Case
Files

What happened

Raymond Tull was made permanent on Friday 7 October. A contract, a pension, and the keys to the yard. He had nine years on the Havelock round.

Fat Sam had eleven. Cash in hand, no contract, no record anywhere in the council system. He had asked for the post three times and been passed over three times, and the reason was always the same one nobody would say out loud: in eleven years, nobody had ever written his name on a list.

The keys were the part that mattered. One of them opened the lock-up behind the weighbridge, the low brick store with the roller shutter, facing the water, where Fat Sam had slept for years. The supervisor’s memo of 6 October ordered it cleared and handed over by the end of the month.

So he was not only passed over. He was being put on the street, in October, by a man he had trained in his first week.

How it was done

He raised the lifter arm on truck 14 by hand, on the manual override behind the passenger-side step, a thing only the men who were on the round before the depot was rebuilt were ever trained to do. He struck Tull once across the back of the head with the steel comb on the underside of the arm, and left him beneath it, so that the morning would read as an arm coming down on a man who had climbed underneath.

The night, hour by hour

• 04:02 The pedestrian gate opens on retired yard code 1180.
• 04:00-04:30 Tull is killed beside truck 14.
• 04:11 The truck’s recorder logs the arm raised on the manual override. Engine cold.
• 04:33 The gate opens again on the same retired code.
• 05:12 Pryce arrives for his shift.
• 05:29 Braithwaite brings the crew in.
• 05:40 They find him.

Why the other four were clear

Alan Pryce is on the gate at 05:12 and nowhere earlier, and truck 14 never moved. Nina Coyle signed in at the Pier Road yard at 03:50 and stayed there, and the guard she had been trying to get taken out of service was still bolted on, which is the whole reason the arm could not have fallen on its own. Ian Sowden’s code is not on the gate that morning at all. Kenny Braithwaite came in at 05:29 with the crew, and it was over by half past four.

What gave him away

The four men the police interviewed all had contracts, codes and records. The man who did it had none, which is exactly why the file never reached him.

Code 1180 was retired in 2030 and only ever issued to men who were on the round before the depot was rebuilt, and it opens the gate twice while the yard is shut. The workshop record lists who is trained on the manual override, and the list is the old hands. The night guard at the scrap yard next door describes a man doing slow karate forms by the gate at four in the morning, and says he has watched him do it for years without ever learning his name.

And the supervisor’s memo, written five days before the killing, says there is a man sleeping in the lock-up who is on no list, will not give a surname, cannot read, and is called something the supervisor will not put in a council letter.

The file was closed in five weeks as a workplace accident. Everything needed to reopen it was inside it the whole time. It was simply written about a man the council had never got around to naming.

What happened

Adam Lister spent six weeks on placement in the Vessant records unit, paginating the Cohort 9 file for release. He read the hundred and twelve pages that were withheld while he was doing it. He wrote fourteen pages about them and sent them to the regulator and to this department. The regulator booked him for interview on Monday 20 June.

The ethics approval for the Etheron trial carries the signature of a member of Vessant's advisory board. That board member is a consultant psychiatrist at St Jude's. Within a month of his statement she had assessed him, sectioned him for a fixed delusional system concerning a former employer, waived the second opinion, and given him one administration of the drug he had written about.

On the evening of 17 June the sponsor's liaison visited him. Two hours later he was placed in seclusion on the consultant's telephone order.

How it was done

At twenty-five to three the patient in bed 6 collapsed and the night orderly took him down to A and E, leaving one nurse on the ward. At ten to three the consultant on call signed a 20 ml ampoule of potassium chloride out of cupboard 5, against bed 4 on Ward 10. Bed 4 on Ward 10 had been empty for six days. At two minutes to three her pass opened the ward door. The corridor camera has her at seclusion room 2 a minute later with a tray. She opened the room alone, which the rules do not allow, and put the potassium through the cannula the day nurse had placed on the 16th.

Potassium stops the heart, leaves nothing to see, and cannot be measured once someone is dead. The pathologist found a recent cannula site and nothing else, and wrote that potassium had not been assessed. She put the typed strip in his mouth, locked the door at 03:22, and left. The expression the first officer called a smile was the drug she had given him nine days before, starting on his brain.

The note

THE PROGRAM IS ACTIVE is not his phrase. It is the stamp across every page of Schedule 2 item 08, the contingency drafted and not adopted, and he says so on the last page of his statement. The ward's note that he had been fixated on it since admission was written by the consultant who admitted him. She put it in his mouth so that whoever found him would read a patient who had died with his own obsession between his teeth. What she left was the one line in the file that could only have come from someone who had read the pages the sponsor swore he never saw.

The night, and the two lies

• 17 Jun, 14:30 to 16:40 Voss visits.
• 20:15 Lister placed in seclusion on the consultant's telephone order.
• 18 Jun, 02:35 The patient in bed 6 collapses.
• 02:40 Mensah takes him to A and E. One nurse on the ward.
• 02:50 Potassium chloride signed out of cupboard 5, one signature, for an empty bed.
• 02:58 Pass 0912 opens the ward door. 02:59, the camera has her at the seclusion door.
• 03:05 A and E logs Mensah at their desk.
• 03:00 to 03:20 Lister dies.
• 03:22 Pass 0912 leaves.
• 04:20 Mensah back on the ward. He fills in sixteen checks he did not do.
• 06:05 Whitlock finds him.

The seclusion record says the orderly looked in every fifteen minutes and found him asleep. He was in A and E. The sponsor's letter says Lister never worked at Vessant. His section order and Vessant's own placement letter say he did. Neither lie is the killing. Both are the reason nobody looked.

Why the other four were clear

Kofi Mensah lied on the seclusion sheet, and the lie is that he was there. He was not. Bernadette Shaw left at 21:58 and her pass does not move until eight. Ingrid Voss was on the ward three times in daylight and never at night, and her letter is a lie about his job, not about his death. Dana Whitlock put the cannula in for a patient who was refusing fluids, wrote it up, found him, and rang it in.

What gave her away

A controlled drug signed out at three in the morning, on one signature, for a bed that had been empty for six days. An on-call pass through the ward door in the one hour the orderly was off it. A cannula site the post mortem could not explain and a potassium level nobody asked for. A section order in her name that records the job the sponsor swore he never had. A statement, in his effects, that named her twice without naming her. And a tape the hospital never handed over.

The file closed in four weeks as a sudden unexplained death in a detained patient. It was written by the people who detained him.

What happened

Nine doses of Etheron came back to Ward B when the trial was stopped, to wait for a destruction run. The sponsor never sent the certificate, so the run was never booked, and the doses sat in a cold storage with a keypad on it. By day the key was with pharmacy. By night it was with whoever was on nights.

Helen Stone was on nights. She had been taking the doses out one case at a time and passing them to the people running the warehouse on the western bypass, the one the Cohort 9 file mentions once and never again. One case is on the log at fourteen minutes past three on the morning of 7 March, against her staff number, marked for destruction.

Robert Ashford did not sleep. He was in the corridor at ten past three and saw her put a blue case in her bag. He asked what it was and she told him it was old stock. In the morning he asked the orderly how a patient could reach the outside monitor without going through the ward's own doctor, and he was given a form. He wrote it out and put it in his locker to send when his head was better.

How it was done

At twenty to four, half an hour after he had seen her, she put a second dose of Etheron through the IV line that was already in his arm for the immune support, and wrote it up as a line flush. No clinician ordered a flush. A second dose does what the first one did, only faster. The cells go to the brain and keep building. He was tired on the 8th, could not find the word for the corridor on the 12th, did not wake properly on the 13th, and died at a quarter to one on the 14th.

It looked exactly like the drug killing him, because that is what it was. The lead clinician signed it off as a known reaction within the hour, and the coroner agreed.

The night, and the week after

• 6 Mar, 22:00 Stone takes the night key.
• 7 Mar, 03:10 Ashford, awake, sees her at the cold storage.
• 03:14 The keypad logs one case out against E-5821, for destruction.
• 03:40 The night chart records a line flush nobody ordered.
• 07:20 Ashford asks Moore how to reach Dr Blake, and writes the note.
• 8 Mar Fatigue.
• 10 Mar Blake counts the store. Eight, not nine.
• 12 Mar He cannot find words.
• 14 Mar, 12:45 Dead.

Why the other four were clear

Dr Marcus Drake signed the death off fast and wanted it quiet, but he was never on the ward at night and his number is not on the cold storage log. Dr Elena Blake is the one who counted the store, found the missing dose and put it in writing, and she was never there after seven in the evening. Timothy Moore was days only, and the note in the locker is the patient asking him for help. Sarah Crane held the day key and ran the count, and it was her February count of nine that made the March count of eight mean anything at all.

What gave her away

The cold storage log has a case going out at three in the morning, for destruction, when destruction is a day job with two signatures and a courier. The patient's own note says the night nurse took a blue case from the fridge at ten past three. The night chart shows her flushing his line half an hour later with nothing ordered. The pathologist found cells in his brain at a density that fits a second dose about seven days before he died, and seven days before he died is that night. And the tape from the ward camera for that night, which the clinic never handed over, shows her at his bed at 03:41.

The file closed in three weeks as a known adverse reaction. It was written about a drug that kills, on a ward where a drug was killing people, and nobody asked why this one was so quick.

What happened

Nadia Draper had eleven years with the ferry service. In October her post was cut to part-time hours, and from about that point she began taking cash out of the fare box, around three thousand nine hundred dollars across five months.

Owen Vance kept the fare-box keys on a chain and was due to hand a five-month reconciliation to the regional manager at nine o’clock that morning. Head office had already written to him about the shortfalls. The memo made plain how short the list of people it could be actually was.

She had until nine in the morning, and she knew it.

How it was done

She let herself in at the maintenance side door at 01:41, on the pass that belongs to the post rather than to any one person. She struck him once with the 24 mm adjustable spanner she had signed out of the workshop at five to midnight, and emptied the till so the morning would read as a robbery.

It did not read as one for long. His wallet was still in his jacket with sixty dollars in it and his watch was still on his wrist.

The night, hour by hour

• 01:20 The last ferry docks.
• 01:30 Malloy signs his tools in and leaves with the crew.
• 01:41 The maintenance side door opens on pass 0417.
• 01:30-02:00 Vance is killed in the ticket office.
• 02:04 The pass is used again. The till drawer is wiped.
• 02:10 Keaton finds the body.

Why the other four were clear

Ruth Keaton’s pass shows one entry at 22:58 and the counter camera has her all night. Sean Malloy signed his tools back in at 01:30 and the crew vouch for one another at the Anchor. Vince Weston was in his cab in front of the doors from twenty past one, and it was he who saw the side door used. Tom Brenner, the rostered engineer, was at St Jude’s with his wife from 23:10 until six, which the hospital confirmed, and that is precisely where the investigation stopped.

What gave her away

The file closed because everybody read pass 0417 as Tom Brenner, and once Brenner turned out to have been in a hospital all night the pass became a dead end.

The pass log says in its own footnote that passes are issued to the post and not to the person. Since October that post has been covered part-time by a second engineer. The workshop sheet carries her signature against a 24 mm adjustable spanner, signed out at 23:55 and never brought back, and Dr. Park matched the wound to that spanner and found marine grease on the till drawer that only comes out of a maintenance store.

Her name was on a form inside the file for nine weeks. Nobody read the form.