|HOMEPAGE||LEGAL||CLINICAL||PRESS RELEASES||LINKS||CONTACT US|
FREEMASON JUDGES VS BRITISH JUSTICE
|The information published herein complies with Human Rights Act 1998, Freedom of expression, Freedom of thought, conscience and religion and Freedom of speech, and Criminal Law Act 1967. In accordance with Contempt of Court Act 1981, neither Harassment Law nor Defamation Law applies to publication herein of material of serious public concern which has been heard in open court|
NEW BOOK : GIGANTIC PERVERSIONS OF BRITISH JUSTICE - A CASE FOR A SECOND INQUEST:
A series of Freemason Judges' Errors Of Law decisions persecute the family for demanding Justice
|CHAPTER 1: Introduction - Freemason army of Judges persecute the family, for seeking justice into Sunaina's highly suspicious and sudden death, in an NHS hospital, at the hands of doctors, in British Courts.|
i. POINTS OF FACT pleaded and argued in open court as tending to show that Sunaina was unlawfully killed.
ii. POINTS OF LAW pleaded and argued in open court as showing that the inquest into the death of baby Sunaina by Coroner Elizabeth Stearns was meant to conceal the causes of unlawful death of Sunaina.
iii. JUDGMENTS given by each and every judge in the cases that raised the issue of the cause of death of baby Sunaina.
iv. PERVERTING THE COURSE OF JUSTICE: i.e how each and every that judgment was, in law, a clear and deliberate perversion of the course of justice.
KEY POINTS FOR PERVERTING THE COURSE OF JUSTICE
Throughout the cases reviewed here, you will find out that where the evidence tends to show clearly, that some senior officials have committed a crime, the court has, invariably, gone the whole hogg to prevent judicial investigation of that crime! Why? It could only be for the purpose of enabling those senior officials to escape the consequences of their crimes. Hence, the judges themselves have committed the offence of perverting the course of justice. It is therefore not surprising that some people have referred to the way the courts have dealt with the investigation of Sunaina death as obstructing the course of justice, or defeating the course of justice or interfering with the administration of justice. Any other names they called it simply meant that the courts had perverted the course of justice. The following 6 points are almost inherent in all the judgments examined below. They prove beyond reasonable doubt, that there was overwhelming perversion of the course of justice in the case of Sunaina. They are:
i. The Judge’s Partiality.
ii. Unequal treatment of the Complainants on the one hand and the suspects on the other hand.
iii. Denial of Legal representation to the Complainants.
iv. Failure to give reasons.
v. Failure to comply with the requirements for death investigations.
vi. The Lawyers and Judges membership of Freemasonry which is perverting the course of justice.
Those 6 points are general points for perverting the course of justice. The specific points for perversion of the courses of justice in each specific cases, are given below under those cases.
a. Ignoring, as in this case, obvious evidence. The evidence of potassium chloride, admitted to be lethal, and to have been administered to the child 3 times in the morning she died, was ignored! The doctor who did post-mortem was not told about it. Nor was the doctor who did the tests required to do tests on the part of the body that would show potassium chloride. In the same way, the evidence of 30 times overdose of Ranitidine administered to the child and admitted to have grave side effects was ignored. No tests was specially ordered for it.
b. Failing to search for corroborative evidence. There was no attempts to find out corroborative evidence that the death of the chld might have been caused either by Potassium Chloride of Ranitidine.
c. Failing to carry out a proper autopsy. The doctor who carried out the autopsy admits that he was not told to look for what the effect of Ranitidine and Ptassium Chloride as the cause of death and he did not do so.
FREEMASONS: OUR INVISIBLE RULERS:
Prior to the death of our child, we did not know about the invisible rule and the invisible rulers. We heard about the supreme rule of the Freemasonry in our legal profession and the judiciary. We did not believe it. But now we are left with only one reasonable explanation about what happened to us. The explanation is that whereas other countries have their Mafia which pervert the rule of law, but we do not have Mafia, yet, we have in the country, the invisible Freemason rulers who pervert our course of justice with absolute immunity. Milton, On his Blindness had concluded:: “They also serve who only stand and wait”. We, in our desperation have concluded: We also serve who only weep and beg. This website is our weeping and begging. We weep for dear Sunaina. We beg you to assist us obtain justice for her.
|CHAPTER 2. Mr Justice Elias abdicates the function of the High Court to a lower court, the Coroner's court, in an Error of Law|
HEARING OF APPLICATION BY MR. JUSTICE ELIAS
On Monday, 10 September 2001, Sadhana Dolly Chaudhari, mother of baby Sunaina, deceased, made a formal application, No. CO/3477/001 in the Administrative Court Division of the High Court before Mr. Justice Elias at St. Dunstan’s House, Fetter Lane, London. She was represented by Dr. Adoko who was given permission to represent her as a Mackenzie Friend but conducted litigation under s.28(2)(c) of the Courts and Legal Services Act 1990.
NATURE OF APPLICATION.
The application was against the Coroner Dr.. Elizabeth Stearns of Walthamstow Coroner’s Court. The main ground of the application was for an order that she was not a fit and proper person to preside over the inquest of the death of baby Sunaina on the grounds of judicial bias.
POINTS OF FACT
The points of fact, pleaded and argued before Mr. Justice Elias were given in the witness statement of the Applicant Ms. Chaudhari as follows:
i. Friday 20/10/00: A conference, attended by Dr Mark Peters, Dr. Andy Petros, Dr Mark Kenny, Dr. Quen Mok, and Dr. Christine Pierce passed a resolution for mercy killing of my baby. The resolution was based on the false premises received from King George Hospital! It stated: "We believe it in the best interests of the child to be allowed to die. We do not think that intubation and ventilation until she dies is in her best interest. Therefore, we are not prepared to admit Sunaina to our Intensive Care Unit. We also feel it may be appropriate to withdraw active treatment and offer palliative care to Sunaina.” This is a confession of a conspiracy to kill my child. The permission of the Court to terminate her life was not sought. The doctors acted the God in deciding to terminate the life of my child without my knowledge and permission! And without the order of the court! . See "Appendix 1".
ii. On 20/10/2000 King George Hospital acted on the termination of life resolution by making a "Do-Not-Resuscitate" Order. See "Appendix 2"
iii. On 20/10/2000, King George Hospital again acted on the resolution to terminate the life of the child, by obtaining an Emergency Protection Order to restrict the visits of the parents of the baby to the hospital. In that way treatment could be withheld and food denied to the child without any complaint from the parents. See "Appendix 3".
iv. On 26/10/2000 when I went to the court to apply to set aside the Emergency Protection Order, doctor Robinson asked me, in the presence of my Solicitor, not to apply to set aside the order as the condition of the child had improved and the child was due to be discharged home in a day or two. A discharge plan had been drawn up. "See Appendix 4". I refused. Clearly the discharge plan was drawn specially to prevent me from applying to set aside the order. When I refused to do so, Dr. Robinson went away but returned to tell me that the baby was dead! See post-mortem report: "Appendix 5".
v. On 28/02/2001 the Home Office informed me that the Coroner Elizabeth Stearns "vehemently" challenged my accusations of the fact that she had lied about the whereabouts of the body and organs. This is proof of the degree of personal bitterness and conflict of interest that has developed between her and me. "Appendix 6".
vi. On 14/07/2001 I applied to the Coroner to permit Dr. Adoko, a voluntarily disbarred barrister to represent me at the inquest. The application was made under the provision of section 28(2)© of the Courts and Legal Services Act 1990 and under sections 2(1) and section 3 and section 6(1) of the Human Rights Act 1998 as well as under Articles 6 and 17 of the Human Rights Act 1998. "Appendix 7".
vii. On 23/07/2001, for the express purpose of unlawfully refusing the application for legal representation, Coroner Dr. Elizabeth Stearns deliberately refused to consider the application under the provision of law quoted above for obtaining the permission of the court. Instead she rejected the application under irrelevant provision of law namely rule 20(1) of the Coroner's Rules 1984 which does not apply for permission, but for legal representation by members of the authorised professional bodies i.e. the Bar, the Law Society and the Institute of Legal Executive. See "Appendix 8".
viii. On 20/08/2001 I reapplied to Her Majesty's Coroner, Dr. Elizabeth Stearns, of Walthamstow Coroner's Court, not to preside over the inquest into death of my baby Sunaina. I gave 10 grounds for my application. See "Appendix 9". Amongst those grounds are the following five:
a. The Coroner had already made a prejudiced decision about the issue of motive for killing the child. She ruled that the unlawful removal and retention of organs of the child for research purposes was not to be an issue at the trial. Yet it was one of the issue of motive! She also lied about the retention of the organs. Although in SC11 she admits that the organs were retained, yet in SC7 she denies that the organs were ever retained!
b. The Coroner had denied me samples and slides which I needed to carry out necessary investigations in preparation for the inquest.
c. The Coroner had refused my sister, who is a joint complainant about the killing of the baby from giving evidence. The evidence to be given by Ms. Neelu Berry is so material that the only reason for preventing her from giving evidence is to defeat the end of justice.
d. The Coroner has refused all the 4 White members of medical staff, whom I accused on good grounds, of having killed my baby by their criminal acts and omissions, from giving evidence at the inquest. Again the sole object is to defeat the end of justice.
e. The Coroner herself admits that there has been serious conflict of personalities and interests between her and me.
ix. On 21 August 2001 the Coroner rejected the application, stating that, "I find nothing in my conduct of the investigation to suggest that I should not hold the inquest, and if you still disagree with that decision, I must suggest you seek judicial review of that decision". See "SC10". Hence this application for judicial review.
POINTS OF LAW.
The 14 points of law pleaded and argued before Mr. Justice Elias were:
01. DECISION ABOUT ORGANS BEFORE HEARING:. On 23/07/2001 Her Majesty’s Coroner, Dr. Elizabeth Stearns, wrote a letter, through her official, in which she wished "to re-assure the family that NO organs were removed from Sunaina’s body prior to post-mortem and following post-mortem ALL organs were returned". Yet, the report of the post-mortem itself admits that the organs were removed on 26/10/2000 and replaced on 30/10/2000 for the purpose of the post-mortem. See "Appendix 5) have pleaded the removal of the organs before the post-mortem as evidence of motive for the killing of my baby. The fact that the Coroner has already made up her mind, before the hearing of the case, on that point, is in law proof of judicial partiality contrary to Article 6 of the Human Rights Act 1998.
02. DECISION ABOUT WHETHER AN ISSUE WAS MATERIAL BEFORE ARGUMENT: The claim by the Coroner that the issue of removals of the organs some 4 days before the post-mortem is not material to the inquest is manifestly not true. "Appendix 13". It is one of the pleaded motives for the killing of the child. It is admitted by medical records that the child was suffering from Trisomy 18. But the same record also admits that in spite of it, the child condition was near normal. Hence, the research interests in the organs. The fact that the Coroner is ruling out this vital evidence of the cause of death, is yet another proof of her judicial partiality. Her conduct is contrary to Article 6 of the Human Rights Act 1998.
03. REFUSING COMPLAINANT LEAVE TO GIVE EVIDENCE: Throughout the material time, my sister Neelu Berry and I have been joint complainants. We have complained that my child died as a result of deliberate acts of commission and omissions by some staff of King George Hospital. Even before the child was killed, my sister had reported the conspiracy to kill the baby to the Prime Minister, her Member of Parliament, the Police, and the Chief Executive of King George Hospital. After the death of the child she has complained to various authorities about the way the child was killed. She has launched an Internet website about the way the child was killed. The Coroner herself has referred to the impact of this website. Yet, the Coroner does not want her to give evidence! Clearly, my sister is being refused to give evidence for the purpose of perverting the course of justice. If she does not give evidence, justice cannot be seen to be done. It is yet another proof of judicial partiality on the part of the Coroner. Her conduct is contrary to Article 6 of the Human Rights Act 1998.
04. ALLOWING PROFESSOR RISDON TO DO POSTMORTEM: When Professor Risdon was asked on 26/10/2000 to do post-mortem, he refused to do so. He said, "What do you expect with Edwards?" meaning that the child had died of natural causes as a result of Edwards syndrome. On 27/10/2000 professor Risdon again commented about a post-mortem saying, "Is this really necessary?" Knowing well that Professor Risdon had already prejudged the cause of death, yet Coroner Elizabeth instructed him again on 27/10/2000 to go ahead and do the post-mortem. Clearly her object of instructing him to do so was to have a bias post mortem report. He was not disappointed. See "SC12". Her conduct was again contrary to Article 6.
05. SELECTING EVIDENCE FOR COMPLAINANT: The Coroner has gone so far as to select, on behalf of the relatives of the deceased the kind of medical evidence which should be given! The relatives have informed the Coroner that they would contact some medical staff and report to the Coroner the medical evidence that they would like to submit to the inquest. In accordance with that undertaking, the relatives have contacted some doctors. Before the relatives have received some of the reports, the Coroner stated that she had learnt from certain sources that she dared not disclose, that Dr. Rita Pal had prepared a report for the relatives and that she would allow the relatives to submit the report by Rita Pal! The personal involvement by the Coroner in secretive investigation of the evidence that I am preparing is evidence of her personal interest in the matter and of her conflict of interest as a person and as a judge.
06. REFUSING TO RECOGNISE S.28(2)© OF THE COURTS AND LEGAL SERVIES ACT 1990, The Coroner erred in law in refusing to consider my application to be represented at the inquest by Dr. Adoko, a voluntarily disbarred barrister. The application was made under the provision of s. 28(2)© of the Courts and Legal Services Act 1990 which allows legal representation by permission of the court concerned. The Coroner held that she had no jurisdiction to permit representation under that section! She held that the only permissible representation was under Rule 20(1) the Coroner's Rules 1984. i.e. representation by members of authorised legal professional bodies i.e. the Bar, the Law Society, and the Legal Institute. This is a manifest error of law on the face of the record.
07. VIOLATION OF S.2 OF HUMAN RIGHTS ACT: My application for legal representation raised points of human rights and asked the Coroner to take account of judgements and decisions of the European Court of Human Rights in accordance with the mandatory provision of section 2 of the Human Rights Act 1998. The Coroner refused to do so insisting that she had no jurisdiction to do so! That is a defect, which violates my human rights for a fair hearing. The defect is "so fundamental that compliance with other fair trial requirements cannot render the proceedings fair": Crocian v. Italy (1980) 23 DR 147 at p. 216.
08. VIOLATION OF S.3 OF HUMAN RIGHTS ACT: 1998. In accordance with the provision of s.3 of the Human Rights Act 1998, my application for legal representation specifically required the Coroner, to read and give effect to the provision of section 28(2)© of the Court and Legal Services Act 1998, under which the application is made, in a way which is compatible with my convention rights. The Coroner refused to do so allegedly on the ground that she had no jurisdiction to do so! Her decision is a breach of my human rights. Again, her decision is an error which is "so fundamental that compliance with other fair trial requirements cannot render the proceedings fair": Crocian v. Italy (1980) 23 DR 147 at p. 216.
09. FAILURE TO GIVE REASONS: RE: TIME FOR HEARING: In order for justice to be done and to be seen as done, the relatives of the deceased asked the Coroner to allocate a reasonable time for the hearing at the inquest. The relatives considered 3 days to be reasonable. The relative justified the length of time required by giving to the Coroner the list of some 66 witnesses and their addresses as well as the gist of evidence each witness will give. The Coroner refused the application and insisted on a one-day hearing without giving any reason. Her decision is contrary to Article 6 of Human Rights Act 1998, which requires reason to be given.
10. EQUALITY OF ARMS: RE: DISCOVERY: In order to avoid any form of legal ambush, I asked the Coroner to allow discovery of documents which I needed for the case. The Coroner did not agree. The result is inequality of arms contrary to the requirement of Article 6 of the Human Rights Act 1998. I specially asked for discovery of the followings:
· A log of the whereabouts of Sunaina’s body since her death and hard copies (non faxed) of Toxicology and post-mortem reports.
· Index of ALL microscopic slides and tissue samples taken from the body after death including the post-mortem.
· Copy of entries for Sunaina’s body at East Ham mortuary and at King George Hospital mortuary (The latter entry was crossed off the KGH mortuary book).
11. PERVERSION OF JUSTICE: RACIAL DISCRIMINATION: RE: SUSPECT WHITE DOCTORS NOT TO GIVE EVIDENCE: I specifically applied to the Coroner for 5 medical staff whom we, the complainants, regard as responsible for the death of the deceased, to be called to give evidence. The Coroner refused to call all the 4 of them who are White but called the Asian doctor. The White members of staff not called are Dr. Kathy Padoa, Dr. Thomas Rager, Dr. David Robinson, and Nurse Chris McMenamin. The Asian Doctor called is Dr. Anand Shirsalkar. This is yet another attempt to pervert the course of justice. The conduct of the Coroner is calculated to pervert the course of justice by preventing the White staff from answering for their conduct.
12. PERSONAL CONFLICT: ADMISSION BY COMPLAINANTS: Both the complainants, my sister Neelu Berry and I have completely lost confidence in the Coroners impartiality and honesty.
13. PERSONAL CONFLICT: ADMISSION BY CORONER: It is clear from the Home Office letter of 28/02/2001 that the Coroner herself admits that her relationship me and my sister Berry Neelu is so bitter that she cannot be seen as an impartial judge. See: "SC6".
14. ACCESSORY TO DEATH: Coroner Elizabeth Stearns is an accessory to the death of my child. I am seeking legal opinion whether I can bring a criminal prosecution against those who have committed the crime of killing my child. I am also seeking advice whether I can join Dr. Stearns amongst the accused persons under the provision of section 4 of the Criminal Law Act 1967 in that she knows that a crime has been committed and is doing everything in her power to prevent disclosure of the evidence for the crime. That is why she would not allow my lawyer to represent me. Or my co-complainant to give evidence. Or the White suspects to give evidence. And that is why she is concealing material documents from me.
DEFENCE OF ELIZABETH STEARNS.
Coroner Dr. Elizabeth Stearns appeared in person. She denied being in anyway judicially bias.
i. She admitted that both the Complainants believed that she was bias. Hence she decided to sit with a jury who would be the judges of fact, to determine whether Sunaina died of natural or unnatural causes.
ii. She denied that any organ from the body of baby Sunaina was removed on 26/10/2000 before the post-mortem on 30/12/2000 as stated by the Complainants. She said the word ‘removal’ used in that context meant removal of the body to the place where it was to be preserved, not removal of the organs. She produced pictures taken by the police, just before the post-mortem, on 30/10/2000. They showed the body intact.
iii. On the issue of not calling me, the Complainant, to give evidence as a witness at the inquest, the Coroner testified that the law conferred upon her the power to call or to refuse to call persons as witnesses as she thought fit. In exercise of that power, she did not call me as a witness but called those persons whom she deemed would assist her to carry out her function.
iv. She claimed that at the time she appointed Professor Risdon to do post-mortem on the baby, she had not received our objection to his appointment. Her appointment was based on paediatric specialisation of Professor Risdon.
v. On the question of refusing to allow Dr. A. Adoko, an advocate, to represent us although he is a voluntarily disbarred barrister, Coroner Dr. Elizabeth Stearns said that under Coroner’s Rules 1994 she could only give audience to practising barristers and solicitors.
vi. On the issue that she had refused to allow 3 days for the inquest in spite of several witnesses called to testify and massive documentary evidence, the Coroner said that as a matter of fact she had allowed three days for the hearing.
vii. On the complaint that the Coroner was denying the Complainants disclosure of documentary and other evidence they needed to prepare their case, the Coroner said that she was even-handed in that she gave to the Complainants, exactly what she gave to the Respondents, i.e. the hospitals concerned.
viii. Lastly, she said that the letter she wrote to the Home Office, was not against the Complainants but in defence of the allegations made by the Complainants against her.
ix. The judge then asked her whether the inquest scheduled for the next day could be postponed. Coroner Elizabeth Stearns answered that there had already been some 3 adjournments. The last adjournment was made because the father of the father of baby Sunaina, deceased, had died. Further that it was very difficult to arrange an appropriate time which suits the many medical sraff called as witnesses.
JUDGEMENT OF MR. JUSTICE ELIAS.
Then Mr. Justice Elias gave his judgement as follows:
1. I have before me an application for permission for judicial review. It is a somewhat unusual application and it stems from a particularly sad event.
2.On 26 October 2000 Sunaina Chaudhari died at the King George Hospital. The family have made various allegations about the cause of death. They believe that Sunaina was killed as a result of a conspiracy of various doctors and others and that it was not, as alleged, death from natural causes. It is common ground that Sunaina had Edwards disease, which is an extremely debilitating disease from which most children, I understand, in the normal course of events, but not always, die within twelve months.
3. The particular application before me relates to the inquest which is to be conducted into Sunaina's death. It is alleged that the Coroner who is to carry out the inquest, Dr Elizabeth Stearns of the Walthamstow Coroners Court, is now so biased against the family that it would be inappropriate and legally wrong for her to continue to conduct the inquest. She was asked by the family, by letter dated 19 August 2001, to agree to release herself and to permit another Coroner to carry out this enquiry, but she refused to do that.
4. I should make certain preliminary observations about this matter. The first is that the inquest has already been adjourned, I think on some three or four occasions. It was due to be heard originally in March but there have been certain adjournments at the behest of the family, on one occasion because the father of Mrs Chaudhari died and Mrs Chaudhari was understandably dealing with that particular grief.
5. Subsequently, I am not certain whether in June or July, the date for the inquest was fixed for tomorrow, that is 11 September. Various medical witnesses have been informed that they will need to be present at the inquest on that date. One is apparently making early return from holiday, one is giving evidence before going off to the Middle East and another witness, I am told, is giving evidence between particular bouts of chemotherapy treatment.
6. The inquest is to be conducted with a jury. That is not legally required, but the Coroner considered that in all the circumstances it would be appropriate that she should sit with a jury and not carry out the inquest alone.
7. The grounds on which the family allege that the Coroner is biased have been known to the family for some time. It is right to say, as I have indicated, that no formal application was made to ask the Coroner to step down until 19 August and her refusal was made on the 21st. The family then made this application for judicial review on 3 September 2001. Maurice Kay J heard an application which appears, in fact, to have been an application for abridgement of time for the defendant's acknowledgment of service. That was on 5 September, but he adjourned the matter into open court so that the Coroner could be represented.
8. It came before me today, the day before the proposed hearing, at three o'clock in the afternoon. The applicant sought to be represented by Dr Adoke, who is a barrister but who no longer practices and voluntary disbarred himself some ten years or so ago. I was reluctant to enter into argument as to whether or not he should be entitled to represent the applicant. He submitted that he should, pursuant to section 28(2)(c) of the Courts and Legal Services Act 1990, but, given the importance of the matter and the need for urgent decision, it seemed to me right that I should in any event hear Dr Adoke. Without determining whether or not he strictly had the right of audience, I decided that he could appear as a Mackenzie friend and I gave him considerable leeway in that position to ensure that all the points wished to be made were made. I should perhaps indicate that I made no ruling either way and did not look into the question whether he should be given permission pursuant to section 28(2).
9. The Coroner is also before me today in person. She was not able to obtain legal representation in the time available to her. In a perfect world I would have wanted to have adjourned this matter to enable that to be done but, given the obvious urgency, I decided that I ought to carry on with the hearing and see if I could properly reach a conclusion on the arguments advanced.
10. A final important preliminary point is this. It is correct to say that the challenge is against the Coroner on grounds of bias but the allegations made against her are particularly serious. Indeed, it is alleged that she has become an accessory to the death of Sunaina as a result of her actions, and it is said that effectively she is part of a conspiracy which is designed to prevent the truth from emerging. That, manifestly, is an extremely serious allegation to make against somebody in the Coroner's position.
11. I should then turn to the grounds relied upon for these allegations. First, it is submitted that the Coroner had misled the family because she wrote in a letter on 23 July 2001 that no organs were removed from Sunaina's body prior to post mortem, and that following post mortem all the organs were returned. The family say that the report of the post mortem itself admits that the organs were removed on 26 October and replaced on 30 October. This is a very significant part of their case because it is submitted that effectively there was a deliberate rewriting of history, because the Coroner was submitting that the organs were taken and put back; save, I should add, for the brain. It was made plain to the family that the brain was being kept for further tests after 30 October.
12. In fact the basis of the claim that the organs were removed on the 26th appears to be a document from the hospital which stated that “date of removal” was 26th 10th. That, however, does not appear to refer in fact to the date of removal of organs but of the body itself. In any event, there is a set of photographs with a statement from a police photographer, confirming that the body was intact prior to the post mortem being carried out on 30th 10th. Dr Adoke says that this shows that the Coroner is biased because it demonstrates that she has come with a closed mind because she has already assumed that the organs were not removed until the 30th and that was a matter which should be determined only after hearing all the evidence.
13. That seems to me to be an unjustified allegation. In this application for judicial review considerable weight is put on the fact that the organs were removed on the 26th and not the 30th, and the Coroner is putting forward evidence which suggests that that is in fact a fundamental misconception. It does not bind the Coroner to any contrary conclusion that she might reach if the evidence at the hearing shows that in any way (if and so far as it is material: I am not suggesting that it is) there may be other evidence to show that the assumption of 30 October is wrong. But on the face of it, it seems that no organs were removed prior to that date and that this allegation to the effect that the Coroner had deliberately misled the family in the reassurance she had given on that point seems not to be justified.
14. The second ground was that the Coroner was refusing to consider when the organs may have been removed from the body. It is said that that is going to be relevant for determining whether or not the cause of death was natural or not. Ultimately it is a matter for the Coroner to determine whether, in the circumstances, certain evidence will or will not be helpful to her in her investigation of that matter. If, after the hearing, the family consider that she has gone wrong in law in some way in her approach to the evidence, then they may at that point seek to challenge the conclusion that is reached by the inquiry in so far as the law permits that, but in my submission it does not begin to show any bias on behalf of the Coroner.
15. Then it is said that the Coroner has shown bias as a result of limiting the particular witnesses who can appear before her. There are a number of grounds which are linked together in this complaint. One is that the aunt of Sunaina (who is, according to Dr Adoke, perhaps the principal complainant in this matter) is not being permitted to give evidence. Another is that it is said that of the (I think it is) five doctors at St George's who made the decision that Sunaina should not be treated, only one, an Asian doctor, is being called to give evidence and the four white doctors are not. It is said that that is evidence of a cover-up and also indeed of racial discrimination. Then there are, I am not sure how many, but I think 22 witnesses in any event, whom the family wish to call. (At one stage I think it was 66 and it is not entirely clear to me what the final number is, but I will assume it is 22.)The Coroner is not willing to hear all these witnesses. Again it is a matter for the Coroner carrying out her investigation to determine which witnesses will or will not provide relevant evidence which will properly direct her to the proper conclusions that she must reach; bearing in mind that, as I said, there is an effective jury in this case in addition.
16. This is not a trial as such. It is an investigation into the cause of death. That is a different matter. There may be a number of witnesses who would be highly relevant in connection with a criminal trial who nonetheless would have no role to play in the particular inquest being carried out by the Coroner. The family have submitted a whole range of matters which they say point towards a conspiracy of the doctors to kill Sunaina. Those matters have of course been considered by the Coroner and, as she has indicated to me, they have in part influenced her in determining which witnesses are going to be relevant to call in order to help her to carry out her inquiry properly.
17. Then it is said that the Coroner erred in asking Professor Risden to carry out a post mortem. He was a doctor at Great Ormond Street Hospital for Children. Initially the Coroner had proposed to instruct another doctor to carry out the post mortem, but the family said that it should be somebody with a paediatric speciality and she concurred with that view and appointed Professor Risden. The family say he should not have been appointed because at an earlier stage Sunaina had been at the Great Ormond Street Hospital and it is suggested that Professor Risden is also involved in the conspiracy, if I can use that word in a fairly general way. The family suggest that the Coroner was informed of their objection to Professor Risden by letter, but she says she did not in fact receive that letter. In any event it has to be said that ultimately it is for the Coroner to appoint somebody they think has the proper specialism in the field and it is difficult, it seems to me, to criticise that particular appointment.
18. I should add that the family has had an opportunity to carry out its own post mortem. It indicated it would want to carry out its own post mortem but in the event that did not happen. There was a second post mortem, but that was at the behest of the police, who put forward various names to the family and they agreed to a particular consultant from Scotland who carried out a further post mortem. As I understand it, the family have not at any stage chosen to take up their opportunity to have a second post mortem.
19. Then it is said that the Coroner showed bias by refusing Dr Adoke the right to represent the applicant before her. Plainly the fact that a body making a legal determination makes a determination against the party making the application does not of itself establish bias. Dr Adoke says that in the circumstances of this case it is plain that under the Human Rights Act he is entitled to act for the applicant. I have to say I think that particular point is misconceived. Plainly the Human Rights Act, read together with the European Convention on Human Rights, will in certain circumstances (and this may well be one) entitle a party to the right to legal representation, and perhaps to legal aid for that purpose. It does not fellow that it has to be legal representation from a person of their own choosing.
20. In any event, whatever the rights or wrongs of the decision reached by the Coroner in this case concerning the right of Dr Adoke to represent the applicant, she took advice before reaching that decision, as she made plain in the letter written to Dr Adoke on this matter. She took advice from, amongst others, the Lord Chancellor's Department, who, apparently, confirmed the conclusion she reached that Dr Adoke could not represent the applicant because of the terms of the Coroner's Rules 1994, which restrict rights of audience to counsel and solicitors (although that right was extended, I gather, at some point to legal executives). But a barrister in that context must be one who has not been disbarred or temporarily suspended from practice, and Dr Adoke accepts he has disbarred himself from practice. Accordingly, whether or not the decision was right (and I have no reason to suggest it was not) what is plain to me is that it cannot be said to demonstrate any evidence of bias. Even if it is wrong, that is because there has been a misconstruction of the law, not because it demonstrates any wish to prevent Dr Adoke making the representations to the to the Coroner. Dr Stearns has taken the view he is simply not eligible under the Rules to represent the applicant, and there is no discretion which she has to permit otherwise.
21. It was said in connection with this part of the case that the Coroner had acted in breach of sections 2 and 3 of the Human Rights Act. They go to the merits of the legal arguments advanced by Dr Adoke on that point. They do not in my judgment go to the question of whether or not the Coroner is biased because of the conclusion that she reached in respect to his right to audience.
22. Other matters have been raised. It is said there is bias because the Coroner refused to give three days for the inquest, as requested by the family, and had stipulated only one day. In fact it appears that three days have been set aside, although on the third day there will be certain matters which have to be dealt with in relation to other events, but there would be at least two and a half days which would be available if necessary. But plainly it is for the Coroner to determine how long he or she thinks is appropriate to set aside to carry out the proper investigation.
23. There has been a complaint that there has been inadequate discovery. The family have asked for various documents to be submitted, and they have alleged that there is again evidence of bias because those have not been disclosed. Discovery again is a matter for the Coroner. She says, and I have no reason to disbelieve this, that she has been totally even-handed and has given the same material to the hospital authorities as she has to the family. Again I reiterate, the Coroner is not a court of law.
24. Finally it is submitted that the Coroner has shown bias because she wrote a letter to the Home Office in which she set out what she said she had done in relation to certain matters raised by the family. The Home Office, in a letter to Mrs Chaudhari, commented that the Coroner had vehemently challenged the accusations made by the family about the whereabouts of the body and the question of whether the organs had been taken from the body. Dr Adoke says that that vehement response is a sign of personal bitterness and that it shows that, whatever the merits of the other points, justice will not be seen to be done if the Coroner is allowed to continue to consider this matter. Again, I do not think that is an arguable point. If somebody makes an allegation about the conduct of a particular public official, then the official is entitled to respond to it in a vehement way. If the effect were that they were disbarred from hearing the case, it would be relatively easy in any particular case to arrange that a particular individual should not hear the case, merely by making allegations which would call for a strong and vehement response.
25. So for all these reasons I reject this application. As I have said, it is a very serious matter to say that a Coroner is involved in a criminal offence relating to the death of a child, and I do not think the evidence here comes anywhere near establishing that. But I have already considered whether there is a seriously arguable case that for other reasons there may be said to be, at least arguably, sufficient bias to justify permission being granted.
DR ADOKE: Much obliged, Sir. May I just point out we will exercise our right to have the application heard by the Court of Appeal and that in that case if the case is heard tomorrow we will ask that the whole thing be declared a nullity.
MR JUSTICE ELIAS: Well, that will be a matter for you to decide, Dr Adoke.
DR ADOKE: Much obliged. I am just informing the court we will continue this case in the Court of Appeal to hear it on its merit.
MR JUSTICE ELIAS: I should, I suppose, add this. One can fully understand the enormous pressures that must be faced by the family, by Mr and Mrs Chaudhari, in the circumstances of this case and I think anyone with children would understand that. But I have to say that I do not think, however understandable their grief may be, that these allegations of criminal activity by the Coroner begin to get off the ground, and they ought not in fairness to be made on what I consider to be such flimsy evidence.
THE FREEMASONRY JUDGEMENT OF ELIAS.
The Judgement of Mr. Justice Elias has the quality of the Shakespearean witches in Macbeth! It fills you with hope in minor matters but lets you down in matters of the gravest consequences! The reasons which Mr. Justice Elias gives on peripheral issues, which do not go deep into the core of the problem, are true. But the reasons he gives for for issues at the core of the problem, the issues that determine the dispute in one way or the other, are wholly false! I was therefore obliged to ask lawyers to tell me the cardinal issues in which we had been betrayed and wherein their falsity lies. I was accordingly given the following quotations from the judgment and a through explanation of their falsity.
The following is the reason given by Mr. Justice Elias to justify the refusal of Coroner Dr. Elizabeth Stearns, to allow me to give evidence as a witness.
“Again it is a matter for the Coroner carrying out her investigation to determine which witnesses will or will not provide relevant evidence which will properly direct her to the proper conclusions that she must reach; bearing in mind that, as I said, there is an effective jury in this case in addition”.
On the face of it, that judgement looks like a correct statement of the law. Its falsity in the affirmation that the Coroner was right in holding that I, as the Complainant, should not be allowed to give evidence because I would not “provide relevant evidence which will properly direct her to the proper conclusions”! The two false prongs of this decision are: First that the court is justified to refuse the only person who is going to give evidence of unlawful death from giving evidence. Second, that the court is right to allow only persons suspected of unlawful killing, to give evidence that exonerate them because the witness with incriminating evidence has been excluded from giving evidence! That was what the Coroner did. And that was what Mr. Justice Elias endorsed. And that is what in layman language is called a Kangaroo Court! I am told that that kind or reasoning is called, in law, the Wednesbury unreasonableness. It applies to:
“A decision which is so outragious in its defiance of logic or accepted moral standards that no sensible person who has applied his mind to the question to be decided could have arrived at it”: Council of Civil Services Unions v. Minister for Civil Service  A.C. 374. H.L.
As a Complainant, whose complaint was accepted, and was being investigated, I was entitled, as of right, to give evidence. The Court always sets aside decisions which fall within the Wednesbury unreasonableness.
LEGAL REPRESENTATION UNDER DOMESTIC LAW
The decision made by Mr. Justice Elias concerning the decision of the Coroner to refuse me legal representation is, I am told, an error of law on the face of the record. The decision states:
“Then it is said that the Coroner showed bias by refusing Dr Adoke the right to represent the applicant before her. Plainly the fact that a body making a legal determination makes a determination against the party making the application does not of itself establish bias”,
That point is not disputed. The Coroner was right to point out that she had no jurisdiction to consider application for permission for audience under the Coroner’s Rules 1994. Those rules provide only for rights of audience by solicitors and barristers. It does not provide for permission for audience. Jurisdiction for permission for audience is provided under section 28(2)(c) i.e. the section under which Dr Adoko applied to the Coroner. It was the function of the Mr. Justice Elias to interpret the law and tell the Coroner, who is not a professional lawyer, that although she did not have jurisdiction to give permission under the Coroner’s Rules 1994, yet she had that jurisdiction under section 28(2)(C) of the Courts and Legal Services Act 1990. He did not do so. Instead, he abdicated his function as a judge. To make matters worse, by quoting with approval, the decision which the Coroner and her advisers made, he delegated the duty of the High Court to interpret the law to them! He had no power in law to make such a delegation! Had he told the Coroner that the Coroner erred in law in not making the decision for permission for legal representation under sectin 28(2)(c) of the Legal Services Act 1990, she would have made the decision and we would have been represented. In short, there had been two errors of law on the face of the record. The error of law by the Coroner that she did not have jurisdiction to consider permission for legal representation and the error by Mr. Justice Elias in not interpreting the law to her that indeed, she had jurisdiction to consider an application for audience under s. 28(2)(c) of the Courts and Legal Services Act 1990. Lord Diplock explains the legal consequences of errors of law thus:
1. “An error of law that can be shown to have been made by them, in the course of their reaching their decision on matters of fact or of administrative policy would result in their having asked themselves the wrong question with the result that the decision they reached would be a nullity”: In Re Rachel Communications Ltd,  A.C. 374.
LEGAL REPRESENTATION UNDER HUMAN RIGHTS LAW
Mr. Justice Elias further states in his judgement:
“It was said in connection with this part of the case that the Coroner had acted in breach of sections 2 and 3 of the Human Rights Act. They go to the merits of the legal arguments advanced by Dr Adoko on that point. They do not in my judgment go to the question of whether or not the Coroner is biased because of the conclusion that she reached in respect to his right to audience.
With due respect, the conclusion of the judge is wrong. Where the conduct of the court amounts to a breach of human rights, and the nature of the breach is explained and the court ignores it, in a case which involves issues of bias, then the conduct of the court would inevitably raise issue of bias. In this case the issue of human rights was very well explained to the court thus:
01. Section 2(1) of the Human Rights Act 1998 provides:
"A court or tribunal determining a question which has arisen in connection with a Convention right must take into account any- (a) judgement …of the European Court of Human Rights".
The relevant judgement of the European Court of Human Rights that the court is asked to take account of is In Airey v. Ireland (1979) EHRR. In that case, the court held that lack of available legal aid for judicial separation proceedings in Ireland at the time, constituted a breach of article 6 and a breach of article 8.
02. Section 3 of the Human Rights Act 1998. It states:
"So far as it is possible to do so, primary legislation and subordinate legislation must be read and given effect in a way which is compatible with the Convention rights".
Hence this application that s.28(2)(c) of Courts and Legal Services Act should be read and given effect to in a way which is compatible with the Convention rights of legal representation in cases of this nature..
03. Article 6 of Human Rights Act 1998 is about a fair hearing.
There cannot be a fair hearing where a lay litigant is not represented in a case involving points of law unknown to her.
|CHAPTER 3 : Coroner Dr Elizabeth Stearns breaches her judicial undertaking in the High Court to allow the jury to be judges of fact by substituting her own verdict in place of that of the jury and defiantly demonstrates further bias by asking leading questions from witnesses|
INQUEST INTO THE DEATH OF BABY SUNAINA
On 11 September 2001 the hearing of the inquiry into the death of Sunaina Chaudhari who died on 26th October 2000 started in Walthamstow Coroner Court, presided over by Coroner Dr. Elizabeth Stearns. She addressed the jury.
DR. STEARN’S INTRODUCTION.
Before we start proceedings, it might be helpful if I briefly explained certain matters for the benefit them who have not attended an inquest before.
The Coroner’s Court in England and Wales, has been in existence for over 800 years. Furthermore a Coroner’s Court is unlike any other court in England and Wales in that it is not a court where we find fault or attribute blame. It is a court where we find fact, we are all here on the same side: here is no prosecution, there is no defence.
We try to seek the facts to enable the Coroner or in this case the jury to answer four important but limited questions. Namely, who the deceased was, how when and where she came by her death and the medical particulars required for the purpose of registration.
Now the question “how” is limited to finding out how the cause of death arose, i.e., the sequence of events that lead to the death. It is not normally an opportunity for us to examine the broad circumstances in which the death occurred.
Now you will be participating in a very real way, because you will have the opportunity of asking questions of the witnesses, if you so wish. In order for you to gather the evidence that you need. However, I do have a duty to exclude any question that is not relevant to the scope or purpose of the inquest.
There will be regular pauses for everyone to stretch their legs, but I must ask you not to discuss the case with any other person either inside or outside the court. The only time you should discuss the case is when you are gathered together as a Jury in your jury room, after I have summed up or you have been directed according to the law.
DR. STEARN’S JUDICIAL UNDERTAKING.
Dr. Stearns then repeated to the jury the judicial undertaking she had made in the High Court, before Mr. Justice Elias, that she would not be the judge of fact, but would allow the jury to be the judges of fact, She said:
Now, before we start the proceedings this morning I think I need to expand a little further on my usual introduction.
As you may well know the majority of inquests are heard by the Coroner or by the Deputy, or assistant Deputy Coroner sitting alone. Now the Coroners Act provides that in certain circumstances it is mandatory for the Coroner to sit with a jury. For example, a death in police custody, a death in prison, a death during the course of employment, a death on the railway.
As the facts of this case unfolds it will become clear to you that Sunaina’s death falls into none of these categories. However, as you will also hear, Sunaina’s family has made numerous allegations against hospital staff, Police and myself about a conspiracy to kill Sunaina, and conceal the evidence and impede any investigation. These allegations have been made to the local M.P. the Coroner’s section of the Home Office, the Home Secretary, and the Police Complaints Authority and published on web-site, which is regularly updated and in flyers left around the hospital where Sunaina died. Consequently I have chosen to sit with a jury because as I will explain to you later, it is members of the jury who judge the facts. You will be specifically directed to disregard any emphasis you may think I placed on the facts in the course of my summing up.
The Coroner then took oral evidence and also admitted documentary evidence she considered relevant to the purpose of the inquest. Many medical staff gave evidence, However, to avoid unnecessary repetitions, I quote in its entirety the evidence given by Dr. Shirsalkar who was in charge of the treatment of the child. Dr. Shirsalkar himself admitted that he was not the authority for the medication given to the baby. Accordingly, I will give the evidence of Eileen Ellingford, the Ward Manager of the baby concerning medicaton. Lastly I give the evidence of Dr. Solebo who told me that although he knew that there was to be No Resuscitation of the baby, yet he still tried to resuscitate the baby. His evidence tend to show that the child had a cardiac arrest. It is the kind of death that might have been caused by potassium chloride. I have not given the evidence of Professor Risdon who did the post-mortem because he himself admitted, in a subsequent court proceeding, that at that time he did not know that the child had been given either Ranitidine or Potassium Chloride. His evidence appears in subsequent chapters.
The submissions, amounting to a conspiracy to pervert the course of justice, by the two lawyers for the King George Hospital and the Great Ormond Street Hospital that the Coroner should breach her judiciall undertaking, and be the judge of fact, for fear that the jury might bring the verdict of ‘Unlawful Death are given in full. So is the submission by Coroner Dr. Elizabeth Stearns, yielding to such a criminal demand.
The sum total of the evidence called by Coroner, Dr. Elizabeth Stearns was that baby Sunaina died of Trisomy 18 or Edwards Syndrome and that if there was any set of conduct which affected the child negatively, it was not the conduct of the medical staff but of the parents of the child! Attack was deemed, by the medical staff concerned, the best means of defence. The relatives of Sunaina saw it as adding insult to injury. All the same, in spite of the strenuous effors, on the part of the Coroner, to conceal the role played by Ranitidine and Potassium Chloride in the cause of death, the truth, about the role they played kept peeping out and threatened to expose the conspiracy to pervert the course of justice.
EVIDENCE BY Dr SHIRSALKAR
(He was the Consultant in charge of treating Sunaina).
CORONER: Thank you can I have your full name please?
A: Anand Shirsalkar.
Q: And you medical qualifications and position please?
A: I am M.R.C.P. and I am a Consultant Paediatrician at King George Hospital.
Q: And how long have you been in post?
A: I have been a consultant for the last three and a half years.
Q: Now there is quite a team at King George’s Hospital, a paediatric team. How many Doctor’s in total?
A: There are four Acute Consultants, two in the community and there is a team often junior SHO and six Middle-Grade Doctors. All in the paediatric department.
Q: It is a big unit isn’t it?
Q: And approximately how many babies and children under a year or so would you treat in a year as a hospital as a whole?
A: We have twenty five thousand A&E attendance’s purely paediatric, last year.
Q: It’s busy isn’t it?
A. It is a very busy unit, on the neo-natal unit we ventilate about 100 babies a year, and we are fully equipped to deal with all premature babies.
EVIDENCE ABOUT FATAL EDWARDS SYNDROME
(N.B: Medical evidence disputing the nature of the sickness or the severity of the illness were wholly ignored).
Q: Now you were part of the team, the main part of the team looking after Sunaina?
Q And as we heard she had been diagnosed as having Edwards Syndrome before she was born. And we have heard from the doctor, Doctor Yates that she had a multiplicity of problems. She Had a diaphragmatic hernia, and potential heart problems.
A: That is correct.
Q: Now as soon as she was born what treatment was provided for her?
A: As the parents were counselled anti-natally and postnatally it was decided that all care be given as was the parent’s wishes. So as soon as Sunaina was born she was intubated because with the diaphragmatic hernia in her chest she would not be able to breathe. She was straight away put on a breathing machine.
Q: So Intubated means you passed a tube down?
A: We put a down into her lung and it is connected to a breathing machine.
Q: Yes. And then we have heard in documentary form and also from Dr Yates, about the discussion that occurred with Great Ormond Street Hospital about the advisability of operating on this diaphragmatic hernia?
A: Yes, in the first instance after the baby was born we actually spoke to another surgical team at the Royal London Hospital, and they felt that the baby having Trisomy 18 and with a very limited life expectancy and a poor prognosis they wouldn’t operate on the diaphragmatic hernia. It wouldn’t be right; it wouldn’t be in the baby’s interest.
Q: So the Royal London refused?
Q: So Then you approached Great Ormond Street. And we have heard that she was seen on the 26th May by the cardiology team and that showed she had a hole in the heart and a PDA.
Q: And everything was discussed with the parents and they were very, very anxious that treatment to be given?
A: True. The parent’s were extremely anxious that they were given time to think over given the bad prognosis, but the parent’s came back and said they wanted all the medical treatment to be given.
Q: And so there was an ethical meeting?
A: There was an Ethic Committee Meeting at Great Ormond Sweet, because initial impressions there were the same.
Q: As the Royal London?
A: As the Royal London. But then you heard from the evidence that the Ethical Committee then decided that they should go ahead and operate.
Q: And the reason that if they got Sunaina off the ventilator so that she could go home and have some time with her Mummy and Daddy at home, that would...
A: That was the decision.
Q: And they operated on it, it was successful, and she returned to you for care.
A: Yes. She came back on the 8~h June and she stayed on our special Care Baby Unit until she was discharged on the 31st July. She came back from Great Ormond Street on respiratory support machine called the CPAP machine, which is a machine that you plug into the nose to help with breathing. We managed to slowly wean her off that, onto low flow oxygen, because thats the natural way. It is easier to provide oxygen at home than to provide a machine at home.
A: So she was weaned to low flow oxygen, and was discharge on low flow oxygen.
Q: Now during the time she was in special baby unit, you did some investigations because she had other problems as well. We now find that she had cysts?
A: Yes. Trisomy 18 is associated with many other problems, and we did a scan of her head, which showed a big hole in the back of the head, and part of the brain called cerebellum was very very small.
Q: And there was a cyst?
Q: Now what would be the consequences of having a small cerebellum, what’s cerebellum responsible for?
A: Cerebellum is responsible, that is the part of the brain that is responsible for movement, and posture and with a very small cerebellum there would be hardly any movement or posture. The posture would be completely abnormal.
Q: Would it affect her ability to suckle, or not? Is it part of her co- ordination?
A: It is part of her co-ordination, it’s likely that her feeding difficulties were probably from the small cerebellum.
Q: And she was also screened and found to have a profound bilateral hearing loss as well, so she was profoundly deaf?
SPECIAL CARE BABY UNIT.
Q And the parent’s were extremely anxious during their stay on the Special Care Baby Unit, which is understandable, what parent wouldn’t be anxious. Now, there was a discharge meeting and it was decided it was decide that Mrs Chaudhari could take Sunaina home, presumably by this time she had come out of the Special Care Baby Unit and she was on a ordinary ward, you didn’t take her straight from special care to home did you?
A: No, she was still on special care, on special care we have three different rooms, one we have an intensive care room where babies are cared for, for needing special care, there is a cold room where babies are given feed and growing, who are on low flow oxygen. She was on Special Care in a low dependency room.
Q: Low dependency room?
A: Yes. And before discharge all the professional’s involved in her care sat down and decided “What is the best way forward for her to go home?” and that was the discharge planning meeting.
TREATMENT AS OUT PATIENT.
Q: Yes. Now you say she presented to the children’s ward, This is Clover Ward, where she had open access, on the 3rd, 10th. 12th.and 13th. August as the parents were reassured and she was able to go home again?
A: That is correct Ma’am.
Q; And she was also seen on the 7th. September, and she also presented herself on the ward on the 25th. and 26th. September?
A: That’s correct.
Q: And at one point, on both those occasions she had a cold.
A: Cold. Yes.
Q: Respiratory infection? Yes. Were you actually treating Sunaina, and if so what medication?
A: Sunaina, I need to look at the notes, can I? Right on the 7th September when I saw her in the clinic she was on
Q: What’s that?
A: That is a diuretic, and she was on an acid blocking agent for her tummy.
Q: Now the diuretic and the other medication is to increase the volume of urine that she passes is to stop her getting waterlogged?
A: True. These were started when she was on special care, and the dose that she was on the 7TH. September was very, very low as what she would normally require. And the plan was for her to outgrow the dose rather than increase the dose because there was no clinical indication that she needed it at the present time.
Q: And the antacid is because she had tummy problems?
A: Yes, on special care unit on a couple of occasions there was some blood aspirating from her tummy, and since then she had been on ranitidine.
Q: Do you think they were stress ulcers, or what do you think that was due to?
A: Could be stress ulcers, but apart from the initial say on special care, when we saw blood, Mum was very reluctant to take her off the medicine.
Q: Now, you have been able to manage Sunni at home, she’s had frequent visit’s to the hospital to be reassured, and two occasions she had a cold, but the parent’s were managing?
Q: And they were looking after her around the clock, she had feeding through a nasal gastric tube, or oral gastric tube, she was having oxygen, low flow oxygen through her nose. But on the 1st October she had to come back into hospital, is that correct?
HOSPITALISATION ON 01 OCTOBER 2000
A: Yes that’s correct. Because she was becoming increasing distressed.
Q: And how did she present on that 1st October?
A: She had, Mum came in saying that she was having more breathing difficulty, and she was assessed by the registrar, who felt that it may be a chest infection. So, bloods were taken to look for a chest infection, and was put on the CPAP support which is the respiratory support to the nose to help her with her breathing, and antibiotics were started. We normally start antibiotics in small children, when we think there is a susceptibility to them, and as soon as well realise there isn’t an infection we stop them.
BAD RELATIONSHIP BETWEEN MOTHER AND STAFF.
(N.B. The cause of the bad relationship is not stated. From the time the child was born the mother had been trained to act as her nurse by giving the medicine, oxygen, and operating all the necessary appliances. Her efficiency in those respects was admired during the First Hospitalisation of the child and during the time the child was discharged from the Hospital. The evidence of Dr. Shirsalkar above, shows the devoted manner she carried out her duty. Yet no reason is given as to why during this Second and Last Hospitalisation, why the relationship between her and the Hospital staff suddenly became bad. In spite of evading the truth, the evidence of Dr. Shirsalkar points out, indirectly, the causes for the bad relationship. First, he said they had decided not to give the baby curative treatment but care treatment. Second, they had decided on a Do Not Resuscitate Order. Third, they had denied the child Intensive Care Treatment. There were other reasons the Mother gave. They all led irresistibly to one and only one conclusion that the staff had decided to kill her baby).
Q: Yes, so because you thought there might be a germ that might respond to antibiotics, you started her, even though you hadn’t grown any germs and didn’t know what they were sensitive to, you started her on antibiotics. But Mother was very anxious?
A: Very, very, very anxious.
Q: And The working relationship we have heard between the nursing and presumably also the medical staff and the Mother started to deteriorate?
A: That is correct.
Q: And you say in your report that parents and relatives were increasingly abusive and aggressive?
A: They would. Any Doctor and Nurse that that went in, who did anything different from what they wanted to do, they would start abusing. In fact when I went in to examine the baby, they said “Only examine the tummy, you are not allowed to examine the chest”, so it was becoming more and more difficult. Even for people, medical people to examine the baby.
Q: And we have heard from several others that they would, or the mother would alter the oxygen supply...
A: That is correct. She would alter the oxygen supply up and down as she wished, against medical advice. She would use the suppositories when not needed.
Q: Was she bringing those in, or were the hospital leaving them?
A: She had a supply.
Q: And finally the situation became very, very difficult
A: That’s is correct.
EMERGENCY PROTECTION ORDER
(The reason given for obtaining Emergency Protection Order to restrict the visits of the parents to the baby were, on their face, suspect. It is said that the Mother was not obeying doctor’s orders. Yet, the doctors were giving contradictory orders. One doctor would authorise the use of CPAP, but Dr. Shirsalkar would order it removed! It was said that the Mother barricaded herself in a room. Yet, Dr. Shirsalkar points out that she wrote on the door, “Knock and Enter”. And, to avoid the staff who entered stealthily doing harm to her baby she put a chair by the door so that when a person entered into the room, it made a slight noise that woke her up. The reason given by the Mother for Emergency Protection Order is credible. Mother said that the Emergency Protection Order, obtained without her knowledge, was to give the doctors the opportunity to kill her child in her absence. Indeed, that was indeed, what happened. When the Hospital knew that she had gone to the court to obtain a court order to set aside the Emergency Protection Order, they ensured that the court did not hear her!. For the first time, the child was given potassium chloride, known to be fatal, not once, not twice but thrice! Not even after a reasonable lapse of time but one after the other! Malice aforethought was clear. Its object was achieved. The child died. Dr. Robinsaon who was in court was immediately telephoned. He told the Mother, in essence: The child is dead; the case has abated).
Q. So what did you decide needed to be done?
A: We were faced with a situation where the parents were asking for something that we couldn’t offer, so we had to seek it. They wanted intensive care for this child and we had to seek intensive care centrally because GOS, (i.e. Great Ormond Street Hospital) we spoke to them and explained the whole situation to them, they decided to come and access the baby, which they did. They did come on ..
Q: But there had also been a meeting, and it was felt that the parents were not necessarily acting in her best interest, they sought The help of the court, what happened?
A: On the 20th October when the situation on the ward became unbearable to the medical and the nursing staff and it was decided we meet with the consultant’s at GOS, and explain the whole situation. There was instances where The mother would barricade herself, wouldn’t allow the doctor’s to go in and examine the baby, there were instances where she would turn up the oxygen and turn down the oxygen off, take The CPAP off, put the CPAP on, suction the baby when not needed...
Q: Would this not be that she just wanted to be awake when anyone came in, and she was just putting something there so she would just hear if anyone came in, or did she make it impossible for anyone to come in the room?
A: I am not sure what her intentions were, but definitely she had put a chair behind the door, because there was a big notice on the door which said knock and enter, so...
Q: So you couldn’t actually enter. So it was felt that there was the need for an emergency protection order.
A: Yes, their advise and everybody’s involved that the parents actions were inappropriate, and they were actually harming Sunaina rather than, even though they were done in good faith by the parents, and on a number of occasions when it was explained to that this was not in the interest of the baby, this is going to harm your baby, they took no notice of it. And it wasfelt That for the baby to be assessed properly, the baby needed to be weaned off the CPAP, so we have to take the Emergency Protection Order.
Q: So that meant going to court and that was granted?
A: Yes it was granted.
Q: And that meant that the mother and father of Sunaina was allowed to visit 4 hours a day supervised, and Mrs Berry was not allowed to visit at all, and we have heard evidence from The Police about the complaint’s they made that this was a plot, so that you could have unsupervised access to the baby in order to kill the baby. And when the parents did attend they were supervised at all times?
A: They were supervised at all times.
Q: So there was no question of fiddling with the oxygen or altering anything after the Emergency Protection Order was granted.
A: That is correct.
Q. So That was granted on which day?
A: On the 2Oth October.
Q: Now on the 23 three doctors came from Great Ormond Street to look at Sunaina, did they discuss Sunaina with you, were you present when they examined her?
Q. And They say they felt that she was?
A Clearly detonating.
Q: Terminally ill. And They felt that it was not in her best interests to put a tube down and ventilate her, but to what make her comfortable?
A: To make her comfortable and let her pass away peacefully and not in pain without much distress.
Q: Now were there decisions communicated to the family, where they aware They Thought she was terminally ill? A:Yes The parents were fully aware of her condition, and also the opinions of all the medical personnel involved, and They wanted all intensive care instituted to this child. So plan was for us to go to High Court to seek an opinion from The Court, whether to withhold or withdraw intensive care.
Q: So what you were going for to the High Court the day Sunaina actually died, was to seek and order from the Court to say just to give her palliative care, or was it to not to resuscitate, what was it that you were seeking from the High Court?
A: The day Sunaina died, in Court when the parents were there with Dr Robinson, it was challenged by the family to remove the Emergency Protection Order.
Q: So you never actually got to the High Court to ask them for directions?
A: True. But the parents were aware of our letter and our intentions to go to High Court and to seek guidance.
Q: And the parents were actually at Court, waiting to into Court with their Legal representative and presumably the Hospital Doctor there was with a Legal Representative, and that particular Court appearance was to challenge, the Emergency Protection Order That had been granted, what 6 days earlier? And the news came to the Court that in fact Sunaina had died. While the parent’s were not there, with her.
A: That is correct.
Q: Now, as you know there has been a lot of publicity about this case including a document by a Dr Adoko who after it adds “Banister at Law” is in fact a voluntary disbarred Barrister at Law, asking who killed this baby, he makes a lot of allegations in it, but he says “At no time described in the medical notes that Sunaina was terminally ill”. Is that correct? Was this ever made clear to the parent’s that you felt that she was moving into a terminal phrase of her illness?
A: The parents were made aware that she was critically ill, definitely.
Q: He say’s that in his opinion the baby on the l4th October at 10 to 10 in the morning, baby was sitting, baby looks pink and screaming and active.
A: No, baby was never sitting.
Q: No. Might have been sitting supported or sitting in a chair, or in parent’s arms?
A: I didn’t see.
Q: I mean you wouldn’t expect a five-month old baby to sit unsupported anyway?
A: That is true.
Q: Because they don’t sit unsupported until they are a little bit older than that.
A: That is true. Every time medical and nursing personnel have seen her, either in her mother’s arm or in a cot lying.
Q: Did she scream, was she active?
A: She cried occasionally, a very weak cry.
Q: Now Dr Sarah Luke say’s there was good eye contact, she was fixing and following, would you expect that in a baby as ill as this? I mean I appreciate it was earlier when she made that report, but baby at that time was three months, Three weeks, she’d only just started to smile. What time do babies normally start to smile?
A: Normally we expect babies to smile with eight to ten weeks.
Q: So it was late?
A: Very, very late.
Q: But she was fixing?
A: She was fixing.
Q: And making some sort of cooing noises?
A: She made some sound, rather than cooing.
Q: Is a profoundly deaf baby more handicapped about vocalisation and things like that, or are babies even as this age who are profoundly deaf, vocalise?
A: Can vocalise. Make some sounds thought not anything necessarily intelligent sounds; it’s a natural process to make sounds.
Q: Now they also allege that all treatment was withdrawn from the baby including giving her any nourishment or water?
A: That is wrong. She was being fed throughout via a nasal gastric tube, she was always given oxygen, and she was given antibiotics when appropriate.
Q: And they say that her care and hygiene was neglected, her clothes remained soiled and smelly with vomit.
A: Whenever I saw her on the ward she was not in that state.
(It seems as if there was a conspiracy between the Coroner and Dr. Sirsalkar not to deal with the issues raised by Ranitidine as a probable cause of death! First, the fact that 30 times the dosage of Ranitidine was given to the child for some four days! Second, the fact that it produced serious side-effects that were likely to cause death. Third, the fact that none of the doctors stopped the overdose which was, stopped by a pharmacist. Fourth, the fact that when it was realized that Ranitidine was causing all those dangerous side-effects, its administration was not stopped altogether, as it ought to have been done! Instead it was continued, at the standard dosage, for some 20 days, till 2 days before the child died! The Coroner did not deal with those issues! And Dr. Shirsalkar referred her to ask the nurse to deal with them. It goes without saying that the nurse did not!)
Q: Now they also are concerned about administration of her medicines, do you know anything about this. This is what they call the criminal cover-up. On Wednesday the 4t October when Sunaina was administered 10 tens the prescribed dose of ranitidine on Clover Ward for a few days. 30mgs instead of 3. Do you know anything about that?
A: I think the Nurse would be more able to answer that question.
Q: Would 30mgs be harmful, for a baby of this age and size?
A: Ranitidine is normally given 1mg per kilo, so 30 mgs is an overdose if that is what was given.
Q: We have had the nurse present anyway, so she will be able to help us. So 30mgs would have been an overdose. They also were concerned about the giving of Potassium, that exercise’s their minds considerably, was potassium been added to her feeds as a supplement?
A: Jam not aware of it
Q: It is not anything you would prescribe?
Q Why would one prescribe Potassium?
A: If a child is on diuretics and the diuretics can drain the body of the potassium so they need replacing, to put the salt back.
Q: So you may well give Potassium supplements?
A: Supplements yes. If she was on diuretics.
Q: But she was not on diuretics she was on frusemide and Spironolactone??
A: But the spironolactone?? is a potassium sparing diuretic, so...
Q: So it would only be for the frusemide.
A: We would not normally give it in combination, only if we see that the potassium leves are low, then we would start the potassium supplements.
Q: And what would be the effect of excess of Potassium on baby?
A: Potassium is a very important electrolyte, high potassium can cause rhythm disturbances to the heart, and actually the heart could stop. If it was too much potassium.
Q: So you would refute their allegations that baby was denied liquids?
A: Oh definitely. She was being given everything; all the care that we would normally institute for any child was being given to that child.
Q: But what you were not prepared to do was to intubate and ventilate her.
A: That’s is correct, in cases of terminally ill patients were life expectancy is not known to be prolonged by the intervention, we would not offer her intensive care.
Q: You would offer her tender loving care?
A: Tender loving care, that is correct.
Q: Now when a baby dies is it customary to remove any marks of medical treatment from the baby, to enable the parents to cuddle the baby when they come?
A: Norm0ally whenever a baby dies say on Special Care, where there are lots of tubes and everything are going into the baby, we normally like to take everything away and give a nice natural looking baby for the parents.
Q: Any other questions? (From the Jury or Solicitors)
EVIDENCE OF WARD MANAGER EILEEN ELLINGFORD
(Although one of our complaints was that the child might have died as a result of the potassium chloride given to it, the Coroner evaded questions that would lead to the conclusion that the child might have been deliberately killed by the administration of potassium chloride. No question about the number of times potassium chloride was given, or the amout given, or on whose order it was given, or why it was given on that particular day).
A: I am Catherine Eileen Ellingford, I was the Ward Manager of Clover Ward and the League’s Sick Children’s Nurse for the Trust.
Q: And you were involved in helping to look after Sunaina?
A: Yes. My involvement at the beginning was delayed because I was actually on annual leave. So Sister Judd went to the discharge meeting in Special Care and liaised back to me on return from leave. Our initial feeling were that this was a family who were in crisis due to having a very special needs child, with a short life expectancy.
Q: So you felt that the family was in crisis?
A: Yes. Both with the acceptance with diagnosis but also as any parent would be dealing with what was ahead of them.
Q: Now you were running the ward, Clover Ward where you were the Ward Manager for Clover Ward, during Sunaina’ s last admission?
A: Yes I was.
Q: And I have a very comprehensive report from you, for which we are not going to go into enormous detail. Are you able to tell me what medication she was on in all detail? You see the parents say that she was taken off all medication and denied all medication, and I am just wondering what she was on at the time she died.
A: The medication on the morning that she died, she was on Cytamen which is an iron supplement 1 .5mls. which she had and was signed for a six o’clock that morning, she was on Abidec 0.6 mls. which she had at six o’clock that morning and signed for. She was on Frusemide the diuretic 2.5mgs which she had that morning and signed for. She was on a potassium supplement 4.7 mls which she had that morning and signed for.
Q: That was given in the feed?
A: That was given in the feed, but it had only been prescribed the night before for the first time. She was also on ventolin
EVIDENCE OF DR. SOLEBO
(N.B. Notice the suddenness of breath stopping absolutely).
Q: Thank you can I have your full name please? A Dr Junaid Oluseyi Solebo.
Q And you are a Staff Grade Paediatrician?
A: I am a Paediatrician at King George Hospital, I have been there now for eight years.
Q: Now you are obviously aware of the background problems with caring for Sunaina, and I believe that on the morning of the 26th October Sunaina had developed a fever is that correct?
A: I had just walked into the paediatric ward, I was not actually working on the ward that particular morning, I was on Special Care Baby Unit. I was told that the consultant had seen baby Sunaina that morning, the baby had a slight temperature and that the consultant had requested that some blood test be done, and the baby should be started on intravenous-antibiotics. The junior doctor on the ward had tried to insert a cannula, a small drip line for her antibiotics, and as I was on the ward she asked me for assistance.
Q: What she couldn’t get it in?
A: She couldn’t get it in. She found difficulty doing it.
Q: It is not the easiest thing to do on a very small baby.
A: It could be quite difficult on small babies.
Q: And, you decided that you would help site the line?
A: I thought I would assist her in doing the line and I had a go and at first found it very difficult, as I was having a second attempt Sunaina stopped breathing. I noticed that she had stopped breathing completely.
Q: So you were in the room, who else was with you?
A: I was there, Dr Hancox who is the SHO was there, there must have been nurses there as well, possibly not in the room but around. Sunaina’s room was just next to the nurse’s station.
Q: So she just stopped breathing?
A: I noticed she had stopped breathing all of a sudden.
Q: So you didn’t have time to take the intended blood for blood samples, that was the last thing on your mind?
Q: Did you attempt to resituate Sunaina?
A: At that particular time things happened so quickly, and the only choice I could make was to actively resuscithate her.
Q: So you did, so you cleared her of secretions, her airway?
A: We used a suction machine to clean any secretions, as Sunaina was producing so much. I gave her oxygen by face mask and also about a minute when there was still no response I then put a tube down into her chest and actually tried to get her to breath.
Q: So you intubated her?
A: Yes. As this did not work I massaged her heart as well, but that didn’t work so we gave her medication called adrenaline to try and restart her heart. In all of fifteen Sunaina had no response at all. She did not breathe at all.
Q: So you tried everything, the normal protocol?
A: I did.
Q: To resituate a baby. Without success, and after what fifteen minutes?
A: After fifteen minutes of doing that, I actually had a Consultant standing by and she took part in what I was doing, at fifteen minutes I consulted her, that we had to stop and we all agreed to stop.
Q: Would that be Dr Samrasekara?
Q And presumably Dr Hancox was also there?
A: She was in there as well.
Q: So in all there was three doctors working on this little baby. And after fifteen minutes tragically you were not getting any response, so death was certified at 11. 10am What did you do then?
A: The nurses took over from me after that, I was aware that Dr Robinson was in Court, I was aware that the parents were in Court as well, the nurses tried to get the parents while I tried to contact my Consultant in Court.
Q: So you paged him?
A: I paged Dr Robinson yes.
Q: And the nursing staff tried to contact Mr. and Mrs Chaudhari at home but there was no response because of course they were actually in Court as well. And at 11.40 you informed the families Doctor and my Officer.
Q And then about 1 .00pm Mrs Chaudhari had at that time come to the ward and you had the opportunity to speak to her?
A: I did, the parents came in about that time and I sat down with them and went through about what happened in the morning. I also informed them that I had spoken to the General Practitioner and the Coroner as well. Mrs Chaudhari wanted to know who the Coroner was and I wrote the name and the telephone number on a paper, which I gave to her.
Q: So to summarise your evidence you just happened to have just walk onto the ward, you were told that the baby had a temperature and that a junior Doctor, Doctor Hancox was having trouble getting a line into, to give intravenous antibiotics and you went to help to do that, because it can be difficult on a small baby. You failed on the first attempt and on the second attempt you notice that baby had stopped breathing.
Q: You tried to resuscitate even though you were aware that this baby had a terminal illness, or was it just that instinct kicked in?
A: I was aware of the clinical advise received from Great Ormond Street, I was aware that the parents and the Doctors were in Court, trying to plan for the EPO. Things happened so quickly that I thought it was best in that particular second was to assist the patient, and so I did.
Q: So you just got in with it. Is there anything else you would like to tell the Court?
A: No thank you.
Q: Did you stop the feed while you were resuscitating or was that the last thing on your mind as well?
A: Sunaina wouldn’t have been fed very much...
Q: She had a nasal gastric tube in place I think.
A: We tried to suck out the mucus as well. The tube would have gone into the nose, then into the mouth and stomach to get out as much milk as possible.
Q: Thank you. Any further questions. (To the Jury and Solicitors)
(When all the evidence had been given, the Coroner began her summing up to the jury),
Make yourself comfortable
This is the resumption into the Inquest of Sunaina, and I hope you feel refreshed.
As you know yesterday we completed hearing the evidence in this sad case. And it is now my duty to sum up for you and to give you directions as to how you should complete your enquiry and direct you on any points of law. Now the summing up is a synopsis of the evidence, it is a reminder of the flavour of who said what. It’s only a reminder and individually or collectively you may have a different understanding and recollection. And it’s for you to assess the value of the different witnesses and asses the importance of the different parts of the evidence. In the course of my summing up you may think I over emphasised certain facts that you don’t consider very important, or under emphasised facts that you consider vital.
You must ignore any emphasis I place on the facts because you and you alone are the judge of the facts. However, when it comes to the law you must be guided by me because I am considered to be the judge of the law.
I will first read you rule 36 and 43. Rule 36.
The matters the proceedings and evidence in an inquest shall be directly solely to ascertaining the following matters, namely who the deceased was, how when and where the deceased came by her death. The particulars for the time being required by the Registration Act to be registered concerning the death, neither the Coroner nor the jury should express any opinion on any other matters. Rule 42: No verdict shall be framed in such a way as to appear to determine any question of criminal liability on the part of a named person or civil liability.
Now, before I sum up, I must ask you do you wish to address me as to the law?
Unknown voice: I do madam.
Q: This is your opportunity to do so in that case. Members of the jury it looks like a point of law may have arisen, I am sorry to make you get up again but could you please return to your jury room. I don’t anticipate it taking very long.
MISS HARRISON: SOLICITOR FOR KING GEROGE HOSPITAL
(The application by Ms. Harrison appears to me to be a conspiracy to pervert the course of justice. I admit that she had a legal right to make an application on a point of law. But the nature of the application she made, namely, that if the jury were not denied the ecercise of their legal function, they might make a decision of Unlawful Cause of Death, was clearly a perversion of the course of justice”. )
Thank you madam. I may just want to make these very short words about the possible verdicts to which you may direct the jury to. In my submission on the basis of the witness expert and the forensic evidence given yesterday, the only verdict which can be safe to direct the jury to consider would be and to return would be natural causes. The only other possible alternative is an open verdict and in my submission on the basis of the clear evidence given yesterday this would not be a satisfactory outcome. I accept that the Coroner of course has a discretion, but would submit that you should not direct the jury to consider ‘unlawful killing’ as a possible verdict, as there is no evidence given yesterday to support that verdict. Whilst that it may be appropriate for the jury to consider other verdicts, in my submission no reasonable jury properly directed could reach a verdict of unlawful killing to the required standard of proof
Coroner: We heard evidence from Professor Vanezis and Professor Weindling, but I do have to direct the jury that they are experts but their evidence does have to be considered in line with all the other evidence. In view of the families allegations I think it would be appropriate of me to discuss what they would have to find to return a verdict of unlawful killing. And then leave it as a matter for their discretion. But I have to accept that as far as the allegation of Murder is concerned there is no evidence, to support such an allegation. We have had evidence, as you know of oxygen being altered and that may be something that the Jury wish to consider, although I would have to direct them that Professor Vanezis said that could have played no part in the death.
I agree with you that an open verdict is not at all appropriate. I am not going to leave that with them. A natural causes is appropriate. And I could also leave a narrative verdict and I am going to direct them on that, which is a perfectly proper verdict for them to return if they are so minded. Mr. Thomas do you have anything you wish to say?
MR. THOMAS FOR THE GREAT ORMOND STREET HOSPITAL
Ma’am I would like to add to my learned friend Miss Harrison’s submissions, I have obviously heard your thinking of the matter, on the evidence even taking it at its highest, it’s my submission that the jury properly directed could not reach a conclusion of unlawful killing in his case. And the evidence justifies only one conclusion and in that case death from natural causes.
RANITIDINE AND POTASSIUM CHLORIDE
(When the jury returned, the Coroner gave a long summing up along the agreed line namely that the Hospital staff had nothing to do with the death of baby Sunaina. She hardly referred to Ranitidine or Potassium Chloride except to say that there was no evidence to that effect whereas the doctor who did post-mortem did not know that he had to look for such evidence. Nor did the doctor who did the subsequent test. He had testified that potassium chloride had to be looked for in a particular part of the body and that part of the body was not the sample given to him to test. Secondly, the test had to be done shortly after death and he had taken the test long after death. On the basis of such premises, the Coroner came to the following irrational conclusion”! )
THE CORONER ON THE TREATMENT:
The toxicology was negative apart from a treatment dose of paracetamol, which is the component of Calpol. They found no findings of violence of poisoning or any evidence of foul play or any evidence of suffocation. Baby according to both pathologists died of multiple congenital abnormalities.
THE CORONER ON THE VERDICT:
Now the law requires that the jury should complete the inquisition. Now This is a statement that sets out those mailers which have been proved from the evidence you have heard in which you conclude lead directly to the death. Now the four questions who, how, when and where have been reduced to four headings and I think you have each been provided with a photocopy of the back page of the inquisition. Now, you have to complete this. Now first of all you have to discuss between yourselves the evidence you have heard, and after discussion you should I hope to be able to agree the factual circumstances, which gave rise to the death. And only when you have agreed the factual circumstances should you seek to come to a conclusion. Now you need to complete the four boxes on the back of the inquisition, you have to use clear words to set out the facts as you find them. And the words you use are entirely a matter for you although we have provided some as a guideline.
Now the first question is who. Now we heard evidence from Mr. Hamilton, one of my Officers’s that Sunaina was identified to him by the parents. And consequently that evidence is not in dispute.
Now number two is the injury or disease causing the death, and as I say normally here I would suggest you are guided by the pathologist’s opinion as to the cause of death. Nevertheless in this case you have heard oral evidence from the pathologist and evidence from the pathologist is just like any other. So you have to decide on a cause of death but I am going to permit you to take both copies of the postmortem reports in the jury room with you, and you will see what each pathologist has given what he considers the cause of death and I would suggest you could be guided by that to come to your conclusion, but it is entirely a matter for you.
Now number three is the time, place and circumstances at where the injury was sustained. Now here you have to discuss between yourselves the factual circumstances, which gave rise to the death, and when describing the circumstances you should be brief and neutral, just factual. You shouldn’t express any judgement or opinion, just set out the facts as you find them upon which you base your conclusion.
Now we have a short note that Mr. Hamilton has prepared, you have got that have you? We have a short note of the type of thing you may choose to write, just to give you an example, and you don’t need to follow word for word. The facts after all are a matter for you to decide, however this section must contain all the relevant facts on which you base your conclusion and there is a typed note there, the sort of things that juries normally write in that slot. As I say it is just given to you as guidance because filling in that section is entirely up to you.
Now number four is the conclusion as to the death, and once you have agreed on the facts you have got to come to your conclusion. Which is popularly known as the verdict. And you have a duty to find the facts and conclusion from the evidence you have heard in court.
Now in this particular case it’s somewhat unusual in that the family have made very, very serious allegations and I think that I would be failing in my duty if I didn’t go through with you the standard of proof and the things that would need to be proved in order to justify a verdict of unlawful killing. Which would justify the family’s accusations.
Now they have made vigorous allegations of both deliberate killing and a conspiracy to kill the baby by an appropriate withdrawal of treatment. And I understand a motive for the actions, the supposed actions is that the original diagnosis of Edward’s Syndrome was incorrect, but part of a face saving procedure, the medical staff determined that the little baby should die anyway as they predicted.
Now the first allegation was one of murder. Now murder is when someone has killed another without legal justification intending to kill or to cause really serious injury. And you would have to be satisfied beyond reasonable doubt so that you were sure that a person either acting alone, or as part of a joint criminal enterprise or conspiracy intended to kill Sunaina. Furthermore you would have to be satisfied beyond reasonable doubt that the act or acts caused the death. And I have to tell you that in this case there is no evidence that any person intended to cause Sunaina any harm or death. And there are no evidence at all that any deliberate acts or omissions lead to the death and therefore, I cannot even allow you to consider that the baby was murdered. I would like you to withdraw that from your possible consideration.
Now, the other allegations was that the baby died as a result of gross negligence on the part of the hospital, which is called manslaughter by gross negligence, that is another type of unlawful killing. This is where one person has caused the death of another but without any intention of so doing, and you may recall the recent case of parents that allowed their children to play on the railway line, and the children were struck by a train and died. That is the type of gross negligence that we are looking at. Now I am going to run through the ingredients and direct you. Now before any jury can find gross negligence manslaughter you would have to be satisfied firstly that the four ingredients, so called ingredients of the offence were made out. And that they are: a duty of care owed to baby Sunaina, that the duty of care was breached; the breach was grossly negligent and the breaches caused the death.
Now I would have to tell you that there could be no doubt that a baby is vulnerable and dependent on others for food and water and medication, warmth and shelter. And that duty is owed by whoever takes care of a baby, be it parent’s, grandparent’s, childminder or hospital staff Consequently whoever looked after Sunaina owed her a duty of care to provide food and water, and in this case via the nasal gastric tube to give her the appropriate medicines in the appropriate doses. Give her warmth, shelter and in her particular case administer oxygen in the correct rate of flow. And the medication and the flow rate of oxygen are a matter for doctor’s to decide. Now you would have to decide whether on the evidence there had been any breach, but even if you decide there had been some breach’s or some variations in this duty you would have to decided that they were grossly negligent.
I am sure you are aware that in certain circumstances one person may sue another in Civil Court’s for monies and compensation, those damages are for personal injury or even death. But we are not talking about that; it is not negligence of that kind that concern’s a Coroner’s Court. If you were so to consider it, the negligence would have to go beyond a matter of compensation. It would have to be more than a degree of fault or mistake or error of judgement, if indeed you did decide that there had been any such errors, it would have to be such magnitude as to demonstrate a disregard for Sunaina’s safety and her life. The kind in your judgement which would have to be described as criminal, and demanding of punishment.
Furthermore even if you did decide that there was a breach of duty of care you would have to be sure that the breach had caused the death, and once again I have to refer you back to the expert’s evidence, the pathologist’s expert evidence. That this was a natural death, it was the end process of a disease and that no alterations of the oxygen or variations of medications, or suppositories had played any part in causing this death.
So, I have considered the verdict of unlawful killing, which I know if the family had been present they would wish to be put to you, but I have to say to you that there is no evidence on which a reasonable jury could possibly come to that conclusion.
I am now going to leave you with the two possible conclusions that you may return, and these two conclusions require a far less high standard of proof, the unlawful killing verdict requires a criminal standard of proof satisfies beyond all reasonable doubt. The two verdicts I am going leave with you are one’s which can be reached on the balance of probability, i.e., more likely than not. Now The first one is ‘natural causes’ and this is the appropriate conclusion to come to after careful consideration of the facts that you decide that the evidence shows that Sunaina had multiple serious health problems, which progressed to death in spite of all the efforts made by everyone to delay what was ultimately inevitable. Now you would want to consider the DNA evidence the chromosomal evidence of Edward’s Syndrome, the evidence of a diaphragmatic hernia, the underdevelopment of her lungs, the strain that places on the heart, the heart defects, the hole in the heart and the cerebellum. And you remember the small size of Sunaina’s head given top us by Professor Weindling, shown to us on the chart. And you should return this conclusion if you consider the death was a natural outcome for a baby with Sunaina’s condition, and it is also the correct conclusion to return if you find that the care was of the highest standard. And The words you should use are ‘she died from natural causes
Now the other verdict I am going to leave with you is a narrative verdict and This isn’t very commonly returned in a Coroner’s Court in England and Wales, but it is very common in Northern Ireland. And there is a place for them over here and after consideration of all the facts you may consider that this is the appropriate verdict to return. Something like Sunaina died from multiple congenital medical problems in spite of every effort to prolong her life, by giving her all possible care. So I am going to leave you with two possible conclusions, one she died from natural causes and one so called a narrative verdict, which is a little bit fuller, which might express in the verdict what you feel has happened. It is entirely a matter for you. Now I would like you to retire to complete your inquisition, you would have to elect a foreperson, please take as much as you like to fill it in and my officer will swear to keep the jury safe.
CORONER: And what did you write under three for the time, place and circumstances?
Jury foreman: Here we wrote little baby girl with Edward’s Syndrome before birth.
Q: And what conclusion did you reach?
A: Natural causes.
CORONER: Thank you very much indeed. Therefore in this inquisition taken for us the Sovereign Lady the Queen this court formally records that Sunaina Chaudhari who was born on the 25~ May 2000, who died on the 26 October 2000 at King George Hospital, the cause of death been given by the jury is Multiple Congenital abnormalities including Edward’s Syndrome and the conclusion of the jury is that she died from natural causes.
HOOK OR CROOK JUDGE ELIZABETH STEARNS.
A STUDY OF HER FREEMASONRY JUDGMENT
Elizabeth Stearns is a hook or crook judge. Openly and without shame, she perverts the course of justice by hook or crook. Especially by crook. It is not good to use this kind of language about Her Majesty’s Coroner. But a spade has to be called a spade. Not an agricultural instrument. None who knows the fact in this case can fail to agree that compared to Lord Jeffrey Archer, she deserved more to be in prison than Jeffrey Archer. In this case, there were at least 7 characteristics of Freemasonry Judgements:
i. Breach of Judicial Undertaking.
ii. Breach of Legitimate Expectation
iii. Conspiracy with Hospital Lawyers.
iv. Concealment of Causes of Death.
v. Denying Complainant the right to give evidence.
vi. Denying Legal Representation.
vii. Asked Leading Question that Indicated Judicial Bias.
1. BREACH OF JUDICIAL UNDERTAKING:
On 10/09/2001, one day before she presided over the Inquest into the death of baby Sunaina, Dr. Elizabeth Stearns appeared in the High Court before Mr Justice Elias, and gave a firm undertaking to the High Court, that although she was being accused of being biased as a judge in the inquest into the death of Sunaina, the question of bias would never arise. She undertook to allow the jury, not herself to be the judge of fact. Mr. Justice Elias believed her and stated so in his judgement. But Elizabeth Stearns did not fulfil her undertaking to the Court. She made herself the judge of fact! She determined that Sunaina had died of natural causes” Unlike Archer, she has not been prosecuted, not convicted, not imprisoned, but beenallowed to continue to pervert the course of justice as Her Majesty’s Coroner!
2. BREACH OF LEGITIMATE EXPECTATION:
Coroner Elizabeth Stearns had notified the complainants in writing that since we considered her bias, she had decided not to be the judge of fact in this case. Both, the European Law Principle of Legal Certainty and the English Law precedent of Legitimate Expectation make it mandatory for her to abide by her undertaking to us. More, they make it mandatory for the court to safeguard our expectation that she had inspired. The Principle of Legal Certainty provides that rovides that measures must not violate the legitimate expectation of those concerned. The followings are some of the statements of the precedent of Legitimate Expectation in English law:
“For a body to exercise discretionary power in a way which confounds expectations resulting from its prior behaviour may itself be considered an abuse of discretionary power”.
“Where a body had previously acted so as to engender in the applicant a legitimate expectation that it would exercise its discretion in a particular way, it will be held no longer to retain the choice of alternatives, but obliged to act so as to fulfil the expectations which its behaviour has aroused”.
“The expectation may be based upon some statement or undertaking by, or on behalf of, the public authority which has the duty of making the decision, if the authority has, through its officers, acted in a way that would make it unfair or inconsistent with good administration for him to deny such an inquiry...: Lord Fraser of Tullyberlton in Ng”.
3. CONSPIRACY WITH HOSPITAL LAWYERS.
On 12/09/2001 Dr. Stearns conspired with two lawyers, Ms. Harrison and Mr. Thomas to pervert the course of justice by her breaching her judicial undertaking not to act as a judge of fact in the inquest into the death of baby Sunaina. The two lawyers had argued, as they were entitled to, that on the basis of the evidence produced, she ought not to allow the jury to determine the verdict of the cause of death but that she hersef should return the verdict of death by natural causes. Both the lawyers knew, and she herself knew, that she could neither honourably nor lawfully make the decision which would breach her judicial undertaking. In the circumstances, she was obliged to honour her undertaking or allow another Coroner to preside over the inquest. Yet, she opted to breach her undertaking. In the circumstances, she became a judge whose word none can believe. She is a judge without honour.
4. CONCEALMENT OF CAUSES OF DEATH
At the hearing of the inquest, the reason why Dr. Stearns insisted to sit as a judge, in spite of being seen as a bias judge became quite clear. She did not want the causes of death Ranitidine and/or Potassium Chloride to be investigated. She knew that if another Coroner presided over the investigation the truth of how baby Sunaina was killed would come out. But if she presided over the inquest she would block the truth from coming out. So, she presided over the inquest and effectively blocked the truth from coming out. Although Dr. Shirsalkar who was in charge of the treatment of Sunaina indicated that he did not know that Potassium Chloride was given to the baby and that he himself would not have given it because it had a tendency to stop the heart, and should not be given in the combination of the drug Sunaina was taking then, and although Nurse Ellingford testified that Potassium was indeed given to the child, the Coroner deliberately ignored its likely effect in the death of baby Sunaina! She did not try to find out how many times it was given to the baby that morning! Nor weather the amount given was lethal or not! Clearly she knew it was fatal! Nor did she try to fiind out who prescribed it and why was it prescribed to be given on the day when the Mother was challenging the Court Order that restricted her visiting her daughter! The Coroner sought to rely on the examination of Professor Vanezis and on the tests by Ian Humphreys that no evidence of Potassium was found in the blood but both those authorities admitted that the nature of their examination and test were not the type that could disclose Potassium. The Coroner had documentary evidence which prove the number of times Potassium was administered that morning and the amount administered. Yet, she ignored them!
In the same way the Coroner had detailed documentary evidence of Ranitidine administered to the child before her. She knew that 10 times overdose of Ranitidine i.e. 30mg was administered to the baby for 4 days from 01/10/2000 to 94/10/2000. Its serious side-effect on the child which included high temperature, breathlessness, anaemia and irritability were manifest. A pharmacist, not the doctors, stopped the overdose. With such side-effects, Ranitidine should have been immediately discontinued. Yet it was continued, at standard dosage, for 20 more days! It was stopped on 24/10/2000 i.e. two days before the child died. The Coroner did not refer to all these pertinent facts. In particular, she concealed from the jury the severe side-effect of Ranitidine which the baby suffered. With such massive and manifest evidence of unnatural death, the Coroner lied to the jury that there was no evidence of unnatural death! That was a gigantic double-crossing of justice.
5. DENYING COMPLAINANT THE RIGHT TO GIVE EVIDENCE
When the Coroner refused me, a Complainant, the right to give evidence in the death of my miece, it was clear to me that the Coroner was determined to turn the public court, into a Kangaroo Court. Even then, I did not know what she most feared from my evidence. It occurred to me that she had no cause to fear what I would say about Ranitidine and Potassium Chloride as that evidence was in medical documents. I did not know then that she intended to conceal from the jury that evidence! It also occurred to me that she might fear my exposing the determined attempts of some Hospital staff to kill my niece. But that would not be entirely new. Dr. Shirsalkar himself pointed out that there was a confrontation between the family over 3 issues. First, they were determined to give the baby only care treatment not what he called intrusive treatment meaning curative treatment. The family was determined that the child be given curative treatment. Second, they were determined not to give the baby intensive care treatment. The family wanted intensive care treatment. Third they wanted No Resuscitation Order. The family was opposed to it. They wanted, in short, the child to die. We wanted in short, the chld to live. What did they expect from us then? Shakespeare, in his greatest wisdom said that the poor wren, the most diminutive of birds, will fight the owl to protect its young ones in the nest. Ultimately I realised that what Dr. Stearns feared from me most was my knowledge as a pharmacist. She knew I would tell the jury the effect of Potassium Chloride and the side effect of Ranitidine. In her desperate effort to betray justice, she did not want the jury to know that much!
6. DENYING LEGAL REPRESENTATION.
It also became clear to me why the Coroner did not want us to have a legal representative. The legal representative would have cross-examined the medical staff at length about Ranitidine and Potassium Chloride. The cause of death would have been laid bare. The legal representative would have dealt at length with the motive to kill the baby. Were the motive not admitted by the staff? Have they not admitted that they did not want to give the baby curative treatment, or resuscitate her, or give her intensive care treatment? Did they not have opportunity to do what they wanted done? What then was the purpose of obtaining Emergency Protection Order if it was not to give the opportunity to kill the baby in the absence of her Mother? And why was the child given Potassium Chloride, known to be fatal, three times when the Mother went to try to overturn the conspiratorial order? Coroner Elizabeth Stearns indeed, had a cause to fear our having a lawyer.
(Incidentally she told the jury that our Lawyer, Dr. Adoko, called himself Barrister-at-Law whereas he has been voluntarily disbarred! Apparently that was not malice, but ignorance on her part. Barrister-at-Law was a title given to those who passed Bar Examinations. At least in those days. It was not conferred by admission into membership of any of the 4 Inns of Court. Some people admitted into the membership of the Inns of Court were not barristers-at-Law. They had their legal qualifications abroad. Members of the Inns of Court were awarded what was then known as the Degree of the Utter Bar. On the strength of his Barrister-at-Law qualification, Dr. Adoko subsequently became a Member of the Middle Temple, Uganda Law Society and Tanzania Law Society. Though he has been voluntarily disbarred and thus not practising law as a barrister, he remains a barrister at Law and Advocates of the Supreme Court of Uganda and Tanzania. In the same way, when Dr. Stearns retires from her medical practice she will cease to be a practising doctor in England but will retain her Bachelor of Medicine and Bachelor of Surgery that she obtained by passing examinations).
7. LEADING QUESTION INDICATING JUDICIAL BIAS
The Coroner Dr. Elizabeth Stearns asked a leading question, that is she put words in the mouth of Dr. Shirsalkar, that indicate judicial bias.
CORONER : But what you were not prepared to do was to intubate and ventilate her.
SHIRSALKAR: That’s is correct, in cases of terminally ill patients were life expectancy is not known to be prolonged by the intervention, we would not offer her intensive care.
CORONER: You would offer her tender loving care?
SHIRSALKAR: Tender loving care, that is correct.
Those words remind me of what happened when Julius Caesar saw the greatest Romans of them all, Brutus, stab him! Poor Caesar cried out, Et Tu Brute (and you too Brute) and ingratitude, more strong than traitor’s arm vanquished him. When I read the leading question by Coroner Elizabeth Stearns: “You would offer her tender loving care?” I wept. I just could not stop the tears pouring down my cheek. All the loving relatives of poor baby Sunaina, her mother, her father, her aunt, her grandfather and grandmother had been cast out from her bedside. The poor baby was left all alone without a single loving soul amidst terrifying strangers who confessed that they were keen to see her die! Yet the Coroner, in her heartlessness, claimed that the Hospital had given Sunaina tender loving care! I realized then that I and you and the whole of our nation will continue to be betrayed by our court as long as these Freemason Judges continue to dominate the courts.
|Application in High Court Chaudhari|
Application in Appeal Court Chaudhari
|HOMEPAGE||LEGAL||CLINICAL||PRESS RELEASES||LINKS||CONTACT US|
Baou, Inc., a New York Corporation is the Registrant of [nhsmurders.org].
The web site is managed and hosted by Baou, Inc. in the USA.
You may use or download Content for research, educational or personal; non commercial
purposes or to assist Baou Trust in our campaign provided the material is used unedited and
you credit our name "Baby Sunaina Campaign", and the URL of this website and our Email
addresse [email@example.com] at all times.
No other use of any Content is permitted. Nothing in theses terms transfers any right, title or interest
in any Content, including any intellectual property or content of third parties included on the web site
other than the above fair use. All Rights Reserved by the Baby Sunaina Campaign.
Permission must be obtained from Baby Sunaina Campaign to use any of the material outside the above terms.
National Registered Agents, Inc.
875 Avenue of the Americas, Suite 501, New York, NY 10001 USA