Special report adds nothing new, say paper authors
We were disappointed that Gornall's article1 was published without a response from us. It added nothing new. 2 3 Our paper reviewed the first 57 deaths on the CONI (Care Of Next Infant), programme. We reaffirm that nine deaths were inevitable (recognised cause), and of the 48 unexpected deaths, seven were probable homicide.
Professor Emery led the CONI steering group until his death (2000). We did not materially change the cause of death for any case he knew about.
There are differences between an earlier report4 and subsequent full paper. 2 In the Lancet, we reported but excluded from analysis deaths over one year and clarified "non-natural" deaths. Four infants who died in bed with their parents were initially classified as "non-natural" as they were possibly accidental and avoidable. They were subsequently categorised as SIDS in line with the CESDI SUDI study. 5 The "non-natural" group initially also included cases recorded as open verdict; their reclassification is detailed. These revisions account for the difference between 14/44 "non-natural" in our earlier report and 7/57 probable infant homicide in the Lancet. No case previously attributed to either NAI or suspected or proven filicide was reclassified.
The assertion that "no explanation for the decision to categorise as natural all 13 deaths for which there was insufficient evidence to reach a conclusion" is a misrepresentation of our text. This states "Eight of these CONI deaths were certified as SIDS. None were attributed to homicide or non-accidental injury." The assertion that, "In five of these cases a police investigation was under way" is not correct. All investigations were complete before the paper was submitted for publication.
For risk factors even to suggest homicide, their prevalence must be known in all relevant groups.
R G Carpenter, honorary professor1, A Waite, national co-ordinator, CONI Programme2, R C Coombs, consultant neonatologist 3, C Daman-Willems, consultant paediatrician4, A McKenzie, research fellow5, J Huber, consultant paediatric pathologist (retired) 6
1 Medical Statistics Unit, Department of Epidemiology and Population Science, London School of Hygiene and Tropical Medicine, London WC1E 7HT email@example.com , 2 Academic Unit of Child Health, University of Sheffield, Sheffield Children's Hospital, Sheffield S10 2TH, 3 Neonatal Intensive Care Unit, Jessop Wing, Royal Hallamshire Hospital, Sheffield S10 2SF, 4 University Hospital, Lewisham, London SE13 6LH, 5 Medical Statistics Unit, Department of Epidemiology and Population Science, London School of Hygiene and Tropical Medicine, 6 University Hospital for Children and Youth, 3501 CA Utrecht, Netherlands
Competing interests: None declared.
Ellipsis marks an important omission
Gornall, in his article about the paper by Carpenter et al on recurrent infant deaths,1 was right to argue that uncertain data should not be translated into statistics that seem clear cut. But his suggestion that a report by John Emery, the pathologist who initiated the Lancet study, upheld the ultra-suspiciousness of "Meadow's law" is curious.
Emery produced the report for Sally Clark's defence in 1999, six months before his death.2 He wrote that in families where there were two cot deaths, a third were due to rare natural causes that had been missed at autopsy, and a third were unnatural deaths associated with abuse. The final third were "true" sudden infant death syndrome (SIDS) in that "no suspicion of unnatural death was found and no natural cause was found."
Although Emery's words make it clear that no basis for suspicion was found in two thirds of recurrent deaths, Gornall writes that Emery reached a "stark" conclusion which he purports to quote: "The occurrence of two unexpected deaths in a family thus raises a definite suspicion of unnatural death which in my experience is confirmed ... in a third of such cases."
The ellipsis is odd. What has Gornall left out? If we check Emery's report we find it was a single word. This is what the sentence said before Gornall edited it: "The occurrence of two unexpected deaths in a family thus raises a definite suspicion of unnatural death which in my experience is confirmed only in a third of such cases."
By omitting the word "only" Gornall changes the emphasis of the entire quotation. Whereas the original implies reservations about Meadow's law, Gornall has adjusted the sense so that he can recruit Emery's conclusion in support of this law.
It is important that medical papers should categorise and report their results scrupulously. But those who seek to criticise them should show an equal degree of scrupulousness.
Richard Webster, author
1 Oxford OX2 6TX firstname.lastname@example.org
Competing interests: None declared.
Carpenter et al fail to address the concern of David Hall, former president of the Royal College of Paediatrics and Child Health, that the conclusions of their paper were "seriously misleading." Such defence as they do mount is equally misleading: "We did not materially change the cause of death for any case [Emery] knew about" and "No case previously attributed to either NAI or suspected or proven filicide was reclassified". All true—but beside the point. The question that remains unanswered is why, after Emery's death, all but those seven cases of "NAI or suspected or proven filicide" came to be classified as "natural" deaths.
The authors did, after all, admit that: "We cannot exclude the possibility in our study that some of the 13 cases in which enquiries were not possible were cases of covert homicide." If so, then how can they justify classifying as "natural" all 13 of these unresolved cases—including seven in which parents or their representatives flatly declined to engage with the study? This benign exercise of the benefit of the doubt may be compassionate, but it is unscientific and alone invalidates the paper's findings.
Webster's suggestion that a report by Professor Emery was doctored to support an argument is absurd. There is, as I showed in my article, 1 overwhelming evidence that Emery's view of the proportion of repeat unexpected infant deaths that could be considered to be unnatural was seriously at odds with Carpenter et al's. The key and indisputable point of the passage that Webster attempts to obscure is that Emery believed suspicion was justified in a third of cases where there had been two unexpected infant deaths in a family. Even (or "only") one third is a proportion sufficiently shocking and substantial to suggest that Professor Meadow was rather closer to the truth with his so-called "law" than his many critics are happy to admit—and to confirm that it was wrong to put Emery's name on this paper.
Jonathan Gornall, freelance journalist
1 London E1 7LQ Jgornall@mac.com
Competing interests: JG is author of the special report.
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