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The Investigation of Events that followed the death of Cyril Mark Isaacs
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| Between 1985 and 1996, 230 brains from Coroners' cases were obtained for the joint programme from three districts: North Manchester, Central Manchester and Cheshire. This chapter describes the extent to which Coroners in the three districts were aware of brain retention. | |
| The chapter is based on contemporaneous papers and the recollections of those involved. | |
| North Manchester | |
| Mr North was the Coroner for the North Manchester district from 1974 to 1994. Mr North stated that he was not aware of, or had ever sanctioned, the removal of brains or other organs without the consent of the relatives unless the organ was required for diagnostic purposes. | |
| Mr North had been asked in July 1985 by Professor Yates, Professor of Neuropathology at Manchester University, about the removal of post mortem samples of brains from Coroner's cases without any supervision of a medically qualified pathologist. Professor Yates had written: 'In all cases the families of the deceased will have known of our interest and intentions and have given their permission for the procedure before the death of the subject'. | |
| Mr North replied: 'I feel it difficult to agree with your request. The only way I could agree is to have my pathologist present at the time of the removal in order that he could give me a full and complete report. That would not seem to me to be a practical proposition as my pathologists are seldom able to carry out post mortem examinations as quickly as one hour after death'. | |
| This exchange of correspondence preceded the start of the joint programme and was about the removal of brains when the relatives had given their consent. | |
| Mr Isaacs' brain was retained in February 1987. | |
| In 1990 Mr North was asked about the removal of specimens for research by Dr Menon of the Department of Pathology at Birch Hill Hospital, Rochdale. Dr Menon's letter is not available, but Mr North replied on 12 June 1990: 'I am of the opinion that before any specimens or samples are taken for research purposes which do not form part of your enquiry as to establishing Coroner's cause of death that the consent of the relatives should be obtained'. | |
| These letters are the surviving documents that set out Mr North's position on the removal of organs and tissues for research purposes. | |
Four members of Mr North's staff and two Coroner's Officers from Bury police district are of the opinion that Mr North 'must have known what was going on'. |
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| There is no contemporaneous written evidence to resolve this divergence of opinion. | |
| Mr Williams' views |
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| In the mid 1980s Mr North invited Mr Barrie Williams to act as his deputy. When Mr North resigned in June 1994 on health grounds, Mr Williams continued as Deputy Coroner until he was appointed to succeed Mr North in 1995. | |
| When asked directly if he was aware of the arrangement, Mr Williams replied 'No'. Mr Williams added that when he was Mr North's deputy, he had not known that the office staff were involved in identifying cases for the joint research programme. He did not find out until after Mrs Langan had retired. Mr Williams assures me that had he known at the time he would have put a stop to the practice immediately. | |
| It is important to record that the morticians at Bury and Rochdale both commented that Mr Williams 'does everything properly', implying that, in their view, had Mr Williams known, he would have put a stop to the practice. | |
| The only relevant written record is a note made by Dr Farrand after an informal discussion with Mr Williams at Bury Magistrate's Court on 22 May 2000. This was a month after Mrs Isaacs had started to make enquiries about why her husband's brain had been retained. Dr Farrand's note records: '22 May - meeting with Mr Williams before inquest at Bury Magistrate's Court. Mr Williams was aware that Joyce would arrange for brains to go for research and he said that this must have had the Coroner's approval'. This note relates to Mr Williams' comments on events that took place at least five years previously. | |
| Dr Farrand's note, in manuscript, is on a memo dated 14 April 2000 from Harold Howard of the Royal Bolton Hospital to Brian Senior at the same hospital. At the time Dr Farrand's note was written, Mr Williams would have recently become aware of Mrs Isaacs' enquiries. | |
| Central Manchester |
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| Mr Leonard Gorodkin has been the Coroner for the Central Manchester district since 1978. He was astonished when he saw the list which included 100 brains taken from Coroner's cases at North Manchester General Hospital. At least one other brain had been obtained from a death reported to him at Manchester Royal Infirmary. | |
| Mr Gorodkin has always made it clear to the pathologists and to his staff that organs of any kind were only to be retained for diagnostic purposes and that he should be informed whenever this occurred. Mr Gorodkin would agree to organs being retained for other purposes, provided the consent of the relatives had been obtained. One such example would be for organ transplantation. However, Mr Gorodkin expected all pathologists working for him to record any organ retention in the post mortem report. As the post mortem reports did not record organ retention, the Coroner and his office staff were unaware of what was occurring in the NMGH mortuary. | |
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Pathologists at North Manchester General Hospital and at the Manchester Royal Infirmary were well aware of Mr Gorodkin's position on organ retention, which makes it the more surprising that the pathologists did not ask questions about the intended destination and use of the brains. |
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| In the 50 post mortem reports examined from North Manchester General Hospital, only one referred to the brain having been retained. In this case death was due to natural causes and there had been no reason to hold an inquest. In these circumstances, Mr Gorodkin had relied on his office staff to check that the cause of death in the post mortem report corresponded to the findings the pathologist had telephoned to his office and on which Mr Gorodkin released the body and notified the Registrar of the cause of death. Mr Gorodkin had required his staff to bring to his attention any discrepancies affecting the cause of death, or other significant features. He was obliged to rely on his staff in view of the very substantial number of post mortems carried out in his district. | |
| Following advice from Professor McClure in April 1995, Chapter 14, Professor Deakin requested a meeting with Mr Gorodkin. This took place on 26 June 1995 in Mr Gorodkin's office. Professor Deakin states that his purpose was to seek Mr Gorodkin's permission to extend the brain collection system into Mr Gorodkin's Central Manchester District and to ascertain his views about retaining brains as part of the Coroner's investigation. | |
| Mr Gorodkin was clear that the relative's consent would always be necessary. This is consistent with Mr Gorodkin's long-held position. | |
| Mr Gorodkin's response to Professor Deakin's request was clearly a major factor in Professor Deakin's decision to end his part in the joint programme, Chapter 24. Professor Deakin states that Mr Gorodkin 'confirmed my view that the joint programme was no longer practicable'. It is not clear what Dr Slater was told about the conversation Professor Deakin had had with Mr Gorodkin. | |
| It appears that at the time of this meeting Professor Deakin was not aware that 100 brains already obtained by the joint programme were from Coroner's cases at North Manchester General Hospital for deaths that had been reported to Mr Gorodkin. | |
| Mr Gorodkin's firm position on organ retention was confirmed by several staff in the North Manchester General Hospital mortuary and Manchester Royal Infirmary. One mortician who had provided brains for the joint programme even stated that he knew that this was against Mr Gorodkin's policy. | |
| It should be noted that the programme continued to collect brains from Coroner's cases without consent until 1996. | |
| Cheshire | |
| Warrington General Hospital was one of the mortuaries within the district of the Coroner for Cheshire. The Coroner for Cheshire between 1988 and 1992, when brains were obtained for the programme from Warrington, was the late Mr Hibbert. | |
| There is no doubt that the staff of the Coroner's office in Warrington were aware that brains were being sent to Manchester University. Mr Stephenson, newly appointed as Coroner's Officer in 1989, made enquiries when he first came across a brain that was being retained for the joint programme, Chapter 15. | |
| After Mr Stephenson was reassured, he and the mortuary staff assumed that the joint programme had the Coroner's approval. | |
| All but one of the 15 Coroner's post mortem reports are available. None makes any reference to brain retention. | |
| There is nothing in any of the documents now available from the Cheshire Coroner's records, or from other sources, to suggest that the late Coroner, Mr Hibbert, was aware of, or agreed to, brain retention for research. There was undoubtedly confusion in the Coroner's office in 1987-88 over the referral of brains to the joint programme. | |
| Summary | |
| Mr North states that he was unaware that brain retention without the consent of relatives was taking place from Coroner's cases in his jurisdiction. He also assured me that he was unaware of his office's involvement in the arrangement. | |
| Mr North's office staff and two Coroner's Officers all take the view that Mr North knew that brains were being retained. | |
| In Central Manchester, all the evidence supports Mr Gorodkin's firmly held policy that no organs should be retained for research without the knowledge and consent of the relatives. | |
| At Warrington, the Coroner's Officer made enquiries when he first encountered a request for brain retention. There is nothing to suggest that Mr Hibbert was himself aware that brains had been retained without consent. | |
| The most likely explanation is confusion within the Cheshire Coroner's office where staff did not appreciate that consent had not been given by the relatives. | |
| Changes in the procedures for Coroners' post mortems since the late 1980s are discussed in Chapter 47. |