On August 31, Dr Freddy Patel, the pathologist who carried out the first post-mortem examination of Ian Tomlinson, was found guilty of misconduct by the General Medical Council (GMC). Tomlinson died after being assaulted by riot police at the London G20 summit in April 2009.
The panel considered three unrelated post-mortem examinations carried out by Patel between 2002 and 2005 and concluded that his fitness to practise was impaired. His post-mortem of Tomlinson was not among those examined at the hearing. Patel has already been suspended from the Home Office register of Forensic Pathologists, as a result of criticism of his post-mortem examination of Tomlinson.
The General Medical Council Fitness to Practise Panel is to decide later what action will be taken against Patel.
Tomlinson, a 47-year-old father of nine, collapsed and died minutes after being attacked by Territorial Support Group police officer PC Simon Harwood during the G20 summit of world leaders in London on April 1, 2009. The Territorial Support Group is a section of the London Metropolitan Police that is mobilised for large-scale demonstrations and protests in the capital.
Tomlinson, a newspaper vendor, was attempting to return home for the evening. His route took him through a police operation against demonstrators. The summit was the centre of a huge security effort, involving up to 5,000 police officers.
Harwood was captured in video footage beating Tomlinson across the legs with a baton before shoving him violently to the floor. Tomlinson was doing nothing untoward. He had his hands in his pockets and was unable to break his fall.
Photograph and video evidence indicate that Harwood’s attack was only the last of three separate police assaults on Tomlinson before he collapsed and was found dead just 100 metres away. Immediately prior to the assault by Harwood, Tomlinson was also bitten by a police dog.
Patel, whose real name is Mohmed Saeed Sulema Patel, conducted the first autopsy on Tomlinson on April 4, 2009. He concluded that he had died of a heart attack, linked to coronary artery disease. Two further autopsies drew markedly different conclusions. A second examination, conducted by Dr Nat Cary on April 17 at the request of Tomlinson’s family, found that he died of internal bleeding as a result of blunt force trauma, in combination with cirrhosis of the liver. The findings of the third autopsy, by Dr Kenneth Shorrock, were consistent with that of the second.
The GMC examined post-mortem examinations conducted by Patel of a five-year-old girl in 2002, a four-week-old baby in 2003 and a woman in 2005.
In relation to the woman, Patel had conducted an examination in January 2005, concluding that she died from a blood clot in the coronary arteries. Just one month later, he changed the reason for her death to a brain haemorrhage, after a second post-mortem by another pathologist came to this verdict. Patel told the GMC panel that he changed his mind in order “to satisfy the family”.
Criticising Patel during the hearing, Richard Davies, the chair of the panel said, “The panel is not satisfied that there is no risk of the relevant conduct being repeated”.
He said that pathologists “must not set aside their professional judgement for any of the parties involved during or after a post-mortem examination for reasons of expediency or anything else”.
The panel ruled in this case that Patel had behaved irresponsibly and that his actions were liable to bring the profession into disrepute. Davies added that his “acts and omissions were very serious” and amounted to misconduct.
In his August 2003 post-mortem examination of the four-week-old baby, Patel had failed to obtain full skeletal X-rays from radiologists prior to his beginning his work. He proceeded to carry out the post-mortem at 7:20 a.m., prior to the radiologists’ 9:00 a.m. start time. It was determined that his decision to do so fell short of professional standards, and Patel was found guilty of misconduct in that case.
Davies said of Patel, “You deliberately ignored the guidelines so as to carry out the post-mortem examination simply at a time of your own convenience, and very shortly before radiographers would have been readily available”.
At an earlier sitting, the GMC panel also found Patel had been “irresponsible” in failing to identify clearly visible marks on the body of a five-year-old girl, suggesting she had suffered a violent attack prior to her death in 2002.
Davies said the panel thought it “probable” that Patel had “performed only a cursory external examination of the body”. Patel was found guilty of deficient professional performance, but not misconduct.
The body of the girl was eventually exhumed to allow a second post-mortem examination to take place. Davies said, “It is noted that in this case if the body had been cremated then critical evidence would have been lost”.
Representing the GMC, Simon Jackson QC, told the hearing that Patel’s lack of understanding or ability to recognise the “serious failings” he had made in these cases could lead to future errors of judgement.
The findings of the GMC raise serious questions as to why Patel was ever allowed to conduct the autopsy of Tomlinson. In addition, it has emerged that Patel should not have been registered to investigate suspicious deaths at all. A BBC Radio 4 report last month revealed that although Patel was listed on the Home Office Register of Forensic Pathologists, he did actually not meet the conditions of registration.
The BBC report stated, “To appear on the register, a pathologist must work alongside other pathologists as part of a group practice, and they must have an official arrangement to work for at least one police force in England and Wales”. It added, “Dr Patel’s practice has not had an arrangement with any police force since 2004 and he has not worked as part of a group practice since 2006”.
Cary, who conducted the second post-mortem examination of Tomlinson, said, “People have to work in groups, and this avoids the opportunity for baseline drift of people’s practice. They also have to be involved in peer review, so checking one another’s reports to make sure, in particular, that the evidence of fact is consistent with the conclusions”.
Professor Sebastian Lucas, head of histopathology at King’s College London, told the BBC that he did not find Patel a suitable choice to conduct an examination such as Tomlinson’s.
“It’s a high-profile death and the pathologist appointed to do it was not up to the mark. Cases that are high-profile, with public interest, really do need to be done by people who will do a first-class job, the first time around, without second or third examinations. Dr Patel’s track record doesn’t include those characteristics”, said Lucas.
The wide divergence between the reason given for Tomlinson’s death by Dr Patel and that of the other two pathologists has far-reaching implications. It has ensured that no police officer, including the main assailant, will be brought to justice for this crime, which was filmed and photographed.
In July, the Crown Prosecution Service cited the divergence as a conflict of evidence and said that it meant that it was not able to bring a charge of manslaughter against PC Harwood. Director of Public Prosecutions Kier Starmer said there could be no prosecution due to “an irreconcilable conflict between Dr Patel on the one hand and the other experts on the other as to the cause of [Mr Tomlinson’s] death”.
Evidence already in the public domain shows every indication that further serious breaches of professional standards and conduct, on the part of Patel, took place in his post-mortem examination of Tomlinson.
According to available records, in his first report on Tomlinson, Patel stated that he found three litres of “fluid blood” in his abdomen. However, a second report authored by Patel a year later, stated instead that he had found three litres of “fluid with blood”.
Patel’s initial findings were critical, as further conclusions by other pathologists depended on his assessment. None of the fluid in question was retained by him for later examination.