nownecessary or desirable in the interests of justice.

The investigation carried out by Thames Valley Police was thorough.The process conducted by the Inquiry was arguably more thoroughthan would have occurred at an inquest. Neither the Inquiry nor anyInquest is required to pursue every conceivable line of inquiry onlythat which is relevant to its subject and is sufficient to allow it to reachan accurate conclusion.

See the responses from Lord Hutton

2. The non statutory Hutton Inquiry established bythe Secretary of State for Constitutional Affairsand commended to the Coroner by the LordChancellor as an adequate means to satisfy therequirements of a Coronial Inquest undersection 17A of the Coroners Act 1988 was not infact an adequate inquiry.

The Inquiry conducted a thorough investigation into the circumstancessurrounding Dr Kellys death. It was assisted by counsel to theInquiry. All relevant parties were legally represented and had accessto the same material and were afforded the same opportunities tochallenge evidence as would have occurred at an Inquest. The onlydifferences of any significance between the process of the Inquiry andthat of an Inquest was that the Inquiry had no power to compelwitnesses and evidence was not taken on oath. Lord Hutton was notin any way hampered by the lack of powers of compellability andheard from every witness he sought evidence from. The significance

of evidence given on oath is very much reduced when the evidence isexpert medical or scientific evidence or can be corroborated bydocumentary, photographic or other evidence.

See also the responses from Lord Hutton


3/60

9 th June 2011

3

3. The conclusions of the Hutton Inquiry whichwere accepted by the Coroner without asubstantive hearing were not the result of a full,frank and fearless investigation. Had the Inquirybeen so, much of the evidence now availablecould have been put before and taken intoconsideration by Lord Hutton.

This is a qualitative judgment not supported by the evidence. None ofthe evidence or material provided to the Attorney General appears toundermine the conclusions of the Inquiry. The Oxfordshire Coronerdid hold a hearing to determine whether to resume the Inquest into DrKellys death pursuant to section 17A of the Coroners Act. The Kellyfamily and the Government were legally represented at that hearing.At the hearing Mr Gompertz QC for the Kelly family argued that therewere no exceptional reasons justifying the resumption of the Inquest.On behalf of the Government, the Treasury Solicitor made nosubmissions.

See the responses from Lord Hutton

4. The Coroner refused to resume the Inquest andrejected relevant evidence following the findingsof the Hutton Inquiry despite representationsmade and evidence submitted to him as to theexceptional reasons why an Inquest should infact be held.

The Coroner gave full and careful consideration to whether there wereexceptional reasons allowing him to resume the Inquest and explainedhis decision when giving judgment. It was open to anyone aggrievedwith this decision and who had sufficient locus to seek to judiciallyreview the Coroner.

See transcript of Coroners judgment.

5. As Secretary of State, Lord Falconer set up a

public Inquiry into the circumstances of DrKellys death. Then acting as Lord Chancellor,he exercised his powers under section 17A totake the investigation from the Coroner to theInquiry. At the conclusion of the Inquiry hedeclared himself satisfied with the results thus

It was open to the Secretary of State to open a Public Inquiry into this

matter. He was answerable to the Prime Minister, Parliament and,potentially, the courts for so doing. As section 17A of the CoronersAct 1988 allows the Lord Chancellor to suspend an Inquest andtransfer the investigation to an Inquiry, it cannot amount to anirregularity of proceedings for the purposes of an application undersection 13.


4/60

9 th June 2011

4

requiring the Coroner to find exceptionalreason to reopen the Inquest. This exercise byone individual of the powers of two positionswithin the governmental executive represents afundamental irregularity in the proceedings bywhich Dr Kellys death was investigated.

See letter from the Ministry of Justice (MoJ) of 24.02.11

6. It was improper to use section 17A in thecircumstances of this case. It was intended thatthe power should be used in cases of particularpublic importance to provide an investigationinto a death or deaths that goes beyond theCoronial remit. In the past it had been used inthe Ladbroke Grove and Shipman Inquiries which were 1921 Act Inquiries.

Section 17A does not limit the use of this power in the way described.As such it cannot be argued that its use was in anyway improper.

See letter from MoJ dated 24.02.11See responses from Lord Hutton

7. Lord Falconer chose to set up an ad hoc Inquiryrather than a 1921 Act Inquiry with the resultthat Lord Hutton had no powers to compelwitnesses to give evidence or that suchevidence should be on oath. Further, the termsof reference given to Hutton were to investigatethe circumstances surrounding the death ofDavid Kelly. They did not include a requirement

to find cause of death.

It was a matter for Lord Falconer to decide the format of the Inquiry.The approach he adopted mirrored that used in a significant numberof other public inquiries. Lord Hutton was satisfied that the lack ofpowers of compellability did not hinder the Inquiry as those witnesseshe wished to give evidence all complied with his request. Nor did LordHutton consider that the quality of his investigation was in any wayreduced by the fact that evidence was not given on oath. Much of thecrucial evidence given to the Inquiry was expert medical or scientific

evidence or was corroborated in some way.

Section 17A specifically allows an Inquiry to take the place of anInquest and Rule 36 of the Coroners Rules 1984 does not apply to anInquiry. It is not accepted that simply because the wording of theInquiry Terms of Reference did not include a requirement to find the


5/60

9 th June 2011

5

cause of death, that in any way invalidates the findings of the Inquiryor justifies an application now being made for an Inquest. Lord Huttondid make detailed findings as to how Dr Kelly came by his death inany event.

See responses of Lord Hutton

8. Section 17A requires a judge-led Inquiry. LordHutton, whilst a serving judge at the time ofappointment, retired before publishing hisreport.

Lord Hutton was a serving judge at all relevant times. Moreover, LordHutton was a distinguished judge of great experience.

See letter from MoJ dated 24.02.11

9. As the Hutton Inquiry was hastily called andconducted, there were no equivalentpreparatory proceedings that would havehappened had the Inquest continued. Thesehearings would normally consider theinvolvement of properly interested persons,defining the scope, depth and breadth of theInquest and the need for a jury. This led to theexclusion of potentially properly interestedpersons from the coronial process.

Whilst the Inquiry was set up promptly after the death of Dr Kelly,Lord Hutton and his team of lawyers thereafter carried out a thoroughexercise of planning how the Inquiry should run and the evidence thatwas to be called.

See the responses of Lord Hutton.

The Oxfordshire Coroner has commented to the Attorney General thatthere is no statutory provision for pre-Inquest proceedings and thatwhilst such hearings have in recent years become more common, in

the Coroners view they were relatively rare in 2004. As they have nostatutory base, they can take many forms. The Coroner is of the viewthat the hearing on 16 th March 2004 could be so described.

No properly interested persons (as defined by the Coroners Rules)were in fact excluded either from the Inquiry or from the proceedings


6/60

9 th June 2011

6

before the Coroner so the issue if of no relevance. Prior to thehearing at which the Coroner considered whether the Inquest shouldbe resumed, prior notice was published seeking applications fromanyone who considered themselves properly interested in theproceedings. That request was repeated by the Coroner at the publichearing. No-one applied. Anyone who had applied and whoseapplication was unsuccessful would have been able to challenge thatdecision by way of judicial review.

See the transcript of the proceedings of 16.03.04 before theOxfordshire Coroner.

10. Had the Inquest been continued, witnesseswould have been examined under oath. The

proceedings before Hutton were not subject tothe usual rules of evidence that would haveapplied in an Inquest.

This criticism is without foundation. It ignores the test the OxfordshireCoroner was required to apply: namely were there exceptional

reasons to resume the Inquest? No interested party claimed therewere such reasons and the Coroner gave careful consideration towhether there were in fact such reasons. His decision was notchallenged.

See transcript of proceedings of 16.03.04

It is not accepted that because witnesses at the Inquiry were not

required to give evidence under oath that it made any difference ofany kind to the evidence received or the weight that could properly beattached to it. Other than repetition of a general view that evidencegiven under oath is more desirable, no example has been provided ofwhen it may have made a difference in this case. Nor has anyexample been given of any significant difference created by the fact


7/60

9 th June 2011

7

that the Coroners Rules did not apply to the Inquiry. Both an Inquestand an Inquiry are inquisitorial in nature, rather than adversarial.There are no parties as such. Lord Hutton was an extremelyexperienced judge with many years experience of dealing withevidence and he and his legal team ensured the evidence was bothfully considered in terms of scope and properly tested. Moreover, theinterested parties at the Inquiry were all represented by highlyexperienced counsel

See the responses of Lord Hutton.

11. The lack of powers of compellability meant thatHutton was unable to compel witnesses such asthe Kelly dentist and Supt Young of Thames

Valley Police (TVP) who could give evidenceas to the extent and nature of the policeinvestigation.

No witness requested by Lord Hutton to give evidence refused to doso and the issue of powers of compellability is entirely irrelevant. LordHutton was fully aware of the evidence that could be given by Dr

Kellys dentist but did not consider it took the matter any further.Neither an Inquest nor an Inquiry is required to call every witness whohas given a statement to the police. It is not accepted that theevidence that could potentially be given by Dr Kellys dentist or SuptYoung would have assisted Lord Hutton. Any of the interested partiesat the Inquiry could have requested these witnesses to be called (inexactly the same way as they could have done at an Inquest) but nosuch applications were in fact made.

See also the responses from Lord Hutton.


8/60

9 th June 2011

8

12. The lack of applicability of the rules of evidencethat would have applied at an Inquest meantthat the evidence provided by witnesses was nottested through cross examination byrepresentatives of other properly interestedpersons to the proceedings. Evidence wasaccepted at face value with minor clarificationonly.

The lack or otherwise of rules of evidence is of no consequence if onelooks at the quality of the investigation. The criticism also appears toignore the fact that the process, both at an Inquest and at an Inquiry isinquisitorial rather than adversarial. It also ignores the fact that allproperly interested parties were present, were represented by legalteams of great experience and seniority, had access to the samematerial they would have had had there been an Inquest, and weregiven the same opportunity to ask questions of witnesses. The valueof any argument that they did not ask the questions thatcorrespondents have subsequently argued should have been raised,is entirely dependent on the merits of the correspondents views.

See also the responses of Lord Hutton.

13. If the Lord Chancellor makes an order undersection 17A the Coroner must adjourn theInquest unless there are exceptionalcircumstances. After adjourning, henevertheless met with the Department forConstitutional Affairs (DCA) official in order torequest that he be allowed to take further

evidence from Dr Hunt as to the cause of death.This was a clear attempt to resume hisinvestigation. And an irregularity in proceedings.

The Oxfordshire Coroner opened the Inquest on 21 st July 2003 andheard evidence of Dr Hunts preliminary views on the cause of death.These views were based on Dr Hunts post mortem examination. DrHunts views were that cause of death was likely to be haemorrhageas a result of incised wounds to the left wrist. The toxicology andhistology tests were carried out quickly and within a few days Dr Huntwas able to inform the Coroner that as a result he needed to expand

on the cause of death by indicating that co-proxamol and heartdisease would be given as contributory causes.

In the meantime the Oxfordshire Coroner had been contacted by theDepartment of Constitutional Affairs (DCA) and told that the LordChancellor would be making a request that the Inquest be adjourned


9/60

9 th June 2011

9

under section 17A(1). The Coroner contacted the DCA and explainedthat if the Inquest was to be adjourned immediately he would have toregister the death with an incomplete cause of death, thereby makinga statement he knew to be false. The Lord Chancellor accepted thepoint made by the Coroner and in a letter to the Coroner from thePrivate Secretary to the Lord Chancellor dated 12 th August 2003 itwas written The Lord Chancellor accepts that, before formallyadjourning the Inquest under section 17A(1), you may need to takeevidence from the pathologist and the analyst on the cause of DrKellys death. The Coroner subsequently took further evidence,registered the death as due to the causes now on record and thenadjourned in compliance with the request made under section 17A(1).There was no irregularity.

See transcript of proceedings of 16.03.04

14. The Hutton Inquiry was described by LordFalconer as adequate to satisfy therequirements of a Coronial investigation. Andyet the requirement of Rule 36 of the CoronersRules was not met in that the place of Dr Kellysdeath is not stated, the time of death only

recorded in broad terms, and the cause of deathsubject to grave doubts.

Rule 36 does not apply to an Inquiry. Its purpose is to limit the scopeof any Inquest into determining, if possible, the matters set out in theRule. Section 17A specifically allows the Lord Chancellor to transferproceedings to an Inquiry. It is not accepted that there is any doubtover where Dr Kelly died or the cause of death. It is not possible todetermine precisely time of death.

See report of Dr Shepherd.


10/60

9 th June 2011

10

15. Lord Hutton never understood that once theLord Chancellor had made the order undersection 17A, Lord Huttons primary duty was toperform the duties normally carried out by theCoroner.

Section 17A places no duty on Lord Hutton. Lord Huttons duty was tocarry out an Inquiry that fulfilled the Terms of Reference given to him.

16. Parliament intended that when Section 17A wasexercised, the Inquiry should be conducted by a judge having powers to compel with evidencegiven on oath.

Parliaments intention is reflected in the wording of its statutes.Section 17A is not limited in the way described.

17. Upon a review of the evidence now available,there was insufficient evidence available to theHutton Inquiry at the time to reach theconclusion that Dr Kelly had deliberately killed

himself and that the primary cause of death wasas recorded on the death certificate.

The circumstances of Dr Kellys death were the subject of carefulinvestigation by both the TVP and the Hutton Inquiry. All the evidencepointed conclusively to Dr Kelly having taken his own life. Thatevidence has been further strengthened by the independent reports of

Dr Shepherd and Professor Flanagan.

18. It was assumed that, as Mrs Kelly had beenprescribed co- proxamol, the empty blisterpacks of these tablets found in Dr Kellys jacketpocket must have belonged to her. However,this was never established adequately at theInquiry. It was not established whether Mrs Kelly

would normally have had such a number oftablets, whether she had recently obtained arepeat prescription, or when and from where thetablets had been dispensed.

There were no assumptions made. The police investigated the matteras far as it was possible to do so.

Thames Valley Police report:

Following the discovery of Dr Kellys body a search was made of hishouse. Mrs Janice Kelly was present and was asked to show officers

any medicines in the house. Mrs Kelly showed the officers a drawer inher bedroom where there were 4 x 10 packs of co-proxamol in foilblister packs. These were not contained within a box. She alsodirected the officers to a kitchen drawer where a full box of 10 x 10packs of co-proxamol were kept.


11/60

9 th June 2011

11

The full pack was issued to Mrs Kelly on the 20th May 2003 by theWhite Horse Medical Practice in Faringdon.

Mrs Kelly stated that her husband would never take any sort of tablet,not even for a headache but that he was aware that she wasprescribed co-proxamol as a painkiller. He also knew that she kepther supplies of these tablets in her bedside cabinet and in a kitchendrawer.

The markings on the packets recovered from Dr Kellys body andthose prescribed to his wife were compared and found to be identical.

The manufacturers of the tablets were approached to ascertain if it

was possible to trace the history of the recovered packets. TheTechnical Manager told officers that each batch release would containapproximately 1.6 million packets which were distributed to numerouscompanies and could end up in chemists anywhere in Britain.

19. The evidence given by Dr Allan as to theingestion and levels of paracetamol anddextropropoxyphene in Dr Kellys blood was notsubjected to scrutiny. The timing of the tests he

carried out is unknown, as is the time of death.Both are essential in reaching conclusionsabout blood drug levels.

The findings of Dr Allan are strongly supported by the independentreview carried out by Professor Flanagan.

See report by Professor Flanagan


12/60

9 th June 2011

12

20. In September 2004 the British Medical Journal(BMJ) published an article pointing out that thelevel of paracetamol and dextropropoxyphenein the blood is not an accurate indicator of theamount ingested.

The relevance of this article to the case is unclear. The measure ofthe drugs in the samples tested is clearly the key indicator indetermining the potential effect on the body. Professor Flanaganfound that the levels of the drugs taken from blood and vitreoushumour were consistent with the ingestion of up to 29 co-proxamoltablets.See report of Professor Flanagan.

21. Although Dr Allan found the quantity ofparacetamol and dextropropoxyphene in theblood to be three times the therapeutic dose, itwas at least three times less than wouldnormally be found in a fatal dose. Although 29pills were said to be missing, the residue of onlya fragment of a pill was found in the stomach.Were tests done on the vomit?

Professor Flanagan states:

Dextropropoxyphene is a very toxic drug in overdose. Co-proxamolwas implicated in 300 400 deaths from overdose each year inEngland and Wales and in almost a fifth of drug related suicides in theyears immediately prior to the withdrawal of its product licence at the

end of 2007. The United Kingdom National Poisons InformationService Toxbase documents that the fatal does of co-proxamol may beas little as 10 20 tablets in an adult.

Professor Flanagan further states: generally blooddextropropoxyphene concentrations above 1 microgram per millilitreare indicative of serious toxicity, but there are many reports of deathsinvolving dextropropoxyphene alone in which the post mortem blooddextropropoxyphene concentrations were less than 1 microgram permillilitre.

Neither Dr Shepherd nor Professor Flanagan consider that testing thevomit would have assisted in any material way.

See further the reports of Dr Shepherd and Professor Flanagan.


13/60

9 th June 2011

13

22. There is no evidence Dr Allan tested for moreexotic drugs such as ricin or saxitoxin or forpoisons that may be delivered transdermally.

There may always be drugs that have not been tested for. ProfessorFlanagan confirms that Dr Allan tested for a wide range of compounds.The evidence, toxicological and other, is entirely consistent with thecause of death as found.

23. There was no independent verification of bloodtest results.

It would be unusual for blood tests to be independently verified withoutapparent reason. There has now been such a review carried out byProfessor Flanagan.

24. Why was Dr Allans testing of blood confined toone site sampling NCH/43 Heart blood? Thesite of sampling may be critical in producingelevated levels.

Professor Flanagan reports that it is of no significance that tests weredone on only one blood sample. Tests done on the sample of vitreoushumour were consistent with the drug levels found in the blood.Further, the levels of paracetamol and dextropropoxyphene found in

the stomach contents tested were consistent with the ingestion of a lifethreatening overdose of co-proxamol.

See report of Professor Flanagan.25. Lord Hutton reported that Dr Allan had found

paracetamol and dextropropoxyphene in bloodand stomach contents but in giving evidence,Dr Allan only states that the stomach contents

were only tested for paracetamol. The failure totest for dextropropoxyphene in the stomachmeans it cannot be stated that Dr Kelly ingestedany co-proxamol.

Dr Allan did test the stomach contents for dextropropoxyphene as wasclear from the statements he had provided and which were before theInquiry. It has also been confirmed by Professor Flanagan who hasindependently reviewed the test results.


14/60

9 th June 2011

14

26. Dr Allans report suggests that only one of fiveblood samples taken was tested. Why?

See above. Professor Flanagan does not consider this to be of anysignificance.

27. Given the amount of water left in the bottle bythe body, he would not have been able toswallow 29 pills.

Dr Shepherd expresses the view that in his opinion it is entirelypossible to ingest 29 or more objects (including tablets) andparticularly those that are designed to be swallowed, using only 300mls of water.

See Dr Shepherds report.

28. Dr Kelly would have become progressivelymore thirsty as he lost blood and yet there waswater left in his bottle.

Why Dr Kelly did not drink all the water in the bottle is not known,could not be determined then or now and is indicative of nothing morethan the fact that the bottle found next to his body contained some

water. Dr Shepherd comments that he was unable to find any medicalreferences that indicate that an individual suffering from acute bloodloss will also suffer from acute thirst.

Small quantities of dextropropoxyphene found in a sample of the wateris consistent with contamination of the contents of the water bottle withsaliva from someone who had ingested dextropropoxyphene recently.

See report of Professor Flanagan


15/60

9 th June 2011

15

29. The measured blood concentration ofdextropropoxyphene of 1 mcg/ml correspondsto about 60 mg in the body. Two tablets of co-proxamol contain 65 mg dextropropoxyphene.Thus the amount in his blood represents lessthan two pills and could not be an overdose andcould not have contributed to death.

The amounts found in the blood of Dr Kelly were consistent with theingestion of up to 29 co-proxamol tablets.

See report of Professor Flanagan.

30. The ratio of dextropropoxyphene toparacetamol in the blood is inconsistent withingestion of co-proxamol as is the lack ofdextropropoxyphene in the stomach.


31. Given Dr Kellys employment, Dr Allan should

have checked to analyse the blood for thosematerials he came in contact with during thecourse of his inspection duties notably supertoxic biological and chemical weapons.

Such speculative tests would only be of relevance if the totality of the

medical, forensic and psychiatric evidence was not entirely supportiveof the cause of death as found. Dr Allan did test for a very wide rangeof compounds.

See report of Professor Flanagan.

32. The vomit found at the scene was not tested forco-proxamol nor were two relevant mortuary

samples NCH/33 and NCH/34.

Neither Professor Flanagan nor Dr Shepherd see any significance inthis and the fact that these additional tests were not carried out does

not undermine the thoroughness of the forensic examination.See reports of Dr Shepherd and Professor Flanagan.


16/60

9 th June 2011

16

33. The levels of paracetamol anddextropropoxyphene were given but noconsideration was given to post mortemchanges in drug levels. Further, as Dr Kelly lostblood it is difficult to back calculate the number

of tablets that may have been consumedwithout knowing how much blood was lost.

The relevance of post mortem effects is considered by ProfessorFlanagan. The number of pills ingested is only of relevance to causeof death if there were evidence to suggest that the drug wasintroduced into his body in some other way. There is no suchevidence. All the evidence there is points to the conclusion that Dr

Kelly ingested a large number of co-proxamol pills that had belongedto his wife. The levels of the drug found in various samples taken fromhis body was of a level of toxicity consistent with the cause of death asfound.

34. Dr Allan refers to a significant amounts ofdextropropoxyphene found in the urine. Thisas a measurement is pointless and should have

been queried by Hutton.

Dr Allan tested for paracetamol and dextropropoxyphene in samples ofblood, vitreous humour and stomach contents measurements foreach were consistent with the ingestion of a sufficient number of co-

proxamol pills to constitute a toxic dose.


35. Lord Hutton did not properly investigate thepossibility that Dr Kelly did not intend to killhimself. He had made plans to meet with hisdaughter and had not put his affairs in order.There was insufficient evidence of an intent todie to support a conclusion of suicide.

The ingestion of a large number of pills by a man who never took pills,coupled with the severity of the wounds inflicted and the choice of asecluded place in which to carry out these actions are all stronglyindicative of an intent to die. Dr Kellys wife gave evidence that prior tohis leaving for a walk he was in a deeply distressed state. She saidshe thought that he had a broken heart, he looked desperate,distracted and dejected, and he could not put two sentences together,he could not talk at all. These issues were all considered by ProfessorHawton and Professor Gudjonsson. At the time Professor Hawtonwas a Consultant Psychiatrist in the Oxfordshire Mental Health Care


17/60

9 th June 2011

17

Trust, a Professor of Psychiatry at the University of Oxford andDirector of the Centre for Suicide Research at Oxford UniversityDepartment of Psychiatry. He had been involved in research onsuicide and attempted suicide since 1973 with expertise in the nature,causes, treatment and prevention of suicidal behaviour and hadreceived three international awards in recognition of his research

contributions in that field. Professor Gisli Gudjonsson was at the timea Professor in Forensic Psychology.

Both experts interviewed close family members, visited the scene andwere given access to documents held by the police investigation team.Both reached the view that Dr Kelly had committed suicide.

It is not unusual for individuals to take their own lives whilst havingagreed to future meetings.


36. Expert psychiatrists, Pritchard and Timmsqueried the finding. Pritchard argued that therewas no evidence of intent before Hutton.Hutton had failed to ask Hawton whether in hisexpert opinion he thought Dr Kelly had killedhimself. As a result, the conclusion was basedon Lord Huttons interpretation of psychiatricevidence. Timms argues that suicide by cuttingthe wrists was very uncommon.

See above.

Professor Hawton was questioned at length at the Inquiry and hadalready provided a detailed statement. It is absurd to suggest thatProfessor Hawton was not aware that he had been called as an expertin this field and that in being questioned it was his views as an expertthat were being sought. In reply to a question from Lord Hutton,Professor Hawton replied I think that taking all the evidence together,it is well nigh certain that he committed suicide.



18/60

9 th June 2011

18

37. Lord Hutton visited Mrs Kelly at home. It is tobe assumed that he took evidence from her andyet none has ever been revealed. As she maywell have had important evidence as to herhusbands state of mind it was vital he madethis public in a public Inquiry.

Lord Hutton, together with James Dingemans QC (leading counsel tothe Inquiry) visited Mrs Kelly and her daughters a few days after hewas appointed to conduct the Inquiry. His visit was to express hissympathy and to assure her that he would conduct a full and thoroughInquiry. He took no evidence from her. The only evidence from MrsKelly was that given by her by radio link to the Inquiry.

See responses of Lord Hutton.

38. The Inquiry spent comparatively little timeconsidering medical evidence. Of the 24 fulldays of hearings, only half a day was taken upwith medical evidence leading to the conclusionthat the scrutiny it was subjected to was

unacceptably limp.

The thoroughness of any investigation is not determined by the lengthof time it takes to carry out. The medical and forensic evidencerelating to cause of death was straightforward in comparison with otherevidence relating to the complex chain of events leading up to DrKellys death.

See responses of Lord Hutton.

39. Vital witnesses who would have been in aposition to provide valuable evidence were notcalled by Hutton.

No witnesses have been identified who could conceivably beconsidered vital or who had evidence to give that could be consideredforensically valuable who were not, in fact, called.

40. Hutton did not investigate what clothing Dr Kellywas found in. The Inquiry heard that Dr Kellywas found wearing a Barbour type jacket. Inconflict with this, contemporaneous reports innewspapers claimed he was found in cottonshirt and jeans

The following clothes were recovered from the body of Dr Kelly;

A green 'Barbour' waxed jacket;

A blue, grey and white-striped shirt;

A pair of blue denim jeans;


19/60

9 th June 2011

19

A brown leather belt with a white metal buckle which was done up atthe waist. On the brown leather belt, over the right hip area, was a'Virgin Atlantic', Velcro closed pouch;

A pair of beige socks;

Underpants; and,

A pair of walking-type boots, brown leather, with the laces done up indouble bows.

Ruth Absalom gave oral evidence at the Hutton Inquiry and said thefollowing of the clothing;Q. How was he dressed?A. Normally. I did not take that much notice.Q. Do you remember whether he was wearing a jacket or ...?A. Well, he had obviously got a jacket on but whether it was a suit oran odd jacket and odd trousers I have no idea. We just stopped, saidhello, had a chat about nothing in particular.

In her police statement she said, He was wearing a light colouredshirt and what appeared to be a tweed jacket that was open at thefront. I cannot remember what else he was wearing.

It is apparent that the meeting of Dr Kelly and Mrs Absalom was oflittle significance to Mrs Absalom at the time and her description of theclothing is vague. However, she does mention a jacket in bothaccounts which does not confirm the press reports that Dr Kelly waswearing only a cotton shirt and jeans.


20/60

9 th June 2011

20

41. It was reported that a Mr Paul Weaving mayhave been the last person to see Dr Kelly alive.Despite this he was not called to give evidence.

This appears to be based on a story in The Guardian published theday after the body was discovered, Paul Weaver (sic), a farmer, mayhave been the last person to see him.Dr Kelly seemed happyenough and smiled at the farmer. The article does not source thisquote but gives the impression it is Mr Weaving himself.

Mr Weaving was interviewed by police on the 20th July 2003. He hadknown Dr Kelly for 20 years and did not see him that day. He hadbeen supervising grass cutting on Harrowdown Hill and describes oneman he saw who was walking a dog. Police Statement - I left theLongworth area at around 7pm and returned home. Apart from theman walking his dog as previously described, I saw nobody else whilstthere.

42. Hutton failed to call DC Shields one of twodetectives who attended Dr Kellys body. DC Shields did not attend Dr Kellys body and had no relevantinformation to assist the Inquiry.

43. Hutton failed to call Dr Eileen Hickey theforensic biologist who was at the scene for mostof the day.

Dr Eileen Hickey attended the scene to assist Roy Green. He was thesenior reporting scientist and her role was subservient to that. Herpolice statement states: I assisted Roy Green in his examination ofthe scene and I acted under his direction. This entailed note-taking,photography and testing various areas at the scene for blood. RoyGreen was the obvious choice of expert to give oral evidence and theappearance of his assistant would have added nothing to thatevidence.



21/60

9 th June 2011

21

44. Hutton failed to call Mai Pedersen who offeredto give evidence. She was conversant with DrKellys conversion to Bahai and on the strengthof Dr Kellys right hand.

Thames Valley officers travelled to the United States and interviewedMai Pederson. She declined to make a statement. Ms. Pedersonprovided an account of her association with Dr Kelly and includeddetails such as his avoidance of taking pills and the fact he hadpreviously broken his arm. She also detailed their shared Bahai faithand her views on the unlikelihood of him committing suicide. The last

time she saw him in Washington DC he had appeared very ashen,drawn pallor that concerned me. However, she put this down totiredness rather than stress.

Discussions were held between senior police officers and the HuttonInquiry team to consider the relevance of her evidence. There wasnothing offered by Ms Pederson that could not be adduced from familymembers. Whilst she had declined to make a written statement her

account was nevertheless known to the Inquiry.See responses from Lord Hutton.

45. Robert Jackson, former MP has evidenceregarding Dr Malcolm Warner. Warner toldJackson that he was asked to view Kellyscorpse on the day it was found. Dr Warner didnot mention this when he gave evidence to theInquiry.

Dr Malcolm Warner was Dr Kellys GP. He was visited by officers fromthe investigation team to view his medical records. He provided astatement in which he outlined that he had been Dr Kellys GP forsome 25 years but had not seen him since 1999.

Dr Warner was not called to the scene and there is no record that heever saw Dr Kellys body. The body of Dr Kelly was identified by thefamily.


22/60

9 th June 2011

22

46. Local friends and neighbours of Dr Kelly mayhave had knowledge of his thoughts and viewson the day of his death. This was notinvestigated.

In the days following the discovery of Dr Kellys body a house-to-house operation was conducted in Southmoor, Longworth and theroutes between the two villages. This included any premise whichoverlooked the possible routes taken. In total 167 premises wereidentified and visited. This was a large operation and took some weeks

to complete.

A checkpoint was established on the public footpaths that crossHarrowdown Hill woods in an effort to identify potential witnesses tothe movements of the deceased.

In addition a policy was set by the Senior Investigating Officer toidentify everyone who may have had recent contact with Dr Kelly in

order to establish if they had any relevant information. Where practicalstatements were obtained from everyone having direct, phone or e-mail contact with the deceased after the 1st May 2003.

This was a lengthy and in depth investigation conducted largely in theglare of enormous press interest. Every effort was made to identifyand interview anyone who may have had knowledge of his thoughtsand views on the day of his death.

47. Nigel Cox received an answerphone messagefrom Dr Kelly in relation to plans on 23 July2003. Despite reporting this to TVP, no-oneretrieved the voicemail or followed this up.

Dr Kelly was a member of the Hinds Head crib team. He last playedfor them on the 9th July 2003. Every other member of that team wasinterviewed by officers from the investigation team. Nigel Cox wasamongst these.


23/60

9 th June 2011

23

Thames Valley Police did listen to the answer machine message andincluded the details of the message in the subsequent statementprovided by Mr Cox.

However, the investigation team, were already aware of matters whichoccurred sometime after the above phone call which were more

proximate to the time of Dr Kellys death, such as arrangements to seehis daughter. This call was therefore considered to be of littlerelevance. These were also matters considered by Professor Hawton.

48. Hutton failed to call any expert in a clinicaldiscipline relating to the cause of death suchas a vascular surgeon. This would have beendone at an Inquest.

A vascular surgeon is not an expert in the causes of death that is thework of a forensic pathologist. There is nothing to suggest that aCoroner would have sought further medical evidence as to cause ofdeath over and above that given by Dr Hunt.

49. A video recording exists of the Foreign AffairsCommittee and the Security and IntelligenceCommittee taking evidence from Dr Kelly. Heappears in this video to be in good spirits.These should have been considered by theInquiry and would rightly have been done so byan Inquest. The Attorney General should watchthe video.

The observation of television footage of Dr Kelly answering questionsby an individual with no expertise in psychiatry or of the detection ofsuicidal intent is of no worth in comparison with the expert evidencegiven by Professor Hawton and Professor Gudjonsson.

50. The Inquiry heard evidence from Rachel Kellythat her father had been detained and hismobile confiscated in Iraq on 19 May 2003when he attempted to enter. It was discoveredhe had an incorrect visa. She believed her

The relevance of this is not clear, nor is it clear how the Inquiry couldbe expected to explore the issue, if it existed, in any meaningful way.Professor Hawton spoke with the family before compiling his reportand would have been told of any events considered significant.


24/60

9 th June 2011

24

father had been greatly upset and embarrassedby the events but the Inquiry failed to explorewhether there was any significance in this andDr Kellys death a few months later.

51. It was recorded that Dr Kelly was found wearing

a Barbour jacket. However readings fromRadcliffe Meteorological Centre about 7 milesfrom Southmoor, reported that July was warmerthan average and would have been a minimumof 16C when he left for his walk. There was norain. Why wear a Barbour jacket rather thansimply a jersey.

The observation is speculative. The Inquiry into how Dr Kelly came by

his death was thorough and exhaustive. Thames Valley Policeconducted their investigation as a potential homicide investigation. Allrelevant matters were pursued and investigated. Dr Kelly was foundwearing a Barbour jacket. It was open and he had only a shirt onbeneath it.

52. Mrs Kelly described him changing into jeansand (walking?) shoes but did not mention the jacket. The report in the Guardian stated that DrKelly had left home in just a cotton shirt and jeans.

See above. There is no source given for the report in The Guardianand is contrary to the evidence given by Ruth Absalom that Dr Kellywas wearing a jacket.

53. Mrs Kelly mentions that Dr Kelly took atelephone call shortly before leaving. Sheassumed it was the MOD. This was notinvestigated.

The matter was investigated. Dr Kelly took a call from the MOD at14.52.


25/60

9 th June 2011

25

54. Why was Susan Melling, a neighbour who hadspoken to Paul Weaving, not called?

Mr and Mrs Melling were also interviewed by police officers in the daysfollowing the death of Dr Kelly. Mr Melling assisted in the search of DrKelly with Mr Weaving, however neither had any further information toassist the investigation.

55. The three officers DC Coe, PC Sawyer andPC Franklin all gave evidence to the Inquiryabout finding the body which differed regardingthe approach to the body and where DC Coewas.

It is inevitable that honest witnesses, recalling details to the best oftheir memory, will give accounts that may vary, sometimes widely. Allcourts recognise this. How important such variation is dependsentirely on how relevant the evidence is to the issue in question. Theaccounts of the officers does not appear to differ in any significantway. Lord Hutton had considerable experience in presiding overcomplex and difficult criminal trials and was very well equipped tomake findings of fact in these circumstances.

56. Roy Greens final report was not before LordHutton.

Roy Greens statement of 27 th September 2003 was available to theInquiry.

57. Evidence before Lord Hutton but not releasedsuggests Dr Kelly had suffered an earlier injuryto his elbow. This might have affected hisability to cut himself. It was not referred to byDr Warner when giving evidence. This was aserious failure by Dr Warner and Lord Hutton.It also calls into question the suicide verdict.



26/60

9 th June 2011

26

58. Dr Warner probably saw the body atHarrowdown Hill. If he had not identified thebody how did Sarah Pape know at 10.30 thatthe body was that of Dr Kelly?

Thames Valley Police has confirmed that there is no record of DrWarner having seen the body of Dr Kelly.

There is a difference between formal identification and recognisingthat the body found was that of Dr Kelly.

59. No-one gave oral evidence to the Inquiryidentifying the body as that of Dr Kelly. There is no requirement that oral evidence of identity is taken. At anInquest the Coroner may accept hearsay evidence in statement form ifthe requirements of Rule 37 of the Coroners Rules are satisfiedinasmuch as the interested persons do not challenge the contents ofthe statement. There was ample evidence before the Inquiry to provethat the body found was that of Dr Kelly, including evidence given ofDNA testing. No application was made for oral evidence to be given.

60. On 17 th July Dr Kelly agreed flight details with

the MOD for a journey to Iraq later in the month.This is inconsistent with a determination to takehis own life.

The overwhelming evidence is that Dr Kelly took his own life.

61. ACC Page gave evidence to the Inquiry aboutDNA testing a subject in which he was not anexpert.

ACC Page gave evidence based on the examinations carried out byRoy Green and others.

62. Lord Hutton should have confirmed that all theblood at the scene belonged to Dr Kelly. Heshould have asked the scientists who carriedout DNA testing to give evidence about wheresamples had been taken from and inquire intothe degree of confidence he had with hisfindings.

A thorough examination of the scene was carried out by Dr Hunt, RoyGreen and others conducted as a potential homicide case. Allappropriate tests were done. Roy Green confirms that DNA testingprovided extremely strong scientific support that blood tested from thedeceaseds clothing and items at the scene originated from Dr DavidKelly rather than from another unrelated person.


27/60

9 th June 2011

27

63. David Broucher gave evidence that Dr Kellyhad once told him he might be found dead inthe woods. Later, Rachel Kelly cast doubt onMr Brouchers recollection on when thatmeeting took place. Lord Hutton found ithappened in February 2002. Broucher later

claimed he had met Kelly in 2002 and 2003.This should have been more rigorouslyexamined.

The issue was sufficiently examined. In any event, the issue is of verylittle relevance as all the available evidence pointed conclusively to DrKelly having taken his own life.

64. DC Shields, Dr Hickey and at least threescenes of crimes officers were not called to giveevidence. Indicative of rejection of evidence.

Neither an Inquiry nor an Inquest require every witness that could giveevidence to be called. The witnesses named would simply giveevidence already given by others.

65. Roy Green stated that some of his tests were

still ongoing but he was never asked for theresults. ACC Page purported to give evidenceon the results of the tests but he is not anexpert. The evidence was not challenged. Thisis indicative of irregularity of proceedings.

It is not suggested that the evidence given by ACC Page was wrong or

that there was any basis to challenge the findings of Roy Green.


28/60

9 th June 2011

28

66. Evidence not on oath; body moved; Only one ofthe 3 officers that went to the body wasquestioned; differing account from DC Coe andfinders as to the number of officers present; thepresence of the third man; whether the creation

of the common approach path could haveobliterated evidence of Dr Kelly being carried tothe scene. These are all matters that LordHutton should have investigated and areexamples, with others, of insufficiency ofinquiry.

The scene was treated as a potential murder scene and theinvestigation proceeded accordingly.

It has not been explained how evidence given on oath might havediffered in any way from that given, most of the relevant information asto cause of death being medical or scientific and therefore capable ofcorroboration in other ways.

As to the issue of the position of the body, Lord Hutton commented onthe fact that in his wide experience indeed the experience of anyindividual with even a slight acquaintance with court processes witnesses may recall events differently.

See responses from Lord Hutton.

The Thames Valley Police have compiled a comparison of theevidence given in relation to the position of the body as found. In factall the evidence, including the photographic evidence is consistentsave for the testimony of the two individuals who first found the body.In respect of one of those individuals, his original statement to thepolice was consistent with the evidence of others that the body wasfound lying on the ground. Only in giving evidence to the Inquiry didthat alter. It is not suggested that this was anything other that faultyrecall.

Further, all the available forensic evidence is consistent with Dr Kellydying where the body was found and inconsistent with it having beenmoved.See Annex TVP3 for further detail.


29/60

9th

June 2011

29

67. Lord Hutton has said subsequent to the Inquirythat he believed that there was little seriousdispute as to the background facts and thatunnecessary time could be taken up by cross-examination on subjects which were not directly

relevant. This indicates he had already madehis mind up prior to hearing evidence.

It is a reasonable assumption to make that, given the circumstancessurrounding the death of Dr Kelly, that he had taken his own life. Thatdid not prevent the Police from investigating the matter as a potentialhomicide nor did it result in Lord Hutton not carrying out a thoroughInquiry.

There was no serious dispute as to the background facts and fewquestions were asked by those present at the Inquiry as properlyinterested persons.

68. The final death certificate in relation to DrKellys death was registered on 18 th August2003 before the Inquiry started hearingevidence.

The death certificate reflects the findings of the Oxfordshire Coronerbefore he adjourned the Inquest. Nothing in the findings of the Inquirywould require the details recorded to be altered.

69. The death certificate was irregular in that itdoes not identify place of death nor have anyexplanatory note from the Coroner. It states anInquest was held on 14 th August 2003, which isincorrect and it gives date of death as 18 th July,although this was not established.

It is not accepted that these points are of any importance. The deathcertificate accurately records that on 18 th July 2003 Dr Kelly was founddead on Harrowdown Hill. The Inquiry was not able to be morespecific nor could any resumed Inquest, had that occurred. Thecertificate also records that the Inquest was adjourned.

70. The death certificate gives neither time norplace of death. These are fundamental. If DrKelly did commit suicide he must have done sowhere he was found.

There are occasions when it is not possible to state either time orplace of death. In Dr Kellys case, the time of death cannot beascertained with any great accuracy other than it occurred some timeafter he was last seen and some time before his body was found. It isaccepted that the certificate could read that Dr Kelly died on


30/60

9th

June 2011

30

Harrowdown Hill but the fact that it simply states that he was found onHarrowdown Hill is neither evidence that he may have died elsewherenor a matter that could lead to the ordering of an Inquest.

71. The secret recommendation from Lord Huttonthat certain documents such as the post

mortem report should not be made public for 70years was irregular and would not have beenopen to the Coroner or to an Inquiry under the1921 Act.

There was nothing secret about the Inquiry that was carried out byLord Hutton. The public had access to transcripts of the evidence

given and the final Report went into considerable detail. Therecommendation and it could be no more than that was designedto protect the Kelly family from further public incursion into their privatelives.

See responses from Lord Hutton.

The recommendation could not in any event form the basis of a justification for an Inquest.

72. Dr Hunt failed to take a rectal temperature untilsome 7 hours after being given access to thesite and 5 hours after he was given permissionto carry out a full site examination. This delayrendered any assessment of the time of deathmore difficult. This was not challenged byHutton.

Of necessity, such a reading could only be taken towards the end ofany examination carried out by Dr Hunt as is indicative of the caretaken by him.

Even so, it now appears that regardless of when the temperature wastaken, the calculation of time of death would not be accurate enoughto assist evidentially

See the report of Dr Shepherd.


31/60

9th

June 2011

31

73. Despite Dr Hunts finding that Dr Kelly diedbetween 4.15 pm and 1.15 am, a helicopterequipped with thermal imaging technologyfailed to spot the body although it flew over thesite the body was found at 2.50 am. This failure

was not queried by Hutton.

Thames Valley Police has provided the following explanation:

In 2003 Thames Valley Police were in the fortunate position of havingaccess to two helicopters shared with other forces in a consortium. Itwas common practice for the helicopter to be deployed during

incidents such as this. The helicopter crew comprise of a pilot and anobserver who is trained in the use of the technical equipment on boardthe aircraft.

During the early hours of the 18th July 2003 the crew were deployedto survey an area which included Harrowdown Hill in the search for DrKelly.

The thermal imagers fitted to police helicopters including those ofTVP/Chiltern Air Support Unit are invaluable in searching large areas,particularly at night, whether for suspects, missing people or otheruses. The thermal imager essentially produces a picture based on thedifferent heat values of all in its view.

The equipment used is not penetrative so cannot look through water,buildings or other cover such as tree canopies. In some cases thelocation of an individual can be given away by the transference of heatfrom them to the object they are adjacent to. For example, if someonehides in a wheelie bin the bin will become warmer where they touch sowill stand out but you cant see through it.


32/60

9th

June 2011

32

In the case of woods or copses, unless it is winter or the woods aresparsely populated with trees, the leaf canopies and branches veryoften preclude any meaningful thermal imager search as the thermalimager cannot penetrate the leaf canopy.

The helicopter is often best employed in searching the open areas

leaving ground parties to search any wooded areas. It is sometimespossible to find someone in a wooded area and certainly if such anarea was part of a wider search area the crew would attempt to do so.However, unless the individual sought was in a bit of a clearing orother open area they would be unlikely to be found. If they happenedto be at the base of a tree in an area densely populated by trees thenthe canopy of that tree and others would in most cases prevent anylocation by the thermal imager fitted to the helicopter.

Two flights were made in the early hours of 18/7/03 as follows:At 0250 it deployed to search for Dr Kelly.At 0320 it arrived on sceneAt 0405 running low on fuel it went to base to refuel.

At 0425hrs it re-launched.At 0435hrs it arrived back on scene.At 0445hrs it resumed back to base. (The pilot was running out of legalflying hours.)

The infrared camera used was a FLIR Leo 2. The camera was subjectto routine maintenance in line with aircraft maintenance schedules. Itwas working correctly at the time of the incident having been lastserviced on 27th June 2003.


33/60

9th

June 2011

33

Both aircraft owned by Chiltern Air Support Unit have had their thermalimage cameras upgraded since 2003 but the same basic principleapplies that thermal imagers are not penetrative.

74. In August 2010 Dr Hunt gave an interview tothe Sunday Times in which he commented onhis findings. In commenting he gave

information that is inconsistent with and wentfurther than his evidence to Hutton. This ishighly irregular but suggests that HuttonsInquiry did not go as far as a Coroner inexamining, testing and exhausting the evidenceprovided by the witnesses he called.

The evidence before Lord Hutton, including photographic evidence,was consistent with a large amount of blood at the scene. It is amistake to assume that in an inquisitorial process, all evidence is given

orally. The interview with The Sunday Times and the justification for itis a matter for Dr Hunt but there is nothing in the account thatundermines the findings of the Inquiry.

See responses of Lord Hutton and report of Dr Shepherd.

75. In particular, in the Sunday Times, Dr Huntsuggests there was more blood on the bodyand around it than he did to Hutton andexplains that it had soaked into the ground,thereby providing an explanation why othershad not seen much.

Lord Hutton had photographic and other evidence as to the amount ofblood at the scene. The statement of Roy Green, the forensic biologistwho examined the scene, also stated The leaf litter nature of theground meant that it would have been very absorbent to blood.

See also report of Dr Shepherd.

76. Dr Hunt stated that he had searched every partof Dr Kellys body for needle marks but hadfound nothing. This is not evidence that therehad been no foul play.

Dr Hunt would no doubt have been criticised had he not examined thebody carefully for needle marks. Dr Hunt carried out a particularlycareful examination in which he specifically searched for any evidencethat Dr Kelly had been subjected to force or any form of coercion. Hefound none.

See further the report of Dr Shepherd.


34/60

9th

June 2011

34

77. Dr Hunt sought to give greater weight to therole played in the death by the hardening of DrKellys arteries. This sudden provision of freshevidence indicates an anxiety on Dr Hunts partthat the evidence he gave to Hutton was not

sufficient to support the conclusions found.


78. Dr Hunt was inexperienced, having only 7 yearsexperience and on the Home Office list for 2.

Dr Hunt carried out a careful and thorough examination that has notbeen undermined by any of the criticisms made of him.

See the report by Dr Shepherd.

79. Dr Hunt used a speculative approach guessingat possible causes of injury and bruising.

It is part of the role of the forensic pathologist to try and interpret whathe has found and what are, in his view, the likely or possible causesfor it. Unless the cause is clear and without doubt, the pathologistsinterpretation is inevitably based on his experience and learning. Anexpert witness will make it clear how certain his findings are or can be.Forensic pathologists are, by definition, well versed in expressing theirconclusions in accordance with the applicable evidential standardsemployed by different courts.

80. Dr Hunt considered that the removal of DrKellys watch by Dr Kelly is indicative of the factthat he removed it to facilitate the cutting of hiswrists. But he does not know when the watchwas removed or by whom.

No-one can know precisely what happened when Dr Kelly died but inthe complete absence of any evidence of third party involvement in hisdeath it is logical to assume that Dr Kelly removed his own watch. It isalso logical to assume that if he wished to cut his wrist he might wantto remove his watch first.


35/60

9th

June 2011

35

81. Dr Hunt delayed in taking the temperature ofthe corpse. The toxicologist found a trace ofacetone in the blood. Even a trace means thatmetabolism continued for at least twelve hoursafter the last meal. As this had been taken at13.00 on 17 th July it is highly probable he

remained alive at 01.00 on 18th

. What had DrKelly been doing since entering the wood atmid-afternoon?

It is not possible to tell what time Dr Kelly died. It is not possible toknow what he did before he died. It is not clear how an Inquest coulddetermine that which is not known.

82. If vomiting had been passive it would haveentered the lungs. Were the lungs tested forvomit?

The lungs were examined in the post mortem . Dr Hunt does not reportthe presence of vomit.

83. Why was there no attempt to discuss thereported levels of paracetamol anddextropropoxyphene in relation to the time ofdeath? Was this because Dr Hunts failure totake a rectal temperature for so long made timeof death vague?

It is not known how many pills were ingested nor when deathoccurred. All that is certain is the amounts of paracetamol anddextropropoxyphene found in the samples taken from the body.

The timing of the taking of a rectal temperature is indicative of the carehe took in examining the scene rather than a proper subject ofcriticism.

84. Dr Hunt stated that he reviewed his findingswith Dr Nat Cary. How and when?

It is not known whether he did, when or how. It is not at all unusual forexperts to discuss their work or to share experience. Dr Hunt is arespected and highly experienced forensic pathologist.


36/60

9th

June 2011

36

85. Both Dr Hunt and Dr Hawton attach someimportance to Dr Kelly removing his watch andspectacles. However, there is no evidence DrKelly always wore spectacles and it is believedby some that Dr Kelly wore his watch on his

right hand.

Both witnesses have some expertise in this matter and if there was anissue about spectacle wearing or watch wearing that was ofsignificance it is not unreasonable to assume that the legal teamrepresenting the family would have raised it. It is not clear why it isconsidered the spectacles and watch may not be Dr Kellys but there

is no evidence to suggest they were not.86. No forensic evidence was given as to how the

knife was used to inflict the wounds noted. Astudy of the knife shape and wound geometrywould have been illuminating.

Both Dr Hunt and Dr Shepherd state that the wounds were consistentwith having been made with the knife found at the scene.

87. Dr Hunt reported that the body of Dr Kellyweighed 59kg. The report states the body wasof an adequately nourished man. Dr Wattbelieves a weight of 69 or 79 kg would becloser to the mark. A mistake in weight wouldhave an impact on time of death calculations.

Dr Shepherd reports that he believes this to be an error and agreesthat a weight of 59kg appears low. However the impact thisdiscrepancy has on estimating time of death is moot given the failingsof the Hessnges nonograms.


88. Dr Watts calculations as to time of death basedon his assessment of Dr Kellys weight is thathe may have been dead by 06.15 on 17 th July.The body may not be that of Dr Kelly.

Dr Watts calculations gave rise to Dr Shepherds conclusions aboutthe accuracy of the Hessnges nonograms used by forensicpathologists. But this means no accurate time of death can be given.The body was definitely that of Dr Kelly.


37/60

9th

June 2011

37

89. Dr Hunt speculates that Dr Kelly taking hisglasses off was indicative of suicide. As theglasses were bifocals, it was more likely he hadalready taken them off to walk through thewoods.

As stated above, no great reliance was placed on what could be readinto the removal of Dr Kellys spectacles.

90. Dr Hunt relied on the removal of the watch asindicative of suicide. However, DC Coesevidence was that the watch was on top of theknife. If that is correct that knife was not usedto make the cuts. This discrepancy was notexamined.

Dc Coe reported that when he first attended the scene he witnessedDr Kelly's watch as being "on top" of the knife. Dr Hunt sets out thatthe knife was actually "adjacent" to Dr Kelly's watch. Photographstaken show that both descriptions could be considered accurate as ashort section of the strap appears to rest on the handle of the knifewhilst the bulk of the watch is adjacent.

91. The Pathologists report mentions broken

branches close to the body. Were the branchesfreshly broken consistent with disturbance by athird party? This was not explored.

The scene was very carefully examined by Dr Hunt, the police and

Roy Green. They found no evidence of any struggle or disturbance.Indeed the evidence suggested the contrary.

92. Dr Hunt refers to Dr Kelly having removed hisspectacles but there is no evidence to suggestwhy he needed spectacles and whether hewould have been wearing then in any event ifthey were, for instance, only for reading.

The common image of Dr Kelly was that of man who regularly worespectacles. It is not unreasonable for Dr Hunt to have assumed thathe had removed his spectacles. No great weight is attached to theissue and it is of little or no significance when considering the weight ofevidence. It is not clear why it is considered the spectacles found

were not Dr Kellys but there is in any event any evidence to suggestthe spectacles were not his.


38/60

9th

June 2011

38

93. Dr Hunt remarks on there being no obvioussigns of trampling of the undergrowth and yetwe know a number of people had stood orkneeled in the area adjacent to the body. DidDr Hunt not notice this?

The police scenes of crime officers, Dr Hunt and Roy Green are allspecialists in examining scenes where deaths have occurred. Thepolice treated this as a potential homicide case as did Dr Hunt and MrGreen. The Inquiry was entitled to base its findings on their evidenceas would any Inquest.

94. Dr Hunt attributes cardiac toxicity todextropropoxyphene but did not consider thelikely greater importance of metabolitepropoxyphene. This absence of informationmakes Dr Hunts speculation more uncertainthan it purports to be.

Dr Allans conclusions are strongly supported by the independentreview carried out by Professor Flanagan. Dr Hunt was entitled to relyon the expertise of the toxicologist.

95. The abrasions to Dr Kellys head might beconsistent with him being dragged. Dr Hunt didnot consider this and Hutton did not inquire.

Dr Hunt took care to consider all evidence that pointed to thepossibility of force being used against Dr Kelly. Had Dr Hunt, whoexamined the body, believed that dragging was a possibility he wouldno doubt have said so. There was no evidence that suggesteddragging. Further, the forensic evidence, the blood and bloodspattering patterns were all indicative of Dr Kelly receiving his injuryand dying where he was found.

96. If Dr Kelly intended to kill himself, why did heonly cut one wrist when cutting both would havemeant a faster death.

Not known, but it might be assumed that the damage done to the wristmay have made holding a knife difficult. Suicides take many formsand not all are either fast or painless.

97. Following the Hutton Report, Dr Frost and otherdoctors wrote to the Coroner expressing theview that the cause of death found was highlyimprobable. The letters were not replied to ormention by the Coroner when he heard

The Oxfordshire Coroner considered whether there were exceptionalreasons for resuming the Inquest and sought representations frominterested parties. He explained in his ruling that it was notappropriate for him to enter into correspondence on the case. Dr Frostand his colleagues are in no different position from any other member


39/60

9th

June 2011

39

representations as to whether to reopen theInquest. This constitutes a rejection of relevantand persuasive evidence which may have hada material and substantive difference to theoutcome of the Coronial proceedings.

of the public. The conduct of Inquests is carefully regulated and onlythose who have a right to take part in the process or are accorded"interested person" status under the Coroners Rules by the Coronerhave any right to engage. The Coroner nevertheless explained that hehad read all that had been sent to him and considered it against all theother evidence. Any individual who felt aggrieved at the Coroner'sdecisions could have sought to challenge them by way of judicialreview.

See transcript of proceedings of 16.03.04.98. The comments of the Coroner were such that

they created the impression that Lord Huttonsconclusions were of the same quality as mightbe reached by the Coroner himself.

The statutory duty on the Coroner was to consider whether there wereexceptional reasons for resuming the Inquest. He did so andexplained his conclusions.

See transcript of proceedings of 16.03.0499. Two weeks prior to the hearing, the Coroner

gave an interview to the media in which heexpressed the view that he was seekingclosure. This indicates he had already made uphis mind.

See responses above which already deal with the adequacy of thehearing held by the Coroner in which he determined the statutoryquestion as to whether to resume the Inquest.


40/60

9th

June 2011

40

100. Ambulance technician Bartlett gave aninterview to the press in which he stated thatwhen he saw the body the left sleeve wasrolled up and you could see a wound withsome dried blood around it. This contradictsDr Hunts account to the Sunday Times wherehe says there were big thick clots of bloodinside the sleeve which came down over thewrist. This gives rise to the question about thevolume and distribution of blood at the scene.

There was before the Inquiry photographic evidence of the body andsurroundings as well as the findings of Dr Hunt and others.

On blood see Dr Hunt, the report of Dr Shepherd and the statement ofRoy Green.

101. Mr Bartlett also claimed that when he arrived atthe scene, Dr Kelly was lying flat out somedistance from the tree. He definitely wasntleaning against it the body was far enoughaway from the tree for someone to get behindit. The searchers who found the body gaveevidence to Hutton that Dr Kelly had beenfound propped up against the tree. This givesrise to questions about whether Dr Kellys bodyhad been disturbed.

See Annex TVP3 on the accounts of the position of the body.

There is no obvious reason why Dr Kellys body should be moved andthe available forensic evidence is all strongly supportive of the factthat he had died where he was found.

102. The trail of vomit is indicative of Dr Kelly being

on his back. When found initially he was sittingup against the tree. He must have beenmoved into that position. Later witness refer tohim being on his back so he must have beenmoved a second time.

Dr Kelly was found on his back. He was not found sitting up against

the tree.

See Annex TVP3


41/60

9th

June 2011

41

103. One of the paramedics told a newspaper thatthe body had been moved. As he was notinformed about the position of the body asfound by the searchers how could he haveknown it was moved?

Lord Hutton referred to the evidence of Louise Holmes in his reportstating that she had found a body slumped against the bottom of atree. As is set out in Annex TVP3, that account is inconsistent withthe accounts given by others and the forensic evidence. Theparamedic may have read the relevant section of the Hutton Report orhad it put to them.

104. The post mortem report states the left handwas over the right side of Dr Kellys shirt.Elsewhere in the report he states the left handwas to the left of the body. This discrepancyshould have been investigated.

The body and scene were extensively photographed. At the scenethe left hand was to the left of the body.

105. PC Sawyers failure to set the time and datestamp on the camera that took photographs ofthe body and scene was extraordinary andmeans that Lord Huttons view of the bodyposition, which was based on thosephotographs, is untenable as it is not possibleto say when they were taken. This shouldhave been questioned by Hutton.

Lord Hutton (or any court) is entitled to accept the evidence of apolice officer or other professional witness as to when photographswere taken. Speculation that the photographs were notcontemporaneous is fanciful and not supported by any evidence ofany kind. Also there is no evidence that the body was moved beforephotographs were taken and clear evidence that it had not beenmoved at that time.

106. The evidence from the ambulance crew wrist

up, wound covered in blood differs from thatof PC Sawyer wrist down wound not visible.This suggests the body and/or wound wasinterfered with.

If it is suggestive of anything it is that the recall of honest witnesses of

the same scene is not always identical. The photographic evidence isquite clear as to the position of the body when first seen.


42/60

9th

June 2011

42

107. The doctors calculated that for Dr Kelly to diefrom blood loss he would need to loseapproximately 2700mls of blood. Theyconsider it impossible for that quantity of bloodto be lost through the ulnar artery. Indeed tolose 500mls thought it would be unlikely.

See the report of Dr Shepherd. He states:It has been suggested that the complete severance of the ulnarartery would not result in fatal haemorrhage as there would beretraction of the artery by the internal elastic and muscularcomponents of the wall of the artery and by the formation of plateletblood clots within the lumen.

This is clearly erroneous since any first aider and practising doctor willbe aware that the severing of an artery requires immediate first aidtreatment with compression of the site of the injury and/or theapplication of a tourniquet, this first aid will be followed by surgicaltreatment of the damaged blood vessel in order to prevent continuinglife threatening haemorrhage. These comments apply equally well tothe ulnar artery as they do to the radial brachial or any other majorartery within the body,

If the normal physiological responses to a severed artery were thespontaneous retraction of the artery with clot formation and cessationof blood loss then there would be no need for emergency actionfollowing the severance of a major blood vessel. This is not theeveryday experience of paramedics and A&E departments.

It is common forensic pathological experience that individuals can anddo die as a result of solitary injuries to arteries or other blood vessels

whether homicidally, suicidally or accidentally inflicted. I have seenany cases of death from haemorrhage following incised injuries to thewrist in my career and I had a case in the last year (HSL82) in whicha young individual died solely as a result of a self inflicted, solitaryincision of her left lunar artery.


43/60

9th

June 2011

43

108. The doctors opine that it is very unusual to diefrom an injury to the wrist.


109. Witnesses gave differing accounts of the bloodat the scene. It would have been a simplematter to collect all the blood stained/soakedleaf litter, soil and nettle leaves and then toelute the haemoglobin by immersion in coldwater. The quantity of blood lost could thenbe calculated.

Dr Shepherd does not consider this practical.


110. In the absence of evidence of blood lost, acalculation should have been made of theblood remaining in the body.

Dr Shepherd does not consider this practical.


111. The ulnar artery was severed but not the radialwhich suggests the wound was caused by theknife being drawn from the inside of the wristoutwards. This may well have been done by athird party. There is no mention by Dr Hunt ofthe direction of the cuts.

Dr Hunt and Dr Shepherd are Forensic Pathologists whose expertiseis in the examination of scenes of death in order to inform aninvestigation. Both the Police and Dr Hunt treated the investigationas a potential homicide and Dr Hunt carried out a careful and detailedpost mortem examination which was photographed. Both Dr Huntand Dr Shepherd are satisfied that the injuries were self-inflicted.


44/60

9th

June 2011

44

112. If there is insufficient blood at the scene thissuggests Dr Kelly was killed elsewhere and hisbody brought to the scene. The body mayinitially have been positioned incorrectly to beconsistent with livor mortis and the vomit stains thus requiring the movement of the body. Orthose setting the scene may have beendisturbed by the searchers before they hadplaced the body correctly and supplied thebottle knife, etc.

None of those who carried out a detailed examination of the sceneexpressed any suspicion as to the amount of blood at the scene. Thebody was not moved and the forensic evidence is strongly consistentwith Dr Kelly cutting his wrist and dying where he was found. Thesesuggestions are not capable of any substantiation.

113. It is very surprising that a top rankmicrobiologist and world expert in toxicsubstances would choose an inept anduncertain method of suicide. Why would hechoose to cut the deeper artery and with ablunt knife?

People chose many varied ways of taking their own life, not all ofthem fast and painless. Professor Hawton and ProfessorGudjonsson, both experts in this field, did not suggest there wasanything suspicious about the method chosen by Dr Kelly.

114. A single artery completely severed would haverendered it more unlikely that he could havebleed to death as a severed, as opposed topartially severed artery retracts.

Dr Shepherd does not agree.

See report of Dr Shepherd

115. A blunt knife would have induced speedierclotting

The comment is suggestive of the assertion that Dr Kelly did not takehis own life. There is no evidence to support that theory. All theevidence points to the conclusion that he committed suicide. NeitherDr Hunt nor Dr Shepherd express any doubt as to the cause of death.


45/60

9th

June 2011

45

116. Given Dr Kellys scientific knowledge it isunlikely he would have chosen to cut thedeeper ulnar artery to the more accessibleradial.

This is an entirely speculative comment of no evidential significancegiven the weight of evidence that has been reviewed.

117. Dr Hunt stated he found rigor mortis. However,if Dr Kelly dies from haemorrhage it is unlikelythere would be significant rigor mortis.

See post mortem report by Dr Hunt and report by Dr Shepherd.Neither found any evidence that was inconsistent with the conclusionsreached as to cause of death.

118. Dr Hunt reported that there was a pool of bloodextending for 2 to 3 feet from Dr Kellys left armat the time he was examining the body. Thiswas not noted by others who attended thescene including those who put electrodes to hischest.

All those attending the scene of a potential homicide have particularfunctions to carry out. None of those individuals whose particularresponsibility it was to examine the site for evidence relating to causeof death expressed any concern as to the amount of blood at thescene. The scene was also extensively photographed and thebloodstaining is visible.

119. Dr Kelly was an intelligent man. As actingdirector at Porton Down he would have beenfamiliar with test animals being put to sleep. Itis preposterous to suggest that he decided totake his own life by cutting his wrists with anunsuitable and blunt knife and by swallowingco-proxamol tablets. If they were self inflicted itis highly unlikely they were done with the

intention of killing himself.

Professor Hawton is an internationally acknowledged expert in thepsychiatry of suicide. Had there been any merit in this suggestion hewould no doubt have raised it.


46/60

9th

June 2011

46

120. Did Dr Kelly have the strength to cut his ownarm? Dr Hunt noted the old operation scar onhis right elbow but did not follow though.Coupled with the evidence of Mai Pedersenthis gives rise to real doubt

It is axiomatic that a person intent on taking their life might carry outactions that are painful and that they would not do, in othercircumstances. The post mortem examination found nothing tosuggest a physical cause that would prevent Dr Kelly cutting his wrist.

See report of Dr Shepherd

121. Dr Hunt made no assessment of whether theknife at the scene was sharp or blunt. Therewas no evidence that the knife at the scenewas the knife used.

Thames Valley Police has indicated:

The "Sandvik" knife was a stainless steel penknife found near to DrKellys left hand. The single blade, which was curved and measuredapproximately 7.5 cm in length, was exposed. The blade and thehandle were heavily stained with blood especially on the right side.

DNA:Swabs were taken from three areas of the knife. Two of these areaswere bloodstained and the third was from an area free from bloodstains.

1. Taken from the blade which gave a full profile with a matchprobability of less than 1 in 1 billion to David Kelly.

2. Taken from the handle of the knife. This produced a full profile

with a match probability of less than 1 in 1 billion to David Kelly

3. Taken from a non bloodstained area which produced a partialprofile (10/20 alleles) which gave a match probability of less than 1 in3000 to David Kelly


47/60

9th

June 2011

47

In effect there is no foreign DNA on the knife as the swab thatproduced the incomplete profile still matched Dr Kelly in all 10 of the20 alleles produced and more importantly none of them did not matchhis profile. If that had been the case then the DNA could not havecome from him.During the examinations of the knife a number of hairs were removedfrom its surfaces. 12 of these were animal in origin, probably from arabbit. Of more interest were 6 human hairs that appeared to havebeen cut (these had no roots). Microscopic comparison of these hairswith the reference samples of hair from Dr Kelly showed that the hairsrecovered from the knife could have come from Dr Kelly's wrist.

In the opinion of the reporting scientist (Roy Green) the presence ofblood and cut hairs on the knife shows that this was the implementthat was used to cut Dr Kelly's wrist.

122. Dr Hunt does not mention the lack of arterialrain.

Roy Green is a forensic biologist and blood pattern analyst whoseexpertise includes the forensic analysis of blood spattering. It was asensible division of responsibilities between Dr Hunt and Roy Greento leave the analysis of arterial rain to Mr Green. The pattern foundwas consistent with Dr Kelly cutting his wrist and dying where his

body was found.

123. Roy Green gave no assurance that the bloodmentioned by others was in fact blood, humanblood or Dr Kellys.

The blood tested from the scene, from Dr Kelly, his clothes and itemsfound with him, matched that of Dr Kelly.

8/6/2019 185. Request for an Inquest into the Death of D

Documents

185. Request for an Inquest into the Death of Dr David Kelly; Schedule of Responses to Issues Raised