I took a call early one Sunday morning in August 1989 to warn me that there had been a disaster. It was during the summer holidays and I was the forensic pathologist in charge of London and the south-east of England. At this stage, no one knew how many bodies there would be but one thing was certain: there would be bodies.

The catastrophe had occurred on the River Thames. I waited for more news before setting off; my first stop was the police pier in Wapping, to the east of the city. A leisure boat had sunk somewhere near Southwark and bodies recovered from the vessel were here. That was all I knew. An old police sergeant greeted me and, to my astonishment, he was close to tears.

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“Almost got my 30 years in, Doc. And now there’s 25 dead from the river, 24 on the boat, another one picked up this morning, eight bridges upstream at Vauxhall. Never thought I’d see anything like this. They’re all kids. Kids in their 20s.”

The boat that went down must have been one of those party vessels, the sort people hire to cruise up and down the Thames, I thought. I had seen them and heard them many times. Young people on the deck, clothes fluttering under the lights like giant moths. Laughter and music discernible from either riverbank. Through the windows, the shadows, colours and movement of a dancefloor. The sergeant added: “The police surgeon’s already been in and certified them all dead.” And now he really began to cry, walking away, shaking his head. I heard him blow his nose before opening the door and going back to the front desk to fend off the press.

Wapping police pier is a Victorian police station standing right beside the river. At the back, an area had been designated the temporary mortuary. It was just a room, really. Its concrete floor was nearly covered by body bags. All of them lay open and in each one lay the body of a young adult. All dressed for a party, many in bright colours.

In the late 1980s in the UK, there were a series of disasters that claimed many lives. Few, if any, of these disasters could exactly be called an accident. They almost all exposed major systems failures. In March 1987, the car and passenger ferry Herald of Free Enterprise capsized outside the Belgian port of Zeebrugge because the bow door had been left open: 193 passengers and crew died. In August 1987, Michael Ryan went on a killing spree and shot 31 people in Hungerford before killing himself. In November 1987, a lit match dropped down through an escalator to the Piccadilly line at King’s Cross station, causing a fire that claimed the lives of 31 people and injured a hundred more. In July 1988, the Piper Alpha oil rig in the North Sea, 120 miles (190km) north-east of Aberdeen blew up, killing 167 men.

On 12 December 1988, three trains collided due to signal failure just outside Clapham Junction; 35 people died and more than 400 were injured, 69 of them very severely. Later that month, a bomb planted on a Pan Am jumbo jet exploded over the Scottish town of Lockerbie, killing all 259 people on board and 11 on the ground. Less than three weeks later, on 8 January 1989, an engine fault developed in a British Midland Boeing 737 which, compounded with pilot error, brought down the plane on the embankment of the M1, just short of the runway at East Midlands airport. Of 126 people on board, 47 died and 74 suffered serious injury.

In April 1989, 96 Liverpool football fans were crushed to death and more than 700 were injured at Hillsborough stadium in Sheffield. In August 1989 a collision between a pleasure boat and a dredger in the Thames claimed the lives of 51 people, most of them under the age of 30.

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Each event shocked the nation. Each resulted eventually in significant improvements, when emotions were calmer and the often multiple, interconnected causes had been unravelled and analysed. Ancient systems were overhauled, the health-and-safety culture blossomed. Employers began to recognise the importance of training, of corporate and state attitudes to risk and responsibility. These areas had suddenly become more serious, and security was no longer just a managerial afterthought, but a necessity.

I was involved, at emergency or inquiry stage, with many of these events. Pathology learned a lot from them about how to deal with mass disasters – and so did I. It was the lessons of this watershed era that enabled us to cope efficiently with the terrorist horrors of the 2000s.

Gradually, the facts about the disaster on the Thames emerged. On that calm summer night in 1989, a huge dredger, the Bowbelle, had collided on the Thames near Southwark Bridge with a small pleasure boat called the Marchioness. The Bowbelle had dumped its cargo of gravel at Nine Elms, about three miles and was proceeding back out to sea to dredge for more. The Marchioness had been hired to celebrate a birthday, and a crowd of young people was partying onboard.

Initially, the Bowbelle hit the little Marchioness at the back on the starboard side. This caused the pleasure boat to rock and keel over: a witness said the Bowbelle then “mounted it, pushing it under water like a toy boat”. In fact, the anchor of the dredger cut right through the pleasure boat’s upper deck before a second impact pushed the back of the Marchioness round to starboard, causing it to roll over.

The passengers’ chances of escape were hampered by the great speed of the sudden rotation, loose furniture, darkness, the cold, turbid water and, for some, the lack of accessible emergency exits. To get away, physical exertion and strength were required, which compromised the survival chances of many.

Over the following months, my team would be involved in reconstructing exactly what happened, and how each person died. Reconstruction is important. It matters a lot to anyone involved, and it matters to the wider world. As humans, we have a need to know – about specific deaths, and about death in general.

My interest in death began when I was just a boy. One of my childhood friends was the son of a GP. When we were about 13, my friend “borrowed” one of his father’s medical books from the shelves at home and brought it to school. It was Simpson’s Forensic Medicine (Third Edition) by Prof Keith Simpson; a small, tatty, red book which promised nothing on the outside. But inside, it was full of pictures of dead people. In fact, mostly murdered people. They were strangled, electrocuted, hanged, knifed, shot, asphyxiated. No hideous fate could escape Prof Simpson. He had seen everything. There was a photo of the fern-like pattern on the skin that a lightning strike can leave, a picture of the inside of the skull of a boy who had been hit on the head with a brick and an astonishing gallery of bullet entry and exit wounds as well as photos of bodies in various stages of decomposition.

When I was nine, my mother had died of heart failure. She had been cared for in hospital far away from our home, and certainly no one had thought it appropriate for me to see her body. Even the most amateur psychologist must deduce that my need to explore death’s presentation was the reason for my extraordinary interest in that book. More than an interest, it was a fascination.

I studied it for hours. Perhaps I wanted to view that horrifying thing, the worst that could happen, that thing called death, through the detached, clinical, analytical eyes of the great Simpson. Perhaps Simpson helped me to manage the unmanageable. Or perhaps I was simply excited by this mixture of medical knowledge and detective work. My future became clear to me.

A drowned body – or a body that is immersed in water after dying some other way – will first develop opaque, wrinkly skin. Anyone who has spent too long in the bath will have an idea what this looks like. It is often called ‘washerwoman’s hands’: the thick keratin layers on the fingers, the palms and the soles become macerated and the skin appears very wrinkled and white, whatever the ethnicity of the deceased. After a few days, if the body remains in the water, this macerated skin will begin to separate and it will eventually peel off.

The Marchioness went down shortly before 2am on the morning of Sunday 20 August. By the end of that day, we still had no idea how many people on board had died, even though I had viewed and organised the bodies with a colleague from Guy’s hospital. There were clearly a lot of survivors, so we were harbouring hopes that there might be few further bodies.

By law, the coroner is in charge of those bodies and Westminster’s coroner, Paul Knapman, came back to London from his holiday in Devon and met with me and senior police officers to agree how we would process the dead. As coroner, he had to establish positive identification of the bodies, and we discussed how he wanted to do this.

In mass disaster management, false identification is the biggest fear. This is obviously hideous for everyone, especially if a family later begins to suspect they may have buried the wrong body. The coroner rightly wanted the most secure and accurate identification methods that were possible. Today, we have the option of DNA analysis, but it was not available to us then. The two most secure means were still fingerprints and comparison of teeth with dental records. The problem with dental records is that you, of course, have to know the name of the missing before you can begin to search for their dentist, and only when the name of the dentist is known can you request their records. That was clearly going to take a long time.

Facebook Twitter Pinterest The wrecked hull of the Marchioness, partially submerged in the Thames. Photograph: Tony Harris/PA

Those who are trying to cope with the possibility of sudden bereavement after a mass disaster often cannot understand why the relatives are not simply invited into the mortuary to walk through the lines of fatalities to claim their loved one. Many relatives of the Marchioness victims, believing that identification must be easy, did in fact suggest that, if they could just be allowed into the mortuary, they could find their family member. I understand their need and their logic, but it is false. And it would have been utterly inhumane to allow this.

People find it hard to believe that, in mass disasters, visual identification is unreliable, especially so when death has been traumatic, or the body has been immersed in water. But even the uninjured and undecomposed dead are often simply not recognisable to those who knew them as animated individuals. Without life, facial expression or movement, robbed of our essential selves, our bodies can look very different. The fact is that relatives, even immediate family, when they are under great stress, are very likely to make mistakes. They may identify a body that isn’t their relative. Or they may not correctly identify a body that really is their loved one.

The coroner’s conclusion, when we discussed identification, was that fingerprinting of each body was essential. As a list of the suspected missing was compiled, police were despatched to homes (unless they happened already to have fingerprints on their database) to collect personal items on which fingerprints might be found, so that these could be used to match those taken in the mortuary.

Our problem was that these were drowned bodies. They were likely to be damaged, either by aquatic predators or by contact with rocks, bridges, boats or other underwater obstructions. Drowned bodies show all the discolouration and bloating of normal decomposition, plus some much earlier skin changes. Even if retrieved from the water within a few hours, those inevitable washerwoman hands can make fingerprinting difficult, and when there is a complete loss of the skin from the hands – called “degloving” – it can be extremely difficult or almost impossible to take fingerprints from the deeper layers of skin.

The first free-floating body was found in the Thames before 7am that Sunday morning. No more were found that day, but in the afternoon, the Marchioness was raised. When I reached Wapping police station, 24 had been found onboard. They were tagged before being moved on to Westminster mortuary.

During a disaster, we work in a world of constantly changing information, often helping to revise and then re-revise it. The key problem for those managing the Marchioness victims was that no one had any idea exactly how many people had been on board the boat, nor who they were. Within a couple of hours, while the rescue operation was still ongoing and before the first body had been found near Vauxhall Bridge, about three miles south-west of where the boat sank, a telephone bureau had been opened to process information from friends and relatives that might help us identify victims. And by that afternoon, as Westminster mortuary prepared for its influx of dead, relatives of some onboard had started to appear at police stations with photos of their loved ones and descriptions of what they might have been wearing.

By the end of that first day, the police believed that there had been 150 people on the Marchioness, of whom 65, including those 24 bodies taken from the wreckage, were considered missing.

I was almost 30 before I performed my first postmortem. The patient was a middle-aged woman who had been admitted to the hospital with severe chest pains and had then died on the coronary care unit some days later. The case had been chosen specially for me because it was considered straightforward. I was slow but I did all right. I put my feelings about older women with heart problems to one side and recalled my training and conducted myself in an entirely clinical way. As I washed afterwards I felt flushed with relief.

But the postmortem turned out not to be the hardest job that day. Meeting the deceased woman’s relatives was far more demanding. Given a choice, I would have preferred not to see them at all. But they had sensibly asked for a meeting with the pathologist to help them understand why she had died.

I was saved by my colleagues, who did all the talking. I was simply not up to the task, so unbearable did I find the relatives’ shock and grief. In fact, I felt utterly helpless in the face of their emotion. Their misery seemed to transmit itself to me, to my mind and my body, as if we were attached by invisible wires. I don’t remember if I said anything at all: if I did, I probably just kept repeating how very sorry I was for their loss. Mostly, I am sure I nodded while my colleagues talked.

The meeting introduced me – or, perhaps no introduction was necessary – to the awful collision between the silent, unfeeling dead and the immensity of feeling they generate in the living. I left the room with relief, making a mental note to avoid the bereaved at all costs and stick to the safe world inhabited by the dead, with its facts, its measurements, its certainties. In their universe, there was a complete absence of emotion.

The second day after the sinking of the Marchioness, I was back at the mortuary starting the long process of identification and postmortem. We learned that 87 survivors had identified themselves and we had 25 bodies, so we knew that if police estimates of the number of people on board were correct, there were a lot more bodies to come.

Expecting so many further arrivals, we worked as quickly as accuracy would allow. It was an extremely intense week. To see so many young people here was not just unusual, it was shocking. I was aware, as though in my peripheral vision, of the intense misery of parents fearing the worst, waiting for news. Bodies were laid out one at a time on the six tables in the postmortem room and we worked our way doggedly from one to the next, feeling the greatest service we could perform for the bereaved was to do our job as efficiently as possible.

By the end of the day there were 30 bodies in the mortuary and the police thought there were 27 more to be found. But by now, immersion time in the Thames was taking its toll. Waterlogged skin was falling off fingers and the officers were having trouble getting prints using the standard inking process. It was now necessary to use a specialist technique and more sophisticated equipment. This equipment was based in a laboratory in Southwark that had no facilities to manage bodies.

Facebook Twitter Pinterest Police at the site of the Marchioness disaster. Photograph: Graham Turner/The Guardian

At the time, the routine process for individual bodies recovered from the Thames that could not be fingerprinted at the mortuary was to remove the hands, fingerprint them at the lab in Southwark, and then return the hands to the body. They were sewn back on to avoid distressing relatives, who, when the body is appropriately arranged, were unlikely even to see the stitches. The coroner allowed this and so the procedure was followed. Seventeen pairs of hands were removed. By the following day there were 48 bodies and, although we had been working as hard as we could, six were still waiting for postmortems. The police were saying they now believed there had been 140 people on board the Marchioness: 84 survivors and 56 lost or missing.

Meanwhile, back at the mortuary, a request was sent to the lab for the return of the 17 pairs of hands as soon as possible so that they could be reunited with their owners. Another eight pairs of hands were delivered to the Southwark lab for fingerprinting. There was not much more we could do now but wait. It was the Friday before the August bank holiday. Outside the mortuary, people were leaving London for the weekend. We were waiting for dental records to arrive, fingerprint information from the labs and more bodies: 50 had now been recovered. After all that frantic activity, the mortuary seemed eerily quiet.

We had worked hard and, I felt, had served the victims and their families well. Only afterwards did I understand that, while I had been immersed in my work at the mortuary, a lot more was happening than I realised.

Everyone responds rapidly and wholeheartedly to an emergency. Everyone does their best at the time. Although everyone, no matter how well-meaning, should be held to account, it is hard to receive criticism afterwards for actions that may have been taken under extreme pressure in a crisis. The emergency and follow-up services, after many of the 1980s disasters listed earlier, frequently found themselves on the receiving end of some very angry criticism. It is such anger that very often fuels reform. This is nowhere more true than after the sinking of the Marchioness.

I learned that, although some relatives early on identified their dead at a special viewing room at the mortuary, many others were told, due to late recovery of the body and the extent of the decomposition, they were not allowed to see their loved ones.

Sad reunions of the living and the dead do not usually take place at the mortuary: more often the body is moved to an undertaker. But undertakers, as well as the police, later claimed they had been told such viewings should be strongly discouraged and, even in the face of opposition, relatives should be refused access to the dead. I do not know who ordered this or why. When I learned of it, I assumed it was the result of misplaced compassion, because someone thought that seeing a son or daughter in a state of decomposition is traumatic. However, that person clearly did not know that not seeing them is even worse.

It would be a few more years before further information emerged to offer us – the relatives and those of us who had worked on the case – a possible reason why bodies were not seen and coffins not opened.

Three years after the tragedy, the story continued. Of course, the grief of those who had lost someone in the disaster could never end – and their grief was turning to anger. We professionals might have thought it was over for us: some parts of the rescue and its aftermath had not gone smoothly, but the focus of attention since the collision had been on its causes. There were many safety systems that should have been in place on the Thames that night and weren’t, and it was generally believed that the disaster happened because neither vessel saw the other in time – because neither kept a proper look-out.

Victims’ relatives were furious that the master of the Bowbelle had been drinking heavily the afternoon before the disaster as he waited for the tide to change so that the dredger could head downriver. But experts (who didn’t believe that the old RAF rule of “eight hours from bottle to throttle” had a marine application) said the master had substantially slept off this alcohol intake in a nap before setting off that night. So the charge against him was his failure to keep a proper look-out.

Two juries failed to reach a verdict on the culpability of the master of the Bowbelle, Douglas Henderson, and a later attempt to prosecute the dredger’s owners privately also faltered.

After the Bowbelle verdict, or lack of one, the coroner decided it was not in the public interest to reopen the inquests, as by now there had been close examination of the causes of the collision and safety had greatly improved on the Thames. But his decision added to the relatives’ pain: some believed this was biased thinking, particularly after he made some unguarded comments about one of them to the press, which were subsequently published. The relatives not only wanted a full inquest carried out, they wanted a full public inquiry.

Their anger was fuelled by their recent discovery – and unfortunately many of them made this discovery through the Sunday newspapers – that hands had been removed from some bodies in order to identify them. Even more upsetting than that, it had now been learned that the hands were sent back to the mortuary but, unforgivably, some were never actually returned to their bodies. And relatives suspected that the only reason they had been denied access to their loved ones before their funerals was not because the bodies were too decomposed for viewing, but because they lacked hands.

Everyone now directed their anger at the pathologist in charge. That pathologist was me. In their position I, too, would have been angry. But it was wretched to become the focus of such fury. It was no use saying to heartbroken, bereaved people that hand-removal was routine in these circumstances. It was no use explaining that fingerprinting the decomposing drowned invariably requires laboratory technology that cannot be carried out at the mortuary. And it was too late to ask whether, just because this removal was standard at the time, it really was an acceptable routine.

In fact, neither the decision to cut off the hands of some victims, nor their actual removal, nor the failure to replace them, was anything to do with me. However, my denials were ignored and my protests taken as somehow incriminating. My photo kept appearing alongside newspaper articles, accusatory or snide in tone. I received phone calls from journalists at all hours of the day and night; I was frequently doorstepped.

As for my colleagues, they shook their heads over my handling of the Marchioness case. They asked: “Couldn’t I have stopped the hands from being removed?” I felt entirely alone with the fury of the press and the Marchioness relatives. It was a difficult position, no matter how much I sympathised with that fury.

The relatives of those who died when the Marchioness went down doggedly pursued their case for 11 years. Finally, they won a victory. Although it must have taken a great personal toll on them to continue their fight, the relatives insisted there was more to learn from their suffering and that a public inquiry was the best forum.

In 2001, the final reports on the Marchioness disaster were released. Lord Justice Clarke held both a formal inquiry into the disaster and a non-statutory inquiry (which is more flexible and generally regarded as less clunking in its approach) into the handling of the Marchioness dead and their relatives. After the formal inquiry, there were still more recommendations for the improvement of safety and lifeguarding systems on the Thames. And, at the non-statutory inquiry, Lord Justice Clarke confirmed that the Marchioness relatives were the victims of a human and systems failure. His report recognised the muddles in management and identification procedures: he noted confusions between key figures who were on holiday and their deputies, between the many ranks of police officers, between police, coroner and fingerprint officers, between coroner’s officers, between the mortuary staff and the undertakers. The pathologists were exonerated of any blame for the errors that had been made. Eleven years after the disaster, the inquiry closed a chapter of my life.

This is an edited extract from Unnatural Causes by Richard Shepherd, published by Penguin. To order a copy go to guardianbookshop.com or call 0330 333 6846

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