MMR and the Inquest into the Death of Toddler George Fisher
The Inquest into the Death of George Fisher
By Allison Edwards
On a dismal and bitterly cold December day, the outside of Gloucester's Shire Hall's was covered up, hidden behind shabby tarpaulin drooped over scaffolding. By the lunchtime break it might have occurred to anyone attending the Inquest into the death of little George Fisher, that some caring renovation work would not have gone amiss on the due process taking place inside the building.
Let me make it clear, procedure may be being followed but there is a distinct air of collaboration amongst the professionals who seek to cover their own backs.
Positioning of the
powerful within the semi-circular chamber
was obvious, in the, more than a
hint-of-sixties styled, brightly lit
courtroom. In command of the proceedings,
for this case is
Coroner Alan Crickmore in the highest
seat with the grandiose pale wooden
surroundings. A clerk chaired at ground
level beneath him facing out to the family,
ready to read statements to the theatre
auditorium calls "all stand" as Mr Crickmore
enters (and leaves), which I thought only
happened in American dramas, obviously not.
Three seating sections sprayed out from the
centre, the middle occupied by the family
fronted by their barrister, to their right
they were flanked by pharma and nursing
representatives, and their left by
Immunisation Department bods and doctors,
most notable being Dr Liz Miller. Media and
public to the rear.
The accepted experience of these proceedings being more "every day" to the Coroner and professionals trained up for just such circumstances is countered by the awesome and menacing importance of this for the Fishers who were thrust into this dauntingly emotional process by the tragic experience of discovering their son dead in his cot. The stuff of all our nightmares'. Scant regard or consideration seemed to be given to how 'abnormal' all of this procedure this is to them was highlighted by an incidence at the beginning when Sarah's disabled Auntie, sitting on an automatic scooter hidden from view behind the half height wooden semi-circular wall in front of her dared to speak up to say (quite rightly) that she couldn't hear. Accompanied by her husband with a hearing aid in each ear. It was all handled so insensitively by Coroner Crickmore who promptly stamped his authority and rather rudely told her to move herself to a better position.
Deposited as she was, on the main carpeted routeway, with no seating he ought to have deduced why she positioned there in the first place. It was left to her old man to explain that she was disabled and couldn't shift, he too was not handled with any deference. An Usher saved the situation by giving her a microphone/speaker set. Nerves were by now jangling throughout the room that if the disabled were handled like this how would the rest of us be treated if we dared make a sound? I think he was rather clumsily, making a point of showing he would not be messed with, by anyone! Quite frankly we were ALL wondering how we were going to hear as she bravely bore the brunt of his opinion on interruptions.
However, he managed to do a fair old bit of it himself throughout, cutting the family barrister off before she'd reached the end of her first sentence on a couple of notable occasions and giving her a verbal dressing down. Do as I say but not as I do! She was a little too obedient for my liking. He was having no "asking a question one way, then putting it in another way in order to extract a different answer" - this sort of directness would indeed be welcomed at the everlasting hearing for Dr's Wakefield, Walker-Smith and Murch.
The mumbling mutterings of Dr Alan Joseph
Day were irritatingly quiet, yet no-one
dared say a thing. He was there to give his
professional opinion, as a local Consultant
Paediatrician, in an evidence report he'd
written in March 2008. It covered George's
medical history relating to his first
febrile convulsion in the September prior to
his death the following January, how it was
a short but dramatic seizure not a fifteen
minute one that would have caused more
concern. No further monitoring of George was
done up to his death. Dr Day did not see
George when he was alive. As far as giving
him the MMR, there were no
contra-indications as far as he was
concerned, he was asked to state his opinion
on MMR, he declined. It was remarkable. His
voice barely audible, crucial sentences were
left unfinished, hanging in the air, for
example, "each case needs it's own......"???
Not a word from the Chair on high - why not?
Perhaps he too couldn't hear.
When Mr Barton, from Sanofi, brought out the big files he deftly rounded on Calpol and Medi-ced as being neither a cure or preventative of fits. He managed to visibly quosh Dr Day's confidence in his 'standard advice' to use them, as he was asked to read out the conclusion from "NICE Guidelines of 'expert opinion' on the clinical handling of fever advice recommendations" that based on reported side-effects such drugs should not be used with other drugs and the dangers of it being given while the child is dehydrated. This is the point where the family's barrister should have leapt to her feet and asked him to read out the list of reported symptoms of adverse reactions to MMR on their own product sheet because Georgie had displayed a range of them, but she didn't an opportunity missed.
The determined base of Sanofi's case is to pin it on another product. Mr Barton is an top barrister, a 'troubleshooter', oozing confidence without a shred of arrogance, he's eloquent and direct and very sharp. There was, however too little Medi-ced left in Georgies bloodstream, as he had been sick after his milk bottle the previous evening to give this as a credible cause of death. No, the MMR had left Georgie with a runny nose, straight after, diarrhoea (he also was teething), sore ears, a temperature of 37.5, vomiting even though he went out and played football after, he was off his food, and had sore red eyes which had prompted his Mum to phone to make a doctors appointment he had died before she could take him to. He reacting to the three live viruses that were in his system. It clearly tortured his Mum wondering if she'd only given him more perhaps his temperature would not have got so high and he wouldn't have fitted.
It was so hard to hear how this robust
toddler died. He was a remarkably good birth
weight almost 8lbs 10oz, he breastfed well
until aged 11 months. He was the youngest of
four children, Sarah and Chris were
well-experienced and instinctive parents.
They too felt they had no real concerns. His
feisty nature was described by them both in
turn, how he could lift a baby sit-in car
above his head at age twelve months and
managed to move his cot across the wooden
floor of his bedroom whilst still in it.
Many times we heard the circumstances in the
run up to and subsequent discovery of his
body and it prompted tears around the room
and broken voices particularly that of the
Practice Nurse, Hannah Mitchell who
administered George with the MMR on January
9th. She could not recall the process of the
case but followed a regular pattern of
checking notes and medical records and
informing the parents putting them at ease.
She, of course attends regular updates.
Chris and Sarah both maintained this was not
done, they were not given the correct advice
or even a leaflet, for had they known to be
aware of monitoring their son more closely
they would have admitted him to hospital or
may not have given him the 3-in-1 jab at
all. Unbelievably, being asked just that by
the coroner, "what they would have done if
they knew" was probably again as insensitive
as could be in the circumstances, seeing as
they were sitting at his inquest. His
parents remained brave and dignified but
also fidgety with concerns that important
points were being missed out which gave rise
to a rebuke by Cornoner Crickmore for mum
Sarah Fisher when she spoke up unannounced
during Dad, Chris's testimony.
How much do a couple need to endure before their words are heard fairly? Patience and time seems to be granted to the emotionally detached, cooly uncaring back saving professionals. Why? What a price to pay 'for the greater good'. Will the same nit-picking as that done into Calpol and Medi-ced be given to MMR? I very much doubt it. For all children due for their MMR, it ought to be.
Later on Dr. Liz Miller admitted this can happen after MMR, that febrile convulsions can happen, and is most active on the tenth day being a true possibility. A damning testimony a little too carefully wrapped up in deniability – with again, no cross-examination worth it's salt. Dr Liz Miller was brought in to replace Dr Fink , to be impartial, but how impartial when she was party to the very introduction process of the MMR into the UK. She's hardly going to admit she made a mistake, so any reservations will be ably batted away with a swipe from her five other experts who are coming over well.
The hardest point raised was the suggestion that on the morning of Georges death, Chris had gone in to the room and moved his sister Meg, who was awake and had got into Georgie's cot, the poor little soul had obviously spotted that something was amiss. Chris had lifted her out and put her in her own bed. There was 18 months between them but they were almost the same size as George was "big for his age", they shared a room. Again, insensitively put, the Coroner's directness asked that there could be no possibility that she might have covered George smothering him? There was none. Dad lifted her out of the cot then he'd gone off to work at 7.30am hoping not to waken George up, but not realizing he was probably already dead.
Sarah found him around twenty minutes later, having beforehand directed clingy Meg to "get into mum's bed for a cuddle" not making the connection for Meg's distress. Then she went to get Georgie, found he was cold, his arms either side of his head, bubbles at his mouth his teeth firmly clenched, dead.
She took him downstairs wrapped in a blanket and laid him on the sofa and rang the emergency services. Police and paramedics arrived to a distraught household, they tried to resuscitate him but failed he was declared deceased at 8.25am on January 19th 2006, 10 days after his MMR. His lungs and blood showed measles virus, he had an enlarged spleen which means he was fending off a virus – or three.
I have never been to an inquest before. I am the Mum of a boy who became severely autistic after his MMR. I sat next to Jackie Fletcher, of JABS a remarkable lady and mother to Robert who has a most profound disability after his MMR too. We have reason to believe that the faith and trust we parents place in those guardians of public health on immunisations has become much more about their own protection than our childrens'. We have been betrayed. We trusted their word and gave the vaccine they recommended. So much more depth and honesty is deserved when it goes wrong but in this case it would be admitting to murder if they knew about adverse reactions yet persisted with their safety assurances. Unfortunately I predict that no-one will be held accountable and the death put down to an "unascertained cause".
My deepest sympathy is with Sarah and Chris Fisher, devoted parents of Georgie, and their family.