Lucia de B. - Grimbergen Report

Committee Evaluation Closed Criminal Cases

(Commissie Evaluatie Afgesloten Strafzaken)

Report of the triumvirate in the case against Mrs. de B.

J.W.M. Grimbergen

M.S. Groenhuijsen

P. Vogelzang

October 2007.

PROLOGUE

Before you lies the report on the inquiry into the case that is known nationally as the case against Lucia de B., instituted in the framework of the Committee Evaluation Closed Criminal Cases.

Those who will search this report for an answer to the question as to whether the triumvirate judges whether or not Mrs. de B. was justifiably convicted of (a.o.) seven murders and three attempted murders of patients in the care of hospitals where Mrs. de B. was employed at the time, will not find it. This is a direct result of the charter for the Committee Evaluation Closed Criminal Cases, that states that the goal of the committee is to evaluate by way of an inquiry whether or not in a specific criminal case serious shortages arose in the detection, prosecution and/or presentation of evidence in court in a certain specific criminal case, which will have obstructed the balanced judgement of the judge on the facts. For constitutional reasons the role of the magistrates is outside of the remit of this inquiry, as set out in article 2 of the charter.

The triumvirate understands that this can be seen as unsatisfactory by some. At the moment of the formation the triumvirate was aware of this limitation. We believe, however, that with this limitation taken as fact, we have had enough room for a thorough inquiry into a number of questions relevant to the inquiry.

The triumvirate requested cooperation from a large number of involved parties. No one refused cooperation and all the parties we approached cooperated with us for which the triumvirate would like to express its gratitude.

The work of the triumvirate took more time than initially estimated. The size of the dossier was of course known beforehand; the complex character of some of the questions to be answered necessitated more and more in depth research than was estimated at the start of the enquiry. Furthermore the triumvirate, during the course of the investigation, was placed in a situation that various involved parties made contradictory statements. These statements concerned cases of a factual nature that were nonetheless subject to differences in scientific insight. This made supplementary research necessary. Within the triumvirate there was never any discussion as to whether certain subjects should be researched less in depth in order to gain time: the end goal of a report adhering to the quality demanded was always a priority.

Family and friends of patients who lost their lives in one of the hospitals in The Hague in which Mrs. de B. worked, and whose passing was part of the criminal case, are one again confronted with the loss of their loved ones by this report and the ensuing publicity. Old wounds are reopened, the triumvirate realises this. As much as possible we have tried to spare the feelings of the family and friends involved and we have kept their privacy in mind. It was unavoidable that individual deaths were discussed in some places. Within the context of the severity of the problems under discussion the triumvirate finds justification to do so, albeit with some hesitance.

The triumvirate has realised during the course of its work that Mrs. de B. was in jail during our inquiry and that some are of the opinion that she was convicted unjustly. This has on the one hand led to expedience in conducting the enquiry and on the other hand in the greatest possible accuracy. This report is the result of that.

Arnhem, October 2007.

CONTENTS

INTRODUCTION

THE FIRST QUESTION

THE SECOND QUESTION

THE THIRD QUESTION

THE FOURTH QUESTION

THE SIXTH QUESTION

SUMMARY

IN CONCLUSION

INTRODUCTION

On July 13 2006 Mrs. de B. was sentenced to life imprisonment for (a.o.) seven murders and three attempted murders of patients in hospitals in The Hague where she was working at the time. There was no cassation initiated against this verdict.

This signalled the (until then) end of this criminal case, which started in 2001. Since her arrest on December 13, 2001, Mrs. de B. was held in detention. On March 24 2003 the court in The Hague convicted her of a.o. four murders and three attempted murders and sentenced her to life imprisonment. This verdict can be found on the internet, on the website www.rechtspraak.nl, under LJN-number AF6172. Both the public prosecutor and the defendant initiated an appeal against this conviction.

The court in The Hague rendered its verdict on June 18, 2004 (LJN-number AP2846). This court also convicted Mrs. de B., for (a.o.) seven murders and three attempted murders. Apart from life imprisonment she was also given a compulsory treatment order. <terbeschikkingstelling met bevel tot verpleging van overheidswege (ook wel: TBS met dwangverpleging)>. The defendant initiated a request for cassation against this verdict.

By verdict of March 14 2006, LJN-number AU5496, the High Court quashed the contended verdict. However they did this exclusively where it concerned decisions regarding the culpability of the defendant and related sanctions and referred the case to the court in Amsterdam. This led to the verdict mentioned earlier of July 13 2006, LJN-number AY3864.

On account of the criminal trial against Mrs. de B, professor doctor A.A. Derksen, emeritus professor of the Faculty of Philosophy of the Radboud University Nijmegen wrote a book, titled Lucia de B. Reconstruction of a Judicial Aberration (Diemen 2006). On the basis of this book Professor Derksen (hereafter referred to as: the initiator of the petition) approached the Committee Evaluation Closed Criminal Cases with a proposal to research the case against Mrs. de B. The Access Committee as defined in article 7 of the Charter Committee Evaluation Closed Criminal Cases reviewed the petition and came to the conclusion that an inquiry was necessary. By letter of October 20 2006 the College of Public Prosecutors appointed a triumvirate. The members of the triumvirate were:

-Prof. dr. M.S. Groenhuijsen, Professor Criminal and criminal trial law and victimology of Tilburg University

-Mr. P. Vogelzang, (a.o.) former head of the Utrecht regional police

-Mr. J.W.M. Grimbergen, Advocate General with the [<RESSORTSPARKET> CHECK TERM] in Arnhem, Chairman.

-The Civil Clerk was Mrs. Mr. I.H.B. van Zevenbergen-Joele, (a.o.) former Advocate General with the [<RESSORTSPARKET> CHECK TERM] in Leeuwarden.

From the start of November 2006 several meetings were held in preparation. Amongst other things these focused on writing a plan of approach which was submitted for approval to the College of Public Prosecutors. After approval of the plan was obtained in writing on December 14 2006, the triumvirate started its inquiry on January 1 2007.

The triumvirate was given six questions to answer:

Is it correct that only (possibly) inexplicable or suspect deaths that Mrs. de B was possibly involved in were investigated and that other deaths, of which it was established that she was certainly not involved in them, were set aside as irrelevant?

Which experts were asked to file a report? On what basis were these specific experts requested?

What was the initial information on which the statisticians that were consulted based themselves? Was that initial information correct and complete?

What information was presented to the medical experts that were consulted? Was that information complete and correct.

Is a possible report of the Pieter Baan Centrum about the value and the interpretation of a number of possibly relevant diary notes by Mrs. de B included in the dossier?

Were relevant differences in scientific insight on dioxin tests sufficiently taken into account in the investigation and prosecution of the person involved?

The triumvirate used the first two months to get acquainted with the (extensive) dossier. During this period from March to the beginning of July 2007 factual research into the six questions posed to it was undertaken. At the beginning of August a start was made with the editing of the final report, whilst several finalising inquiries were made. In the middle of October 2007 the triumvirate completed its work.

Several conversations took place with the initiator of the petition and Mrs. de B.'s attorney. Amongst other things the question was discussed whether or not they were of the opinion that the questions posed to the triumvirate were correct and if there were any other aspects that required a closer examination.

Both indicated that they were largely in agreement with the questions. Mrs. de B.'s attorney did however make two remarks. In the first place he proposed that the triumvirate would address the question if the criteria laid down by the Public Prosecution to come to a satisfactory conclusion[<BEWEZENVERKLARING> CHECK TERM] (in summary: there has to be a sudden or unexpected death, natural causes are not plausible and Mrs. de B. was present during death) are the correct criteria. The triumvirate pondered this question and came to the conclusion that these criteria fulfil a crucial role in the argumentation in the arrest of the court in The Hague. By making a declaration about whether or not they are correct, the triumvirate would judge the verdict of the court in The Hague. The charter Committee Evaluation Closed Criminal Cases does not give any leeway for this. For that reason the CECCC decided not to send a proposal to the College of Advocates General to expand the questions.

The second remark of Mrs. de B.'s attorney concerns the fifth question. This is the question if a possible report of the Pieter Baan Centrum about the value and interpretation of a number of possibly relevant diary notes of Mrs. de B. was included in the dossier. The triumvirate came to the conclusion that there are no indications that this is not the case. The initiator of the petition and the attorney were asked if they have indications along that line. Since both have declared that they have no reason to assume that the dossier was incomplete with regard to this issue, the triumvirate can simply answer this question in the aforementioned sense. For this reason there is no separate chapter dedicated to this question.

Mrs. de B.'s attorney requested that the triumvirate explicitly comment the value of the diary notes. As the court in The Hague explicitly commented on the question of how the diary notes in its judgement should be interpreted, the triumvirate has decided that there is no leeway within the Charter CECC to honour this request.

A separate chapter in this report is dedicated to each of the five remaining questions. For each question the chapter notes what inquiries were made by the triumvirate and of course on the basis of what data it came to its conclusions.

THE FIRST QUESTION

The first question the triumvirate examined is:

To be able to answer this question the triumvirate examined the dossier extensively. It also interviewed both case public prosecutors [CHECK TERM -CJ], as well as two officials of the police region Haaglanden. Four interviews took please with the latter; they also presented the triumvirate with additional files. On the basis of the information available the triumvirate came to the following conclusions:

The enquiry that eventually led to the conviction of Mrs. de B., was started as a result of the death of baby A.Z. in the Juliana Kinderziekenhuis in The Hague (hereafter referred to as JKZ) on September 4 2001. Since, as is evident from the statement of September 17 2001 by the director of the ??institute of hospital colleagues Red Cross Hospital?? Stichting Samenwerkende Ziekenhuizen Rode Kruis Ziekenhuis / Juliana Kinderziekenhuis, questions arose about the cause of death, police and the judiciary were approached.

The triumvirate has concluded that the investigation can be distinguished by two overlapping phases. The first phase is restricted to the death of baby A.Z., in the second phase a number of deaths and reanimations in the JKZ were investigated.

Where the first phase is concerned, it can be determined that around the time of the death of baby A.Z., two nurses were charged with her care, one of whom was Mrs. de B. Shortly after the death telephone lines of both nurses were monitored. This occurred from September 7 2001 onwards. What stands out is that from that moment Mrs. de B. is referred to as a suspect, whilst the other nurse is referred to as witness/involved person. Various telephone lines of Mrs. de B. are monitored until after her arrest on December 13 2001; the monitoring of her colleague's line however is ended on October 5 2001.

The reason that of all persons working at the JKZ who were involved with baby A.Z. at the time of death, only Mrs. de B. is given the status of suspect, must be found in what was discussed between personnel of the JKZ. According to the statement of the director a certain nurse had approached the head of the ward where (baby A.Z.) was nursed and told her that she had serious doubts about the functioning of a fellow nurse. This complainant had come forward also because of the reanimation of a different child that occurred earlier that weekend. She mentioned (Mrs. de B.). Mrs. de B., according to the director, was involved with reanimations and suspect deaths so often that it was very striking and that she had her suspicions.

The question the triumvirate will formulate an answer to in this chapter is in essence the question whether or not police and the judiciary too quickly pointed at Mrs. de B. as (the only) suspect. When looking at the first phase of the investigation, where the death of baby A.Z. was investigated, it must be concluded that two nurses were present at her death. The most important difference is that stories were doing the rounds about Mrs. de B. at the time. When asked the public prosecutor stated that furthermore the witness interviews of both nurses on September 6 and 7 2001, the statement of Mrs. de B. that baby A.Z. was her patient and under suspicion her actions played a role.

The triumvirate remarks in this context that the statement of the direct, from which the quote above concerning the frequent presence of Mrs. de B. at reanimations and suspicious deaths took place on September 17 2001. This was after September 7 2001, the day on which Mrs. de B. - in contrast to the other nurse - was given the status of suspect. Article 27 of Criminal Law states that a suspect is someone against whom there is a reasonable suspicion of guilt of any criminal fact based on facts and circumstance. In that light the triumvirate deems the basis for the suspicion in that stadium of the investigation is insufficient.

The signal that Mrs. de B. was present at a strikingly large number of deaths and reanimations was taken seriously by the director, as is shown in the director's statement: "Based on these statements and to separate the stories that do the rounds from the facts I conducted an internal investigation. For that reason a list was made of all children that died in the last 2 years and all reanimations of children about which suspicions arose. In all these deaths and reanimations the nurse Mrs. de B. (�) was present." The triumvirate concludes that the question whether or not there were suspicions about a specific incident was posed in the JKZ in the period around the statement.

In the statement the director provides the police with names, dates of birth and limited medical data of five children that died in the JKZ when Mrs. de B. was present and then states: "I want make the remark with this list that we have given this list to a professor of paediatrics (by the name of Mr. A.K.A. Visser; retired paediatrician in Utrecht) to review these cases. This man stated that all these children separately could be considered likely to die but that the cases taken together combined with the unknown cause of death made them suspicious (literally couldn't be right). In his opinion and that of the attending doctors each individual child should have had several weeks/months to live.

For an understanding of the further progress of the investigation it is useful to know that Mrs. de B. worked at the JKZ from September 1 1999 up to and including September 4 2001, almost exclusively in the MCU 1 unit. As an explanation: during the largest part of Mrs. de B.'s employment the following wards existed within the JKZ.

intensive care neonatology (ICN)

intensive care paediatrics (ICP)

medium care unit 1 (MCU 1, until November 9 1999 this was called ward internal 1, IN 1)

medium care unit 2 (MCU 2, until November 9 1999 this was called ward internal 2, IN 2)

medium care unit 3 (MCU 3, until November 9 1999 this was called ward paediatric surgery, IN 3)

The statement of the director solely concerns deaths and reanimations which had taken place in the ward MU 1, the ward where Mrs. de B. worked for most of her time in the JKZ. Furthermore it solely concerns the period in which she worked in the JKZ. The director also provides the police with a list which contains all deaths on all wards within the JKZ in the years of 1999 up to and including 2001.

What is remarkable is that the second phase of the investigation, which starts with the statement of the director, concentrates on the ward MCU 1 and the period under investigation is limited to the time period within which Mrs. de B. worked at that ward. All incidents - which means deaths and reanimations that aroused suspicion - that occurred within MCU 1 during the period of September 1 1999 up to and including September 4 2001 were investigated.

From information that was given to the triumvirate by the police it is clear that the police team investigated sixteen incidents that occurred in the period during which Mrs. de B. worked in the JKZ. These are mentioned in list number 1, as shown in this chapter�s appendix. (Note: various lists are mentioned in this chapter, all of which are partial selections of list 1. For clarity all other lists are derived from list 1, where the incidents that feature on the list concerned are bolded).

Of these sixteen incidents, eleven ended up in the minutes [<PROCES VERBAAL> CHECK TERM].

These are mentioned on list 2, as per appendix. What is striking is that of the five incidents that merit a separate chapter, three did not take place on the ward MCU 1. Furthermore two incidents that did take place on the MCU 1 (and that both concerned the same patient S.S.) are not included in the minutes [<PROCES-VERBAAL> CHECK TERM]. When asked why this was so, police answered: "During the investigation and having studied the medical dossiers we had permanent support from an expert in that area. (�) While discussing the medical dossiers provided we found incidents described concerning patients in his or her dossier. With (patient S.S.) this was clearly the case. However in the case of this patient, while this can also be the case with other patients an incident can be the consequence of that patient's illness (for instance an acute apnoea attack). Eventually the incidents in the dossier of (patient S.S.) led to the establishment of two separate criminal dossiers (7 and 7a) because these incidents were clearly remarkable and pointed towards a possible criminal act.

As indicated the director speaks of deaths and reanimations in his statement. In total he mentions five deaths and five successful reanimations. These can be found on list 3 in the appendix to this chapter. The director has also made a supplementary statement in reference to the one incident that is mentioned on list 2, but not on list 3.

The triumvirate is faced with the question whether in the second phase of the investigation (the first phase concerned the death of baby A.Z.) - into other deaths and reanimations about which, as the director states, suspicions arose - it was justifiable to choose to limit the investigation on the ward MU 1 (where Mrs. de B. worked for the majority of her time in the JKZ) and to the period during which she was working in the JKZ.

Within that context the triumvirate wishes to remark that the selection of deaths and reanimations which aroused suspicion, had already been made within the JKZ and that Mrs. de B., as is clear from the statement, was involved in all of these cases. The triumvirate deems the initial choice to concentrate the investigation in the second phase on the incidents mentioned in the statements understandable.

During the police investigation it should have been established that in none of the (eventually deemed proven) offences a witness has come forward that saw Mrs. de B. execute life threatening actions. Furthermore, from the list of deaths in the JKZ during the period of 1996 up to and including 2001 it is established that in 1996 up to and including 1998, seven patients died on ward IN 1 - which later became MCU 1 - whilst in the years of 1999 up to and including 2001 on IN 1 and MCU 1 six patients died, one of which in March 1999, when Mrs. de B. was not employed yet. A possible explanation for the fact that the number of deaths in the period preceding the employment of Mrs. de B. was higher than during the time she was employed there, may be the change in policy which aimed at allowing patients to die at home instead of in the hospital.

The Triumvirate finds it important that a thorough investigation of incidents in the JKZ is undertaken outside of the period during which Mrs de B. was employed. This is especially important in a case (such as this) where no direct evidence is available. The number of deaths that occurred is not in itself a motive or reason to limit the investigation in the way that occurred.

It should also be said that in the period of 1996 up to and including 2001 101 patients died in the JKZ. By far the most deaths (a total of 71) understandably occurred on the neonatal intensive care unit. On ward MCU 2, however, three children also died in the period between 1999 and 2001 inclusive. The police conducted investigation on two of these three deaths (see list one of this chapter�s appendix) within the context of the investigation into Mrs. de B for a short while although they were dropped. This may be because the wards MCU 1 and MU 2 are on the same floor.

When reviewing all this data within its proper context, the triumvirate firstly repeats its conclusion that Mrs. de B. was considered to be a suspect too quickly in the first phase of the investigation into the death of baby A.Z. At the start of the second phase of the investigation, the triumvirate finds it understandable that the investigation was limited to incidents that had aroused suspicion, on the basis of the statement by the director of the JKZ. During this second phase however, there was every reason to look further than MCU 1 and the period that Mrs. de B. was employed there. Simply the number of patients who died during her time in MCU 1 is not sufficient justification to limit the investigation in the way it was done, since in the period preceding this, the number of deaths was even greater. Now, even after intensive investigation, the conclusion must be drawn that only indirect evidence was available. It is imperative that with an accusation as serious as this - the sentence passed on Mrs. de B. doesn't leave any room for doubt in that matter – that everything possible should be done to exclude alternative possibilities. What should happen in the case of deaths that do not occur within the area of suspicious activities is that upon investigation the possibility that other causes of death might arise which might then be considered in the context of the deaths under suspicion. Should it appear that no other such deaths inside or outside MCU had occurred, but before the period in which Mrs. De B. was employed on this ward, that would have perhaps strengthened the veracity of proof. Since no such investigation occurred the triumvirate concludes that there was insufficient eye for alternative scenarios.

As far as the investigation that did take place and which concerns the period of September 1 1999 up to and including September 4 2001 and which concentrated solely on MCU the triumvirate remarks the following:

This investigation looked at both deaths and reanimation. As far as the latter category is concerned, it is not clear if a consistent registration of these cases was kept. That such a thing is possibly not the case could be concluded from the director's statement, in which he states that on the basis of the list he provided of children reanimated in the presence of Mrs. de B.: "Of this last list I must say that it is a provisional list and that it may be extended, because this list was made on the basis of statements of nursing staff and were recited from memory as being reanimations that had occurred on the ward and with which Mrs. de B. (�) was involved.".

Another statement also seems to indicate that there was no registration of successful reanimations. A paediatrician and trainer in the JKZ who was closely involved with the internal investigation in the hospital stated to the public prosecutor on August 7 2002: "We don't register successful reanimations. So we have had to go on peoples' memories: we asked for peoples' recollection to be able to determine which children were successfully reanimated. This provided us with a number of patients. We also had all discharge letters printed. The discharge letters always mention serious incidents and that way we could continue our investigation. () Of the cases that involved an incident we took the dossier. Then we investigated the dossiers in the same way as we did the deaths.

This is in contrast to a statement of the Head of the Wards intensive care neonatology (ICN) and intensive care paediatrics (ICP) of February 4 2002. She provides a list of reanimations (of which several were successful) with a starting date of November 9 1999, en which concerns the wards MCU 1, MCU 2 and MCU 3. This list is included in the appendix to this chapter as list 4. When asked about the completeness of the list she states: "This number is quite accurate. I'm off at most by one or two cases."

During the course of the investigation an expert by the name of Prof. Dr. H. Elffers was consulted. He did statistical calculations on the basis of the data on incidents that were provided to him, where the definition of incident was: cases in which patients had to be reanimated, whether or not they ended in the death of the patient. When asked to, Prof. Elffers provided the triumvirate with the list of incidents as provided to him. This list is included as list 5 in the appendix to this chapter. (Note that the appendix also contains lists 6 and 7, which contain the cases that Mrs. de B. was charged with and which were considered proven by the court in The Hague.)

The triumvirate finds that of those deaths investigated a complete picture could be obtained, since they were registered consistently. It cannot, however, be stated with certainty that there is a complete picture of successful reanimations; furthermore the selection was partly based on the memories of personnel. The chances that cases of reanimation at which Mrs. de B. was not present, but which did take place caused by an unexpected or inexplicable medical problem, were left out of the investigation since they were not mentioned to the police or judiciary are less than remote. This in itself cannot be laid at the door of police and the judiciary. However, the conclusion must also be drawn that a statistician (Prof. Elffers) was asked to make calculations with the knowledge that Mrs. de B. was involved in all reanimations that took place; this however is not proven fact as far as the triumvirate is concerned. (n het driemanschap niet onomstotelijk vast). We will revisit this subject when answering the third question posed to the triumvirate.

As far as the cases of deaths and reanimations under investigation were concerned the police team compiled a list of personnel on duty during and shortly before an incident. A table was provided to the triumvirate, containing eleven incidents which took place in the JKZ and into which further investigation took place and the people who were questioned based on a certain incident. This concerns the cases on list 2 in this chapter�s appendix. From the lists it was clear that Mrs. de B. was present in each case. However, it also became clear that another nurse was involved in some way in each of the seven incidents. The triumvirate also found that a different nurse was involved in four of the seven incidents the court in The Hague considered proven, amongst which the two cases in which the court concluded that the cause of the incident (in the form of administration of an overdose of a certain matter) could be determined.

In this context it is important to remember that suspicions regarding Mrs. de B. arose on the basis of stories doing the rounds amongst personnel and her frequent presence at patients who - in retrospect - either died unexpectedly and inexplicably, or who unexpectedly required reanimation. When the subjective component, the view of (part of) the staff on Mrs. de B. is left out, what rests is the frequent presence. The triumvirate concludes that in the case of such grave suspicions as were raised about Mrs. de B., in the absence of direct proof, it is necessary to keep an open mind for alternative scenarios with regard to this aspect.

Now that such a frequent presence has taken such a prominent place in the collection of evidence, the triumvirate feels that a presence or involvement in seven of the eleven incidents (or four of the seven) a relevant fact. The triumvirate would like to stress that in this case it is not formulating even the start of a suspicion.

During interviews with the triumvirate, personnel from Haaglanden regional police gave an explanation of the list of eleven cases (list 2 in the appendix to this chapter and the associated cross table). These police personnel stated that it is not possible to deduce from the list and/or the cross table the manner in which a member of staff was involved in an incident.

The triumvirate realises that the list and cross-reference table were only used as aide in deciding the course of the investigation. As is established earlier however, Mrs. de B. was considered a suspect from very early in the investigation. With that in mind the question therefore arises as to whether or not a sufficiently open mind was kept when assessing the criminal involvement of others. The triumvirate has gained the distinct impression during interviews with police and judiciary personnel that as far as the incidents that took place in the JKZ, an attempt was made to abstract from the suspicions against Mrs. de B. However, the triumvirate is of the opinion that insufficient attention was paid to alternative scenarios.

Regarding the extent to which investigation on the question as to whether Mrs. de B. was possibly involved in those potentially inexplicable or suspicious deaths and if other deaths, with which it was certain that she was not involved, were set aside as irrelevant, the triumvirate has established the following:

In the phase of the appeal process at the court in The Hague, an official of the regional police Haaglanden drew up two minutes [may also translate as points], based on questions raised by the defence. In the phase of the investigation (some) attention was given to possible incidents with four patients - mentioned by name in the inquiry - in the JKZ. On the basis of these minutes it can be concluded that no incident occurred with one of these patients. For that reason this case is not contained in any list, as included in the appendix to this chapter.

In the case of the other three (mentioned on list 1 in the appendix to this chapter under numbers 2, 3 and 4) it was established that none of these patients died in MCU 1 and that there was no sign of any involvement of Mrs. de B. in the deaths of one or more of these children. For that reason there was no investigation into these deaths.

As was noted before, the police and the judiciary made the choice to focus the investigation on ward MCU 1 and on the period during which Mrs. de B. was employed on this ward. The triumvirate has already made some critical notes regarding this choice above. However, this choice is a fact.

In those cases that the minutes [possibly translates as points] that were made during the appeals process refer to, the investigating team - as it stated to the triumvirate when asked - had obtained indications from either her diary notes or other written materials, that Mrs. de B. had also been involved in a number of incidents that occurred within the JKZ, but not on ward MCU 1. From the standpoint of the decision made to limit the investigation in the way described above, the triumvirate feels it is a defendable choice to not investigate those (possible) incidents that do not show any involvement from Mrs. de B. The triumvirate did not find any indication that during the investigation concerning the JKZ suspect incidents were set aside - for any reason other than the choice to limit the investigation to the MCU 1 and the period during which Mrs. de B. was employed there - because Mrs. de B. was not involved in them.

Mrs. de B. did not only work in the JKZ, but also in three other hospitals within the municipality of The Hague. These are the Leijenburg Hospital, the Penitentiary Hospital and the Red cross Hospital. The police team also investigated deaths within these hospitals.

The triumvirate has determined that the investigation into these deaths was conducted in a different manner than the investigation into the incidents within the JKZ: in that it was suspect oriented. A distinction has to be made between the Leijenburg Hospital and the Red Cross Hospital on one hand and the Penitentiary Hospital on the other hand.

Where the Leijenburg Hospital and the Red Cross Hospital are concerned, the period during which Mrs. de B. was employed at these hospitals and the wards on which she worked were investigated. With this as a starting point both hospitals were asked for dossiers that showed sudden and unexpected deaths. They were not asked to take Mrs. de B.'s presence or role into account when making the selection.

As far as the Penitentiary Hospital is concerned the team had the witness statements for one patient at their disposal. The dossier was made available by the [rechter-commissaris in strafzaken <Commissioner for judgmental rights?>]. As far as the Penitentiary Hospital is concerned, that was the full extent of information available.

The choice to conduct a suspect oriented investigation in the other hospitals - as was revealed in discussions between the triumvirate and the acting public prosecutors and police personnel - was made on the basis of the fact that the suspicion of Mrs. de B., as a consequence of the results of the investigation into the incident in the JKZ, became stronger in the eyes of the police.

The triumvirate sees itself faced with the question if this is the correct course of action in light of the outcome of the investigation into possible criminal offences committed in the JKZ.

If on the basis of the material available then it could be concluded that Mrs. de B. could be considered a suspect in several �offences against life� [direct translation], committed in the course of her work, it seems logical and responsible that a further investigation was done into possible offences committed under the same circumstances. This is especially valid at the moment the investigation team has witness statements that point in that direction.

As mentioned before, the available information mainly boiled down to the fact that colleagues had made incriminating statements about Mrs. de B. concerning the fact that there were a number of incidents that in the eyes of medical experts were unexpected and inexplicable, and that Mrs. de B. was present at a large number of those incidents. Taking this into account the triumvirate comes to the conclusion that the choice to focus the investigation in the other hospitals on Mrs. de B. was defendable.

The question may be asked if, when the team in its opinion on the one hand found a number of unexplained and inexplicable deaths but also had to draw the conclusion that in the deaths of these patients no witnesses were found that had seen Mrs. de B. take life threatening actions, it would not have been a good course for the team to investigate if there were no alternative explanations available. In an ideal situation, with unlimited time and police capacity, the investigation into possible alternatives would have contributed to a further strengthening or weakening of the suspicions against Mrs. de B. The triumvirate realises that each investigation has limitations in time and capacity and that for that reason choices have to be made. Now that at no point there were any clues to an alternative course, the triumvirate deems the omission not incorrect.

To summarise, the triumvirate comes to the conclusion that Mrs. de B. was indicated as a suspect - and as the only suspect - too soon in the first phase of the investigation of the murder of baby A.Z. and that the investigation was biased towards her.

Concerning the second phase of the investigation, in which a number of deaths and reanimations within the JKZ that had caused suspicion were examined, the triumvirate is convinced that the police and the judiciary attempted to look at the case with an open and unprejudiced eye. It also finds it reasonable that - taking into account the statement of the director - the focus was initially on the ward where Mrs. de B. worked and on the period during which she worked in the JKZ. However, when this investigation yielded no direct evidence in the sense of for instance statements of witnesses who had seen Mrs. de B. perform life threatening acts, there was insufficient attention taken to the search for alternative scenarios.

The triumvirate has therefore come to the conclusion that during the course of the investigation into the incidents in the JKZ, the choice to limit the investigation to the ward where Mrs. de B. worked and to the period during which she worked was incorrect. With this choice - which the triumvirate criticises - as a given, the triumvirate has no (further) indications that cases of which it was certain that she had nothing to do with them had been set aside as irrelevant.

APPENDIX TO CHAPTER THE FIRST QUESTION

List 1: incidents within the JKZ that were investigated by the police in the context of the case against Mrs. de B.

1. 17 January 2000: reanimation patient S.U. on ward MCU 1

2. 3 April 2000: death patient K.Z. on ward MCU 2

3. 29 April 2000: death patient I.K. on ward MCU 2

4. 2 August 2000: death patient M in A&E

5. 18 September 2000: reanimation patient E.I. on ward ICN

6. 11 October 2000: death patient J.E.G. on ward MCU 1

7. 25 October 2000: death patient K.C.F. on ward MCU 1

8. 27 October 2000: reanimation patient S.S. on ward MCU 1

9. 6 December 2000: (possible) intoxication patient S.S. on ward MCU 1

10. 20 December 2000: reanimation of patient S.S. on ward MCU 1

11. 25 January 2001: (possible) intoxication of patient A.N. on ward MCU 1

12. 23 February 2001: death of patient A.N. on ward MCU 1

13. 2 March 2001: reanimation of patient S.S. on ward MCU 1

14. 18 April 2001: death of patient S.H. on ward MCU 1

15. 1 September 2001: reanimation patient A.E.G. on ward MCU 1

16. 4 September 2001: death patient A.Z. on ward MCU 1

List 2: incidents within the JKZ to which the verbal description <eindproces-verbaal> is dedicated (concerns only incidents in bold).

1. 17 January 2000: reanimation patient S.U. on ward MCU 1

2. 3 April 2000: death patient K.Z. on ward MCU 2

3. 29 April 2000: death patient I.K. on ward MCU 2

4. 2 August 2000: death patient M in A&E

5. 18 September 2000: reanimation patient E.I. on ward ICN

6. 11 October 2000: death patient J.E.G. on ward MCU 1

7. 25 October 2000: death patient K.C.F. on ward MCU 1

8. 27 October 2000: reanimation patient S.S. on ward MCU 1

9. 6 December 2000: (possible) intoxication patient S.S. on ward MCU 1

10. 20 December 2000: reanimation of patient S.S. on ward MCU 1

11. 25 January 2001: (possible) intoxication of patient A.N. on ward MCU 1

12. 23 February 2001: death of patient A.N. on ward MCU 1

13. 2 March 2001: reanimation of patient S.S. on ward MCU 1

14. 18 April 2001: death of patient S.H. on ward MCU 1

15. 1 September 2001: reanimation patient A.E.G. on ward MCU 1

16. 4 September 2001: death patient A.Z. on ward MCU 1

List 3: incidents mentioned in the statement of the director of the JKZ (concerns only incidents in bold).

1. 17 January 2000: reanimation patient S.U. on ward MCU 1

2. 3 April 2000: death patient K.Z. on ward MCU 2

3. 29 April 2000: death patient I.K. on ward MCU 2

4. 2 August 2000: death patient M in A&E

5. 18 September 2000: reanimation patient E.I. on ward ICN

6. 11 October 2000: death patient J.E.G. on ward MCU 1

7. 25 October 2000: death patient K.C.F. on ward MCU 1

8. 27 October 2000: reanimation patient S.S. on ward MCU 1

9. 6 December 2000: (possible) intoxication patient S.S. on ward MCU 1

10. 20 December 2000: reanimation of patient S.S. on ward MCU 1

11. 25 January 2001: (possible) intoxication of patient A.N. on ward MCU 1

12. 23 February 2001: death of patient A.N. on ward MCU 1

13. 2 March 2001: reanimation of patient S.S. on ward MCU 1

14. 18 April 2001: death of patient S.H. on ward MCU 1

15. 1 September 2001: reanimation patient A.E.G. on ward MCU 1

16. 4 September 2001: death patient A.Z. on ward MCU 1

List 4: reanimations registered on ward MCU (consisting of units 1, 2 and 3) from November 9 1999 to February 4 2002 (concerns only incidents in bold)

1. 17 January 2000: reanimation patient S.U. on ward MCU 1

2. 3 April 2000: death patient K.Z. on ward MCU 2

3. 29 April 2000: death patient I.K. on ward MCU 2

4. 2 August 2000: death patient M in A&E

5. 18 September 2000: reanimation patient E.I. on ward ICN

6. 11 October 2000: death patient J.E.G. on ward MCU 1

7. 25 October 2000: death patient K.C.F. on ward MCU 1

8. 27 October 2000: reanimation patient S.S. on ward MCU 1

9. 6 December 2000: (possible) intoxication patient S.S. on ward MCU 1

10. 20 December 2000: reanimation of patient S.S. on ward MCU 1

11. 25 January 2001: (possible) intoxication of patient A.N. on ward MCU 1

12. 23 February 2001: death of patient A.N. on ward MCU 1

13. 2 March 2001: reanimation of patient S.S. on ward MCU 1

14. 18 April 2001: death of patient S.H. on ward MCU 1

15. 1 September 2001: reanimation patient A.E.G. on ward MCU 1

16. 4 September 2001: death patient A.Z. on ward MCU 1

List 5: list handed to expert Prof. Elffers of incidents within the JKZ, which was the basis of the statistical calculations (concerns only incidents in bold)

1. 17 January 2000: reanimation patient S.U. on ward MCU 1

2. 3 April 2000: death patient K.Z. on ward MCU 2

3. 29 April 2000: death patient I.K. on ward MCU 2

4. 2 August 2000: death patient M in A&E

5. 18 September 2000: reanimation patient E.I. on ward ICN

6. 11 October 2000: death patient J.E.G. on ward MCU 1

7. 25 October 2000: death patient K.C.F. on ward MCU 1

8. 27 October 2000: reanimation patient S.S. on ward MCU 1

9. 6 December 2000: (possible) intoxication patient S.S. on ward MCU 1

10. 20 December 2000: reanimation of patient S.S. on ward MCU 1

11. 25 January 2001: (possible) intoxication of patient A.N. on ward MCU 1

12. 23 February 2001: death of patient A.N. on ward MCU 1

13. 2 March 2001: reanimation of patient S.S. on ward MCU 1

14. 18 April 2001: death of patient S.H. on ward MCU 1

15. 1 September 2001: reanimation patient A.E.G. on ward MCU 1

16. 4 September 2001: death patient A.Z. on ward MCU 1

List 6: incidents within the JKZ which Mrs. de B. was charged with (concerns only incidents in bold)

1. 17 January 2000: reanimation patient S.U. on ward MCU 1

2. 3 April 2000: death patient K.Z. on ward MCU 2

3. 29 April 2000: death patient I.K. on ward MCU 2

4. 2 August 2000: death patient M in A&E

5. 18 September 2000: reanimation patient E.I. on ward ICN

6. 11 October 2000: death patient J.E.G. on ward MCU 1

7. 25 October 2000: death patient K.C.F. on ward MCU 1

8. 27 October 2000: reanimation patient S.S. on ward MCU 1

9. 6 December 2000: (possible) intoxication patient S.S. on ward MCU 1

10. 20 December 2000: reanimation of patient S.S. on ward MCU 1

11. 25 January 2001: (possible) intoxication of patient A.N. on ward MCU 1

12. 23 February 2001: death of patient A.N. on ward MCU 1

13. 2 March 2001: reanimation of patient S.S. on ward MCU 1

14. 18 April 2001: death of patient S.H. on ward MCU 1

15. 1 September 2001: reanimation patient A.E.G. on ward MCU 1

16. 4 September 2001: death patient A.Z. on ward MCU 1

List 7: incidents within the JKZ that the court in The Hague determined to be proven (concerns only incidents in bold)

1. 17 January 2000: reanimation patient S.U. on ward MCU

2. 3 April 2000: death patient K.Z. on ward MCU 2

3. 29 April 2000: death patient I.K. on ward MCU 2

4. 2 August 2000: death patient M in A&E

5. 18 September 2000: reanimation patient E.I. on ward ICN

6. 11 October 2000: death patient J.E.G. on ward MCU 1

7. 25 October 2000: death patient K.C.F. on ward MCU 1

8. 27 October 2000: reanimation patient S.S. on ward MCU 1

9. 6 December 2000: (possible) intoxication patient S.S. on ward MCU 1

10. 20 December 2000: reanimation of patient S.S. on ward MCU 1

11. 25 January 2001: (possible) intoxication of patient A.N. on ward MCU 1

12. 23 February 2001: death of patient A.N. on ward MCU 1

13. 2 March 2001: reanimation of patient S.S. on ward MCU 1

14. 18 April 2001: death of patient S.H. on ward MCU 1

15. 1 September 2001: reanimation patient A.E.G. on ward MCU 1

16. 4 September 2001: death patient A.Z. on ward MCU 1

List 8: incidents within the JKZ, that the court in The Hague determined to be proven and that were the basis of the conviction of Mrs. de B. (concerns only incidents in bold).

1. 17 January 2000: reanimation patient S.U. on ward MCU 1

2. 3 April 2000: death patient K.Z. on ward MCU 2

3. 29 April 2000: death patient I.K. on ward MCU 2

4. 2 August 2000: death patient M in A&E

5. 18 September 2000: reanimation patient E.I. on ward ICN

6. 11 October 2000: death patient J.E.G. on ward MCU 1

7. 25 October 2000: death patient K.C.F. on ward MCU 1

8. 27 October 2000: reanimation patient S.S. on ward MCU 1

9. 6 December 2000: (possible) intoxication patient S.S. on ward MCU 1

10. 20 December 2000: reanimation of patient S.S. on ward MCU 1

11. 25 January 2001: (possible) intoxication of patient A.N. on ward MCU 1

12. 23 February 2001: death of patient A.N. on ward MCU 1

13. 2 March 2001: reanimation of patient S.S. on ward MCU 1

14. 18 April 2001: death of patient S.H. on ward MCU 1

15. 1 September 2001: reanimation patient A.E.G. on ward MCU 1

16. 4 September 2001: death patient A.Z. on ward MCU 1

THE SECOND QUESTION

The second question that was put in front of the triumvirate was as follows:

Which experts were asked to file a report? On what basis were these specific experts requested?

When studying the relevant files, the triumvirate has concluded that during the entire criminal trial a large number of experts reported or were at least interviewed. A conservative estimate is a total of about seventy. Since the triumvirate feels that the question posed above cannot be seen separately from the other questions, the first decision was to decide whether or not it was necessary to research the questions asked of all seventy experts and not others. The fact that if the question before the triumvirate would be answered by all seventy experts, an excessive time might be taken into account.

For that reason a shortlist of experts was created that the triumvirate was of the opinion that they could also provide feedback in light of the other questions -

- it was important to judge why they were asked. Eventually a list of eleven names was compiled. To ensure that no names were omitted the petitioner, as well as Mrs. de B.'s attorney were given the opportunity to propose additions to the list. However, both indicated in a discussion with the triumvirate that they could agree with the shortlist. As indicated earlier, article 2 of Charter of the CECCC states that for constitutional reasons the role of the acting magistrate is outside of the scope of the commission's inquiry. When the list of eleven names was scrutinised, it was noted that with regard to three of them the courts had independently - meaning not at the instigation of the public prosecutor or defence - decided to appoint them. Answering the question as to why these experts were chosen would imply judgement on the role of the acting magistrate. For obvious reasons the triumvirate will not make statements on these three experts.

Furthermore the JKZ, as indicated in the answer to the first question, they asked Prof. Visser to advise the board on whether or not to file charges. The triumvirate feels that it is not up to the commission to judge the reasons of a private institution as to why they consulted this expert. For that reason, Prof. Visser will be disregarded when answering the question in this chapter.

The Dutch Forensic Institute (NFI) was asked to (a.o) conduct toxicological tests. Eventually a particular pharmacist/toxicologist reported on behalf of the NFI on toxicological matters. Since it wasn't this specific pharmacist/toxicologist who was consulted but the NFI, and since this decision is not ultimately under review, the triumvirate will also refrain from answering the question as to why this expert was consulted.

This leaves the following experts:

-Prof. Dr. D.R.A. Uges, Clinical Forensic Pathologist/Pharmacologist, appointed/proposed by the public prosecution.;

-Prof. Dr. H. Elffers, (then) Professor Judicial Psychology at the University of Antwerp and Senior Researcher with the Dutch Research Centre of Crime and Law enforcement, currently Professor at the Vrije Universiteit in Amsterdam, requested by the police team and/or the public prosecution;

-Prof. Dr. A.G. Vulto, Professor of Hospital Pharmacy and Practical Pharmacotherapy, appointed/proposed by the public prosecution.;

-Prof. Dr. F.A. de Wolff, Clinical Chemist and Toxicologist, appointed/approved by the defence;

-Prof. Dr. R. Meester, Professor of Probability at the Vrije Universiteit Amsterdam, requested/approached by the defence.;

-Prof. Dr. M. van Lambalgen, Professor of Logic and Cognitive Sciences at the University of Amsterdam, requested by the defence.;

The triumvirate saw itself faced with the question as to whether or not it should say anything about the experts appointed by or at request of the defence. The charter of the CECCC the triumvirates working in this context are not charged with including (aspects of) the role of the defence in their report. On the other hand the charter does not - in contrast to the role of acting magistrates - lay any pressing restriction on the triumvirate in this aspect. Since at least one of the experts proposed by the defence played a prominent part in the criminal case, the triumvirate feels it should also make a statement about this group of experts.

Both the public prosecution and the defence were asked in writing what their reasons were to choose a certain expert. On behalf of the public prosecution one of the two public prosecutors on the case replied in writing. A written reply was also received from Mrs. de B.'s attorney. On the basis of this the triumvirate concludes the following:

As far as Prof. Uges is concerned the public prosecutor states that in the context of the investigation into the death of baby A.Z., with which the case against Mrs. de B. started, the attending cardiologist suspected administration of potassium and that they eye fluid could be tested for potassium levels. She states that Prof. Dr. D.R.A. Uges was generally regarded as the expert in this area. The triumvirate notes that it does not wish to question Prof. Uges expertise, but that a further substantiation of the statement of the prosecutor regarding the expertise is missing.

The public prosecutor states that Prof. Elffers was known to the police investigation team. He was approached by the coordinators because of his expertise in the field of statistics. He was not appointed as expert by the public prosecutor, nor by the Commissioner for Rights <direct translation from RECHTER-COMMISSARIS>. Later further investigative questions were posed, also on the basis of what the court had indicated. This mostly concerned the question which facts needed to be taken into account in relation to the final indictment. The triumvirate finds that the public prosecutor incorrectly transferred responsibility for the consultation/choice of this expert to the police team, since it was not an optional consultation, but a report that was included in the dossier. Since the public prosecution is responsible for the compilation of the dossier, the public prosecutor should account for this. It is not clear if the prosecutor ascertained the expertise of these experts.

On the appointment as expert of professor Vulto the public prosecutor states that during the investigation into a certain case - later included as attempted murder in the indictment - she needed a more extensive assessment of the influence of the substances administered. "I have," according to the prosecutor, "consulted experts at an academic level. I did not want to appoint an expert who already had occasion to have knowledge of the case Mrs. de B. (�). Furthermore en expert must be willing to occupy himself with this sensitive case. Vulto is an eminent expert in the field of medication/side effects etc. He is one of the writers of the handbook Medication in The Netherlands and he was willing to report in this case.". The triumvirate understands that this expert was consulted because he wasn't polluted with knowledge of the investigation against Mrs. de B. The reasoning and criteria by which the public prosecutor reviewed this expertise is - apart from a reference to a publication - not clear.

With regard to the experts consulted by or recommended by the defence, the triumvirate established the following.

Mrs. de B.'s attorney has informed the triumvirate that Prof. De Wolff was already recommended by a colleague who was handling the case for the defence at the time of the court case who, as he understands, attended a lecture by De Wolff during a course on toxicology.

Prof. Van Lambalgen and Prof. Meester's (who jointly submitted a report) recommendations came about in a similar manner, states Mrs. de B.'s attorney: "Through a colleague of mine I came into contact with Van Lambalgen in order to have the secrets of statistics explained to me. At the suggestion of Van Lambalgen we then also involved his colleague Meester. Both then declared they were available to act as expert and as a consequence I proposed them in the appeal."

The triumvirate concludes that the most important reason for the experts proposed by the defence was information from colleagues.

In light of the preceding, the triumvirate firstly remarks that there was no investigation into the measure of expertise of the experts proposed by the public prosecutor and the defence. It appears to the triumvirate that there is no structural investigation into the specific qualifications of the person to be proposed at the basis of the answer to the question as to why one, and not another expert is consulted.

Relatively arbitrary arguments such as random knowledge of (the name of) a person played an important part. A system of certification of experts and the establishment of a register could be a start to a solution regarding this. Incidentally, this idea is not new and important steps have already been taken.

The triumvirate also points out that as far as experts that are appointed by the judge are concerned, it is an established custom that the opinion of the trial party that did not propose the expert is also sought. The extent of that custom should not be underestimated: agreement with the appointment of a certain expert can be seen as (a measure of) recognition of their expertise.

Furthermore the appointing judge will also form an opinion on the expertise of the person proposed. When there is consensus on a certain expert and the defence, then this will usually only involve a limited review.

The position of experts that were consulted independently by one of the persons or parties involved in the case without the intervention of a judge is entirely different. Review of the expertise is in that case a matter for the person consulting the expert. Only when the results of the investigation by the expert are known is there an option for other parties in the case to form an opinion on the expertise of the reporting expert. In the opinion of the triumvirate those who did not consult that expert are placed before a fait accompli and are therefore at a position of disadvantage. In a case where there is only circumstantial evidence, the triumvirate deems it desirable to avoid such a situation.

Lastly the triumvirate realises that the judgement on the matter of expertise is accompanied with a certain measure of subjectivity. Regardless of this, objectification is possible to a certain extent. One of the measures could be the number of times an expert is quoted in scientific literature. On the internet search engines can be employed that can give information on this. Especially in a case such as that against Mrs. de B., in which the opinion of experts plays a crucial role in the evidence, the triumvirate feels that this objectification is necessary.

THE THIRD QUESTION

The third question as put before the triumvirate is as follows:

What was the initial information on which the statisticians that were consulted based themselves? Was that initial information correct and complete?

To be able to answer this question the triumvirate studied the relevant files. Further interviews took place with Prof. Dr. H. Elffers, senior researcher for the Dutch Research Centre Crime and Justice and also, at the time of his reports, Professor at the University of Antwerp, currently at the Free University of Amsterdam, who reported in the case against Mrs. de B. Interviews were also held with Prof. Dr. R.D. Gill, Professor of Mathematical Statistics at Leiden University. Furthermore interviews with public prosecutors as well as personnel of the Haaglanden region were undertaken concerning the question of the initial information. This has led to the following conclusions:

In the case against Mrs. de B. a number of experts reported on statistics. Prof. Elffers, mentioned before, wrote reports dated February 5 and May 8 and 29 2002. He was also heard as expert in Court. In a report of August 31 2002 Prof. Dr. R.V. de Mulder, Professor of Information Systems and Law at the Erasmus University in Rotterdam answered several specific questions about Prof. Elffers' report. He was also heard in Court.

In the phase where the case was before the court in The Hague, Prof. Dr. R. Meester, Professor in Probability at the Vrije Universiteit in Amsterdam and Prof. dr. M. van Lambalgen, Professor of Logic and Cognitive Sciences at the University of Amsterdam criticised the reports by Prof. Elffers in their report of February 18 2004. Both were also heard in Court.

Of the experts that reported in the area of statistics, only Prof. Elffers made calculations based on the information provided to him by the police and or the Public Prosecutors. Professors De Mulder, Meester and Van Lambalgen did not independently make calculations, but have only remarked on Prof. Elffers finds. Therefore in the case of the question into the accuracy and completeness of the starting information used, the triumvirate can limit itself to the information as used by him.

Before looking at the initial information as used by Prof. Elffers, the triumvirate wishes to state that the question as to whether or not the events were coincidence became an issue in the case against Mrs. de B. very quickly. The retired Professor of Paediatrics Prof. Dr. Visser who was consulted by the board of the JKZ stated early on to the police, on October 12 and 29 2001: "I have stated to (�) that, in light of the medical conditions of the children, the medical inexplicability of the death and or the necessity of reanimation and the exceptionally improbable statistical chance that the same nurse was involved in all cases, that it is improbable that these children all died a natural death." On that basis he advised the board to press charges. In the opinion of the triumvirate this aspect, referred to by the public prosecutor in an interview with the triumvirate as gut feeling, made its influence felt right up to and including the presentation of evidence by the public prosecution in Court.

When studying the three reports by Prof. Elffers the triumvirate notes that a starting protocol or paragraph with full and exact definitions was not included. Definitions as to what exactly was meant by reanimation, what exactly a shift was and what was meant by the time of an incident did not exist. In the opinion of the triumvirate, this immediately addressed the issue of the question of the correctness and completeness of the initial information. By full information the triumvirate means the type of information on the basis of which an expert can do a valid and reproducible calculation. Because of the fact that there are no definitions for several important terms the triumvirate concludes that there is already an issue of incomplete initial information.

When we look at the report of February 5 2002, we can read that Prof. Elffers has made calculations for the period in which Mrs. de B. was employed at the JKZ and the RKZ. The question he poses is whether or not it could be a coincidence that a certain nurse () is confronted with incidents of reanimation, whether or not resulting in the death of patients, during her shifts at a certain Medium Care Unit of the JKZ and on wards 41 and 42 of the RKZ. He defines incidents as case where reanimation was necessary, whether or not they resulted in the death of a patient.

The triumvirate has tried to ascertain who decided to consult Prof. Elffers. There is no certainty to be had about this. The police stated that the initiative lay with the public prosecutor; in the perception of the case officers of the public prosecutors the police team consulted Prof. Elffers, with permission from the public prosecutors.

In light of the formulation of the question Prof. Elffers stated to the triumvirate that he was asked to address the question whether or not this could be coincidence. The police and the public prosecutor were, the triumvirate found, in broad agreement about the question to be posed to Prof. Elffers. The exact wording of the question was - it seems - left to Prof. Elffers himself.

After studying Prof. Elffers' reports the triumvirate firstly concludes that although the definition of the term incident is clear in and of itself, that it is not used consistently. The term is defined as those cases in which reanimation was necessary; and therefore includes only those cases of successful and unsuccessful reanimation. Deaths of patients which did not involve attempts at reanimation fall outside of the definition and therefore do not full under the definition of incidents.

In the various reports by Prof. Elffers he used as far as the JKZ is concerned numbers that include both successful reanimations and deaths after unsuccessful reanimations. In this case, the definition was used correctly (with the exception of a case of (possible) intoxication, which will be addressed later). When the numbers for the RKZ are concerned however, they only include deaths; successful reanimations are not taken into account for the calculations. The triumvirate has also concluded that in five of the six deaths in the RKZ it is not possible to distil from the dossier whether or not an attempt at reanimation was made. In light of the definition of the term incident, these cases should therefore not figure in the calculations. Now that they were included, the triumvirate concludes that the term incident is not used consistently in the reports. The starting information is incomplete as a manner of supporting the statistical calculations.

The triumvirate also notes that the meaning of the term reanimation is also not consistent and that no guarantees can be given as to the completeness of the registration of reanimations. In a statement made to the investigating police team on February 4 2002 the unit head of the units intensive care neonatology and paediatrics units stated that in the period of November 9 1999 up to and including September 4 2001 a total number of 9 instances of reanimation took place on the ward MCU, consisting of units 1, 2 and 3. She presented a list of names and dates which revealed that all these reanimations took place on unit MCU 1. This is list 4, as included in the appendix to the chapter on the second question. She adds to say: "this number is fairly accurate, I can be at most one or two cases off."

It seems that the unit head defines reanimations as those cases in which a reanimation team is active. This registration was set up with the goal of charting how often nurses, for how long, cannot be present in their own wards, but have to assist in other wards for the purpose of reanimations. On the wards intensive care there is always a complement of nurses and facilities that ensure that a separate reanimation team is never needed. For that reason reanimations that occur on these wards are not consistently registered. That also explains, according to this employee of the JKZ, why a reanimation of a patient on September 18 2000 is not included in the list provided, since it occurred on the ward intensive care neonatology. Mrs. de B. was involved in this reanimation and it was included as attempted murder in the charges and later declared proven, but is not listed on the overview by the unit head.

The charges also include a case that took place on January 25 2001 which was also considered proven. There is no reanimation, but a case of (possible) intoxication. The triumvirate would like to point out that in the statement of the director of the SSZ RKZ/JKZ, made in the starting phase of the investigation, this case is included as a case of reanimation. Even though this case is clearly not a case of reanimation it was nevertheless included in Prof. Elffers' calculations.

In a memo handed over by Prof. Elffers during an interview with the triumvirate he states on the question of what information he used with regard to the JKZ: "Then I again notified the investigation team in writing that I need "all cases of reanimation of the ward MCU, including their date and time", so that I could see if the suspect was on duty or not. I was presented with such a list, and the investigation team explicitly asked the unit head in charge of reanimation about the completeness of this administration." The incidents included by Prof. Elffers in his calculations are in list 5 of the appendix to the chapter: The First Question. Why these cases were included in the calculations is not clear to the triumvirate. It seems that it includes those cases named in the statement by the director of the JKZ and they occur after October 1 2000. (The incidents the director included in his statement are in list 3 of the appendix to chapter: The First Question). This choice is in the opinion of the triumvirate inexplicable where it concerns the first report by Prof. Elffers, as the report covers the period of November 9 1999 up to and including September 9 2001. In the statement by the director an incident is also included that took place on the ward MCU 1 on January 17 2000. In light of the period referenced by the first report by Prof. Elffers, this incident should also have been included in the calculations. In any case, this means that the starting information where it concerns this report was incomplete and therefore incorrect.

To this is added the following aspect. As has been stated before, the definition of the term reanimation is not consistent. Furthermore there is no certainty about the completeness of the list of reanimations. The public prosecutor interviewed a paediatrician/trainer in the JKZ. They confirm that there was no registration of successful reanimations: "We have had to rely on people's memories." Since there were plenty of stories doing the rounds about Mrs. de B. among the hospital staff, it is not entirely outside of the realm of possibility that in this selection from memory only those reanimations that she was involved in came to the fore and that other successful reanimations were not included. Also because of the fact that there is no definition of the term reanimation and the uncertainty about the completeness of the number of reanimations the triumvirates deems the initial information not clear and from a standpoint of statistics incomplete and (possibly) incorrect.

The triumvirate has also noted that a case of reanimation was included in the charges (and considered proven) that was not included in Prof. Elffers calculations. It concerns the reanimation of patient E.I. on September 19 2000 on ward ICCN. Since this reanimation did not occur on MCUC 1 it was - in view of the definition used by Prof. Elffers, rightfully not included in the calculations.

As indicated Prof. Elffers wrote three reports. In the first, dated February 5 2002 he makes - as noted before - calculations on the period of November 9 1999 up to and including September 9 2001. Although Mrs. de B. worked from September 2 1999 until she was relieved of duty on September 9 2001, as Prof. Elffers states the JKZ cannot guarantee the accuracy of the numbers of the period of November 8 1999 (when the ward MCU 1 was still called IN 1); de numbers for MCU 1 are complete.

In his report of May 8 2002 Prof. Elffers made a different choice: "I will choose the period of October 1 2000 up to and including September 9 2001. From October 2000 (Mrs. de B.) had the Specialised Nurse Paediatrics Certificate and she worked as a fully qualified paediatric nurse on ward MCU 1. Prior to that date she did not have the paediatrics certificate and was dependent upon another member of staff for certain procedures. In earlier periods (Mrs. de B.) was also working in the JKZ and partly in other wards, like ICN, MCU 2 and MCU 3. These periods will not be considered."

The Triumvirate will not comment on the question if that later choice, to shorten the period significantly, was rightfully made: it doesn't touch on the questions posed of the Triumvirate of the correctness and completeness of the initial information. The Triumvirate did conclude that in both cases the basis is the same number of incidents, namely 9. This, despite of the fact as noted in the statement by the director of the JKZ that a reanimation did occur on January 17 2000 (of patient S.U.) on MCU 1. When asked, Prof. Elffers stated to the triumvirate: "A reanimation on January 17 2000 is not present in my material, it is not on the duty roster list that was my source material and such a case is also not mentioned in the copy of the charges that was made available to me." Although the last statement is correct - this fact was not included in the charges against Mrs. de B. - the Triumvirate concludes that the question whether or not an incident was included in the charges, is not a selection criterion for the cases put before Prof. Elffers. So the starting information was also incomplete where this point is concerned.

The Triumvirate also notes that a list handed over by the police entitled �Duty Roster (Mrs. de B.)�, included all wards and incidents, mentioned two reanimations that fall within the shorter period as used in the second report of Prof. Elffers, but which are not present on Unit Head�s list. This concerns reanimations on October 27 and December 6 2000, both of patient S.S. When questioned, police personnel from Haaglanden stated: "this also came up when answering the first question: "during the investigation and whilst studying the medical dossiers we had permanent support from an expert in that area (�). During discussion of the medical dossiers provided we came across incidents recorded in patients' dossiers. This was the case with (patient S.S.). However, where this patient is concerned, and it can also be the case for other patients, the incident could be a consequence of the patient's illness." Furthermore: "Because some incidents were not noted as incident or reanimation by the nurses it was not clear whether or not they were incidents normal consequences of the disease. It is clear from this that by us, the police, but also colloquially, the definition of a reanimation is interpreted entirely differently." These facts also support the conclusion that the term reanimation was not used unambiguously.

On May 29 2002 Prof. Elffers made a third report. He stated in this report: "The question was to indicate the way in which the first report should be adapted when we only took into account those cases with which Mrs. de B. was charged. In comparison to the first report, the charges do not include the death of April 18 2001 in the JKZ. Where it concerns the JKZ a different case, one that took place on September 18 2000 is included�. Since the first case falls outside the shorter period covered in the report of May 8 2002 he deemed it less correct to include this in his calculations.

As was previously concluded by the Triumvirate, this reanimation did not take place on MCU 1, but in neonatology intensive care. Therefore, taking into account the question formulated by Prof. Elffers, the Triumvirate�s opinion is that this fact alone should lead to this incident not being included in the calculations.

In his last report Prof. Elffers did his calculations with eight incidents rather than nine. The Triumvirate has attempted to determine at whose request this was done, but has been able to gain no insight. Prof. Elffers� notes indicate that he was asked to redo the calculations with different numbers, but not who made the request. The Triumvirate determined that on March 25 2002 a court hearing occurred that did not involve a discussion of the fact. Due to a change in the composition of the Court, the case started again on June 20 2002. The second report by Prof. Elffers is dated May 9 2002 and the revised (third) report is dated May 20 2002. There was no court session between second and third reports.

Because the calculations have been performed again to exclude one case in the JKZ because it was not on the charges, the Triumvirate believes that a fundamental issue regarding the initial information was changed. The incidents covered in the reports of February 5 2002 and May 8 2002 covered objective facts(cases where a patient was reanimation, whether or not the patient died). The Triumvirate notes that it has already criticised the manner in which this changing criterion was applied.

The removal of one case because it was not on the charges means that the information presented changing from objective knowledge to reanimations that are suspicious as decided by the Public Prosecutor and implies the Public Prosecutor�s decision that there is enough suspicion against Mrs. de B. to charge her. The Triumvirate concludes that the addition of this different component detracts from the reliability of the statistical calculations. In an interview with the Triumvirate Prof. Elffers himself also stated that this was an illogical step.

The Triumvirate has concluded that – irrespective of the value of any other results contributed by Prof. Elffers (about which the Triumvirate explicitly did not comment) - the introduction of this different component into the calculations greatly decreased the value of the statistical calculations. If only those incidents that the public prosecutor found sufficiently suspicious to include in the charges are included, is it then not also inherently consistent to make the calculations with those cases that the court has deemed proven? As far as the Court is aware, there are five such from the list used by Prof. Elffers, and as far as the Court of Appeal is concerned there are seven (of a total of nine). The results of Prof. Elffers� calculations would in that case become a lot more favourable for Mrs. de B. Furthermore the Triumvirate notes that in four of the seven cases deemed proven by the Court of appeal another nurse was present with Mrs. de B. Triumvirate wishes in no way to implicate this nurse.

The Triumvirate has also examined cases that took place within the RKZ which were also included by Prof. Elffers in his calculations. In his first reports he used six deaths in the RKZ, then in his report of May 29 2002 he used five incidents because one of the incidents was not included in the charges. Against this choice the Triumvirate has the same objections in principle as against the removal of one case from the calculations of the JKZ in the same report. These objections have already been explained above.

The Triumvirate also noted that of the six incidents in the RKZ, five were entered into the charges and only three were deemed proven. The Triumvirate concluded once again that if the calculations had been made with only the cases deemed proven, the results for Mrs. de B. would be less damaging.

When the evidence was presented by the Public Prosecutor in Court in September 2002 he made the following statement about Prof. Elffers� conclusions: "And that is exactly what the public prosecution has in mind with including this statistical data, the calculation only shows that this is not a case of coincidence, but that there has to be an association, as stated by Elffers." The prosecutor added that during the period from 1996 to date only five patients died in MCU 1. The suspect was involved in all five. In other words: on the MCU 1 there have been no deaths in the last five years that the suspect was not involved in. This cannot be coincidence. The Triumvirate notes that while this remark is strictly speaking correct but that MCU 1 wasn't instituted until November 1999.

In the period between 1996 and November 1999 this ward was called IN 1. The Triumvirate has a list, made available by the police team, which lists eight deaths in the same period (January 1996 to November 1999 inclusive). The dossier contains a list given to the police by the director, listing eight deaths on ward IN 1 in this period. Therefore the Public Prosecutors paragraph was incorrect in spirit. When asked, the Public Prosecutor states that he did not have access to this data and that he regrets the inaccuracy of his statement. The Triumvirate notes that the director's list mentioned above is - as was noted earlier - present in the dossier.

The Triumvirate notes that, for the conviction of a suspect. it is necessary to have lawful and convincing evidence to support the charges. Lawful evidence is easily provided. The triumvirate points out that conviction of a suspect also requires that the Judge should also hold the conviction that the suspect did indeed commit the act with which he or she is charged.

Both aspects were mentioned in the Commissioning Investigation <?requisitor> of the Advocates-General in the Court of The Hague, when the report by Prof. Elffers was discussed. Even so, the experts report in general - and in this case the experts report by Dr. Elffers - with the addition of the statements he made during the Court hearing play a large part. Specifically that the conviction that the suspect did commit (some of the) crimes of which she was charged were probably based on this specific evidence. In our opinion the expert opinions of Elffers fulfilled such a role. Furthermore, the statistical report by Elffers was presented as a powerful, forceful and undeniable message. In essence this report stated that this was not a matter of a coincidental series of suspicious incidents.

Taking into account the conclusions formulated by the Triumvirate regarding initial information as used in the three reports by Prof. Elffers, the Triumvirate concludes that a more critical approach to Public Prosecutor�s reports would have been appropriate.

The Triumvirate would also like to note the following:

In an interview with the Triumvirate, Prof. Elffers stated that there was a difference in expectations in the police team. One of the detectives was of the opinion that the occurrence of these incidents could be sheer coincidence, whilst others were of the opinion that this could not be the case. That is when he was asked to review the case. In that same interview he stated: "My research regarding involvement in this case was as a planning instrument for the police: to see if it was useful to involve more detectives, or determine whether or not we were chasing a ghost." The police employees of Haaglanden police and the public prosecutor spoke of this in similar ways. The Triumvirate is under the impression that the function of the work by Prof. Elffers changed without a definite decision, at one moment it was a planning instrument for the police and the next potential evidence.

When asked, the Public Prosecutor indicated that striving towards the greatest possible transparency caused the Public Prosecution to include the reports by Prof. Elffers in the dossier. Since the Judge was entirely free when selecting evidence, the risk was taken that these reports would attain the status of evidence. In their investigation <inquisitor> the Advocates-General even insisted that both Report and Statement made in Court by Prof. Elffers would be used as evidence. Since the reports in no way relieved the burden on Mrs. de B., in the judgement of the Triumvirate nothing stood in the way of leaving the reports out of the dossier, especially since it was only planning information. The public prosecution denied the original function of the reports by the way they were used.

Although including a report in a dossier is the responsibility of the Public Prosecution, the Triumvirate is of the opinion that the expert consulted also has an obligation. It is up to him to explain what the report can and cannot be used for. The expert consulted must realise that inclusion of his report can result in - and in this case did result in - his work playing a role in the evidence of the public prosecution.

Statistics played an important role in the public discussion that arose around the case against Mrs. de B. Issues that have regularly arisen include the question whether the findings of Prof. Elffers played any role in the judge's conviction in the criminal procedure, and if the contents of his calculations adhered to the strict scientific demands. Neither question was researched by the Triumvirate; it limited itself to the question posed to it regarding the information on which it was based. As far as that is concerned, the Triumvirate concludes that it (the information) is �insufficiently singular� <probable meaning – germane> and therefore incomplete.

THE FOURTH QUESTION

The fourth question posed to the Triumvirate is as follows:

What information was presented to the medical experts that were consulted? Was that information complete and correct?

During the entire investigation that resulted in the conviction of Mrs. de B. a great number of medical experts were heard. Most of them made a statement to the police, but several also submitted written reports, either at the request of the Commissioner for Rights <rechter-commissaris> or at the request of the Judge in Session. During the hearing several experts were heard, mostly as a result of their written reports.

Since the Triumvirate is of the opinion that answering the fourth question with regard to all medical professionals concerned would be too time consuming on the one hand, and on the other hand would bear no relevance to the other questions put before the Triumvirate, a selection was made. The criterion was the statement whether or not a certain case was a natural death, or the formulation of the conclusion about possible intoxication.

When answering the second question posed to the Triumvirate (the question asking which experts were asked to file a report and asking on what basis they were requested) a selection was made of the experts that the Triumvirate believed were important in relation to the other questions to be answered. This resulted in a shortlist which, as indicated as part of the response to the second question, was discussed with the petitioner and with Mrs. de B.'s attorney who agreed with the choices made.

In light of this, the Triumvirate investigated what information was provided to the following medical experts:

1. Prof. Dr. H.K.A. Visser, retired Professor in Paediatrics

2. Prof. Dr. D.R.A. Uges, Professor of Clinical and Forensic Toxicology and Pharmacology.

3. Prof. Dr. A.G. Vulto, Professor of Hospital Pharmacy and Practical Pharmacotherapy

4. Prof. Dr. F.A. de Wolff, Clinical Chemist and Toxicologist

5. Prof. Dr. G.B.A. Stoelinga, Professor of Paediatrics (retired)

6. Prof. Dr. R. van Furth, Professor of Internal Medicine and Infectious Diseases (retired).

Although pharmacologists and toxicologists are strictly speaking not in the medical profession the Triumvirate felt that they were necessary for it to be able to determine an appropriate response with regards to the question about starting information. This took into account their close ties with the work undertaken by medical profession and also had great relevance in answering some of the questions posed to the Triumvirate.

The Triumvirate also chose only to examine the initial information given to the experts in question to enable them to write their reports. All were also heard in session and were possibly confronted with new information there. This was not included in the answer to this question because, on the one hand, it is not possible to determine the details and relevance of the information provided at that time and on the other hand because the judge may have played a leading role in providing additional information.

As mentioned before, Article 2 of the Charter CECCC states that for constitutional reasons the role of sitting judges is excluded from the Triumvirate�s deliberations. This is one of the reasons that information provided during the trial will be left outside of the deliberations of the Triumvirate.

The Triumvirate is of the opinion that the question regarding the initial information cannot be seen separately from the question posed to each expert. Incomplete information can, in light of the matter put before the expert for that goal be considered complete and correct under certain circumstances.

Where it involves the initial information as provided to the medical professionals, this document first examines that provided to Prof. Dr. H.K.A. Visser. He was consulted by the JKZ in an early stage of the investigation. The statement by the director of the Stichting Samenwerkende Ziekenhuizen Rode Kruis Ziekenhuis / Juliana Kinderziekenhuis and a statement of a paediatrician/trainer employed there shows that within the JKZ all deaths and reanimations were reviewed during the period that Mrs. de B. was employed there. This provided a list of cases that were considered suspect. This list was put to Prof. Visser along with the request to see if he also had his suspicions with one or more of the cases. The paediatrician/trainer mentioned provided him with an extract of the medical dossiers of the selected cases. In a statement to the police on October 12 and 29 2001 he advised the directors of the JKZ to press charges. Although the Triumvirate does not have access to these extracts it has not found any evidence that the information provided was incorrect or incomplete in light of what was asked of him at that time.

Some time after the statement was made, Prof. Visser was questioned by the police. He then made detailed statements on each incident, which also (as far as appropriate, were included in the case dossiers in the formal end of the verbal process <eindprocesverbaal>. In that phase he viewed more than just the extracts made by Mrs. Derksen. In Court in The Hague on February 12 2004 he stated: "On October 29 2001 I saw more than those extracts. At the police station there were also the medical and nursing dossiers. I don't know how complete they were. On the basis of files I recently received, I assume that I did not see the complete dossiers at that time. (). At the time that I formulated my conclusion on October 29 2001 I did so assuming I had all the necessary materials. On October 29 2001 I did not myself request additional materials that I did not have at my disposal."

By recently received files, Prof. Visser meant the complete medical dossiers sent to him in the run up to the Court session. On the basis of these dossiers he revised his conclusion about whether or not the death of one of the patients was natural (in a manner unfavourable to Mrs. de B.). Although the Triumvirate does not have access to the dossiers as supplied to Prof. Visser on October 29 2001, on the basis of his statement during the Court session it has assumed he had access to correct but incomplete information. In the later phase of the Court session he did have complete information at his disposal.

Prof. Dr. D.R.A. Uges was appointed by the public prosecutor to investigate against Mrs. de B. within the framework of the preliminary proceedings. The possible cause of the death of baby A.Z. on September 4 2001 - the case with which the proceedings against Mrs. de B. started - was cited as intoxication with potassium. A method to gain more clarity on this is to ascertain the concentration of potassium in the eye fluid, which was made safe during the autopsy. Prof. Uges received this material from the Netherlands Forensic Institute, and he was asked to determine the potassium concentration. In his report he concluded: "the amount of potassium found in the eye fluid (vitreous fluid) of the victim is such that it cannot be ascertained whether or not potassium was administered so that a useful answer on the question whether or not death was caused or hastened by potassium suppletion cannot be answered."

From a supplementary report by Prof. Uges of June 21 2002 - made on the basis of additional questions from the defence - it can be concluded that he was not privy to information that potassium had been administered to baby A.Z. shortly before her death via IV. The Commissioner for Rights <rechter-commissaris> asked him about additional information about the structure and strength of the IV.

In the phase of trial in the Court in The Hague, Prof. Uges has indicated that he did not have all information from the dossier. He was not aware of the ECG of the patient. He remarked in general at the session: "I now have more information that I had previously at my disposal."

The triumvirate sees itself posed with the question as to whether - within the frame of the questions posed to Professor Uges - he was provided with correct and complete information. Although it has become clear that he had not received complete information, the triumvirate concludes that, weighed against the limited scope of the matter to be investigated (the determination of the level of potassium in the eye fluid), he was informed correctly and in the context of that question was in possession of all information.

Professor Dr. A.G. Vulto was asked to report to the commissioner for rights <rechter-commissaris> by request of the public prosecutor. The questions he had to answer concerned a (possible) intoxication by chloral hydrate of a patient in the JKZ on January 24 or 25 2001 and about the death of that same patient on February 23 2001. To this end he received, according to his report of September 3 2002 the following:

- a partial copy of the patient dossier, containing documentation on the patient's stay in the JKZ in The Hague up to and including his death on February 23 2001;

- the report of an autopsy on the (then exhumed) remains on March 21 2002;

- a toxicological report on an examination on parts of the exhumed body by a pharmacist toxicologist of the NFI of May 8 2002;

Although partial copies of a patient dossier are by definition not complete, the triumvirate concluded in the matter of the (possible) intoxication that Professor Vulto's report contains concentrations in the blood of the patient, on the basis of which he made calculations which led him to conclusions concerning this point. The triumvirate has found no indication that the information given to Professor Vulto was incorrect. In the light of the question asked of him, the triumvirate concludes that the information was (sufficiently) complete.

Where it concerns the death of that same patient, Professor Vulto outlines a scenario in his report of September 3 2002, where as a consequence of the administration of three sedatives in combination of several factors - suffocation on vomit because of a reduced reflex - death can be explained.

Professor Vulto wrote an additional report based on written questions from the defence. This report however contains no additional starting information.

In the appeals phase the court decided to supply Professor Vulto with all files concerned with the death of the patient in question. When questioned by the court on February 16 2004 he states: "when going through the additional dossier I received, I noted that a dose of chloral hydrate was administered at about 19.30 on request of the mother." He reasserts his answer that the combination of factors mentioned in his report of September 3 2002 could have lead to the death of the child in the scenario he outlined.

From the remark by Professor Vulto during the court session of February 16 2004, as quoted above, the triumvirate concludes that at the time he wrote his report - in the phase before the court session - he was not in possession of complete information.

At the request of the defence of Mrs. de B. the Commissioner for Rights <rechter-commissaris> on September 11 2002 - therefore in the phase of the criminal trial - assigned Professor Dr. F.A. de Wolff to report. This concerned the death of baby A.Z. on September 4 2001. The NFI did an investigation into the presence of certain substances, amongst which dioxin, in the body of the girl. Professor de Wolff was asked if the method that was used is reliable and whether or not he believes it was intoxication.

In his report of September 12 2002 Professor Wolff indicated he had available to him the autopsy report from the pathologist of the NFI, the report on the toxicological investigation by the same institute as well as an addition to that, both written by a pharmacist/toxicologist of the NFI, and a letter from the defence of Mrs. de B. of September 10 2002, which contains the question to Professor de Wolff. With regard to the question about digoxin poisoning he stated: "to be able to make a more definitive statement, the entire medical dossier from the last days until death should be studied". And he also states: "The method used by the NFI is reliable".

The triumvirate concludes on this basis that in light of the question posed to Professor de Wolff, there are no indications that the information he was provided with is incorrect. Since the medical dossier, a dossier that Professor de Wolff according to the statement quoted above did find necessary, information in that phase of the investigation was incomplete.

In the appeals phase Professor de Wolff was again asked to report in writing, which resulted in the report of March 16 2004.

Three questions were asked of Professor de Wolff by the court. One of the three questions asked in the appeals phase concerned the report by Professor Uges. In that context the results of the test for potassium in the eye fluid, two documents by Professor Uges, a protocol of a session of the court in The Hague during which Professor Uges was interviewed and a print of an email discussion on a website for toxicologists started by a question asked by Professor Uges on the site were made available to him.

The other two questions concerned aspects in connection of the matter of possible digoxin poisoning. In order to answer these questions Professor de Wolff had made available to him all materials already provided by the Commissioner for Rights <rechter-commissaris> and the complete medical dossier.

The triumvirate notes that baby A.Z. died at about 3am on September 4 2001. That same day around 13.00 an autopsy was performed on the body of baby A.Z. in the JKZ. The autopsy report amongst other things notes moderate dilation of the heart. On September 6 2001 around 10.30am a court autopsy was performed by the NFI.

It is assumed that the report of the autopsy performed in the JKZ was part of the medical dossier. In order to answer the question whether or not there was digoxin poisoning this report could be important, as it states that the heart was dilated. In a case of digoxin poisoning, a contraction of the heart would be expected. The JKZ was asked about the presence of this report in the medical dossier. The triumvirate was informed that usually such a report is part of the dossier; whether or not that was the case for the medical dossier of baby A.Z. could not be ascertained. Since this report was found in the dossier by the triumvirate, we assume it was part of the medical dossier.

When asked, Professor de Wolff told the triumvirate that he did not know the report although he was later apprised of it. The contents did bring him to different conclusions regarding the question as to whether or not there was digoxin poisoning evident.

On the initiative of the court in The Hague, Professor Dr. G.B.A. Stoelinga and Professor Dr. R. van Furth were assigned the task of investigating the incidents mentioned in the charges. The court decided which starting information would be made available to both experts. Judging the question whether or not the judge made the correct decision would be against article two of the charter CECCC as mentioned before, which states that for constitutional reasons the role of the acting judiciary should remain outside the commission's investigation.

In the case of the opinion and actions of both experts, two questions remain:

- Did the police and the public prosecutor correctly execute the court's assignment? The triumvirate has found no indication that this was not the case.

- Was the information provided in itself incorrect or incomplete? No indications were found that this was the case.

The triumvirate concludes that there are no indications that incorrect information was provided to the medical experts consulted. However Visser, Vulto and De Wolff (the experts consulted by the triumvirate) had incomplete information. It is certain that Prof. de Wolff did not receive a certain report and was not aware of its contents. After being made aware of the contents of this report, he came to no other conclusions.

THE FIFTH QUESTION

The fifth question concerns the matter whether or not a certain report by the Pieter Baan Centre about the value and interpretation of a number of possibly relevant diary notes by Mrs. de B. were included in the dossier. The Triumvirate concludes that there are no indications that this is the case. The Petitioner and Mrs. de B.'s attorney were asked if they had any indications that this was the case. Since both have indicated that they have no reason to believe that the dossier was incomplete the Triumvirate can simply answer the question as is. Therefore there is no separate chapter dedicated to this question in this report.

THE SIXTH QUESTION

The sixth question put before the triumvirate was:

Were relevant differences in scientific insight on digoxin tests sufficiently taken into account in the investigation and prosecution of the person involved?

To be able to answer this question the triumvirate investigated the dossiers extensively. Furthermore interviews took place with the petitioner, a pharmacist-toxicologist who was employed by the NFI and with Prof. dr. F.A. de Wolff, a clinical chemist and toxicologist. The triumvirate also asked questions of Prof. G. Koren; Professor of toxicology at the university of Toronto in Canada. This resulted in a number of findings, listed below.

Before commenting on the digoxin matter it is important to set the scene. As mentioned before, the direct cause of the criminal investigation against Mrs. de B is the death of Baby A.Z. on September 4 1001 in the JKZ. The court in the Hague came to the conclusion that Mrs. de B had taken the child�s life based on proof that demonstrated that the act was done by administration of (an overdose of) digoxin. This is medication produced from digitalis (foxglove). It influences the working of the heart and in high doses can be fatal.

In this, the reports compiled by Prof. de Wolff and the NFI expert (mentioned earlier) as well as their formal statements in court play important roles. The court concludes:

�During the appeal investigation it was proven that Baby A.Z was poisoned: digoxin administered non lege artis led to a fatal contraction of the heart muscle and caused her death. This is no longer disputed by the defence.�

Taking into account the triumvirate's task and article 2 of the charter CECCC as mentioned before (This states that due to constitutional reasons the role of acting judiciary is outside the scope of the CECCC's investigation) the triumvirate will not comment on the accuracy of this conclusion. However, whether or not the judge was given enough information to come to a correct conclusion was investigated. In that context the following was concluded:

There are several methods to measure the concentration of digoxin in the body. In the criminal case against Mrs. de B. the immuno assays EMIT 2000 and Imx and the more modern methods HPLC-MS and HPLC-MS/MS were used. An important difference between the immunochemical methods and the modern methods is that the latter category only measures digoxin. The immunochemical methods not only establish digoxin, but also biological conversion products and products of chemical decomposition [ontledingsproduct] of digoxin, as well as naturally occurring substances which are similar to digoxin, but are not (These are DLIS, Deigning Like Immunoreactive Substances). The immunochemical methods will give a higher concentration than the modern methods, because they measure more than just digoxin.

During the case against Mrs. de B. in the court in The Hague, the results of three methods were established: the EMIT 2000, the Imx and the HPLC-MS. A new test was ordered with a modern method. The material was sent to a laboratory in Strasburg. The expert of the NFI explained the reason for this extra test to the triumvirate: The expert explained that during this investigation it came to light that the HPLC-MS method as used to measure digoxin did not give usable results, because of a less accurate performance of the NFI equipment involved. Strasburg was and is better able to perform accurate tests. While there are other reasons the most relevant is that they use the newer HPLC-MS-MS-triple quad equipment (...).

The court in The Hague - with the agreement of all parties participating in the trial - did not wait for the results of the tests in Strasburg. Instead the Court rendered its verdict on June 18 2004. The report from Strasburg dated June 22 2004 was sent to the NFI the same day. However it was not until two years had passed, on June 28 2006, that the NFI expert of the NFI sent the report, (together with a report in his own hand) to the public prosecutor at the ressortsparket [evidence and review board?] in The Hague. The triumvirate asked the NFI expert why he waited so long to send this report on. His response was that, in his judgement the test result was no longer relevant. After all, he reasoned, the investigation had been formally closed and there was no longer a case. He only changed his mind after a television programme reported on the death of baby A.Z. and doubts were voiced in the programme about whether or not there was digoxin poisoning. "It was only then considered important to publicise the results from Strasburg to support our earlier finds. Strasburg confirmed our results."

The triumvirate is of the opinion that this is incorrect. There are no indications that the results from Strasburg were suppressed in bad faith. But especially in a case such as the one against Mrs. de B., one concerning a case where the accused has always insisted on their innocence the utmost transparency is required. The judgement as to whether or not a report is exonerating (or whether it should be offered to be reviewed at all) is not one that an NFI should. The report should have been sent to the parties in trial immediately after arriving according to the triumvirate.

The triumvirate concluded the following concerning the possible digoxin poisoning of Baby A.Z: A total of 4 different testing methods used to determine the presence of digoxin in the body of the baby. The amounts measured were always nanograms per gram or per millilitre, or micrograms per kilo or litre. When digoxin concentrations are mentioned below it is the latter that is always used.

The question arises when there is a therapeutic concentration and [on establishing] at which point toxicity is an issue. Prof. de Wolff in his report for the court in The Hague states: "The therapeutic range of this concentration is in the order of 1 to 2 microgram per litre of blood. In various hospitals small deviations above and below this range are used; below 0.6 microgram per litre the digoxin is unlikely to provide a therapeutic heart supporting effect, whilst above 2.5 micrograms per litre symptoms of toxicity can arise."

During the autopsy two gauzes were secured. These contained blood and were retrieved from the body of baby A.Z. about 48 hours after her death. This blood, as well as tissue from a number of organs, was tested for the presence of digoxin. Several methods were used to establish the following amounts in the blood from the gauzes:

-EMIT 2000: 22

-IMx: 25

-HPLC-MS: 7

-HPLC-MS/MS: 7,4

As indicated above, the first two tests mentioned measure more than just digoxin; the latter two tests are specific for digoxin. At first glance it would be possible to draw a quick conclusion from the numbers above, in all cases there is a concentration that is higher than would be expected in a normal, therapeutic administration of digoxin.

It should be noted that the treatment of baby A.Z. had not included therapeutic administration for quite some time. And furthermore that an elevated concentration need not be deadly.

Still the matter is more complicated than that. This has to do with the phenomenon of post-mortem redistribution. In patients treated with digoxin, this substance is stored in much greater concentrations in tissue than in blood. After death digoxin is released from the tissue into the blood, in the sense that it strives to an equal concentration in blood and tissue. This is called post-mortem redistribution.

Professor Koren of the University of Toronto, Canada, with others published a research article. This measured the concentration of the substance before and after death in 27 children who were treated with digoxin. This showed that there is an increase of digoxin concentration in the blood after death with an average of 5.1. This increase is caused by post-mortem redistribution.

When applied to baby A.Z., a subtraction of 5.1 from the value of 7 or 7.4 would mean that the concentration of digoxin while alive would be 1.9 and 2.4 respectively; concentrations that professor De Wolff states are not deadly. With this calculation, administration of digoxin would not explain the death of the baby. This scientific insight is mentioned by the petitioner. He points to the research of Y. Bentur et al. from 1999, where it is determined that the concentration of DLIS in the blood - in contrast with that of digoxin - does not increase after death. He concludes: theoretically it would be possible that the increase in digoxin measured by Koren consisted predominantly of an increase of DLIS. But this is not shown empirically. The DLIS concentration hardly increases after death. The increase in digoxin measured by Koren et al. is predominantly digoxin increase. For this reason the measured value of 7.4 which pertains solely to digoxin should have 5.1 subtracted.

In a conversation and a written explanation professor De Wolff states that he has a different opinion. He emphasises that the EMIT 2000 and the Imx measure something else than the HPLC-MS and the HPLC-MS/MS. As explained above, the first two methods measure more than just digoxin. Since the research of professor Koren in 1989 also used immunochemical methods, the average of 5.1 as calculated by him can be subtracted from the concentrations measured with those two methods, but not from the concentrations found with the newer methods. Otherwise, in his opinion, it would be like subtracting guilders from euros. He also states that the immunochemical measuring methods are quantitative and the newer methods are qualitative: they can determine with certainty that digoxin is present, but the amount present can be determined best, in his opinion, by the older methods. Finally he is of the opinion that post-mortem redistribution can only take place if the concentrations in the tissues are significantly higher than in the blood. He bases this on research from Strasburg, where a concentration of 0 was found in the liver, 4.7 in the brain and 10.2 in the kidneys; the concentration in the blood was 7.4. According to Professor De Wolff this excludes post-mortem redistribution.

An employee of the NFI, who was asked by the triumvirate to submit his opinion in writing, comes to a similar conclusion: the fact that the concentration of DLIS does not increase post-mortem, does not mean that the concentration measured in post-mortem materials with an immunochemical method are digoxin exclusively. The value of 7 ng/ml, measured with HPLC-MS/MS represents only digoxin. The measurement of 5 ng/ml as measured by Koren et al. (1989) almost certainly represents more than digoxin - and based on the article by Bentur et al. (1999) almost certainly more than digoxin + DLIS. These numbers can therefore not be compared and should not be subtracted from each other.

After conversations with the petitioner, with professor De Wolff and with the expert of the NFI, and after reading their written reactions, the triumvirate concludes that there is a definite difference of opinion between on the one hand the petitioner and on the other hand professor De Wolff and the expert of the NFI. Since the petitioner is not a toxicologist, the question whether or not there were significant differences in scientific opinion could not be answered.

The triumvirate decided to write the aforementioned professor Koren and ask his advice. The triumvirate has noted that he is the (co)author of over a hundred - partly very recent - articles on digoxin, many of which are cited by colleagues in the scientific field. He has been awarded several prizes in his field. Since his work is mentioned both in the reactions by the petitioner and by Professor De Wolff and the expert of the NFI, the triumvirate asked his advice. Professor Koren was supplied with the translated relevant files.

In a mail of October 2 2007 he notifies the triumvirate: "a concentration of 7.4 ng/ml digoxin in full blood from gauzes is not necessarily an indication of a high concentration of digoxin in the blood serum, since the full blood has red blood cells that tend to concentrate digoxin. It is therefore more than possible that the digoxin concentration in blood serum at the time of death was in the normal range."

Professor Koren does not agree with the opinion of Professor De Wolff and the expert of the NFI about post-mortem redistribution: "most of the digoxin in a body is distributed to various tissues and only 0.4% remains in the blood. Therefore even a slight post-mortem redistribution can increase the digoxin concentration in the blood dramatically. In this case there is no measurement of the concentration of digoxin in the muscle tissue, the tissue that would hold the most digoxin. Furthermore the concentration mentioned in the kidneys of 10.2 ng/ml is higher than in the blood. Measurements of zero in the liver must represent an artefact, as a major part of the blood stream goes to the liver and that same blood was supposed to have a concentration of 7.4 ng/ml."

When applying his own research from 1989 to the case of baby A.Z. professor Koren states: "This means that the digoxin concentration in (baby A.Z.) before death was probably around 1 - 3 ng/ml." His opinion is clear: "in conclusion I am of the opinion that any attempt to interpret the post-mortem concentration as evidence of poisoning (whether accidental or deliberate) is incorrect and, in all honesty, quite shocking. The idea that a health care professional could be incarcerated because of such an incorrect interpretation would be entirely unacceptable."

On this basis the triumvirate concludes that there are relevant difference in scientific opinion on the digoxin tests and their interpretation. It is evident that these differences were not included in the investigation and prosecution of Mrs. de B. Since the triumvirate investigates the role of the police and the public prosecution in the case against Mrs. de B., it wishes to state the following: Professor De Wolff was appointed as expert in this case on the recommendation of the defence. In court the defence was of the opinion that baby A.Z. died as a consequence of digoxin poisoning; an opinion that Mrs. de B.'s counsel retracted in a conversation with the triumvirate. The triumvirate concludes that under those circumstances the public prosecution or the police are not to blame for not investigation possible differences of opinion in the world of toxicologists.

The petitioner also argued that on basis of many other arguments baby A.Z. did not die as a result of digoxin poisoning. Since the triumvirate has determined a relevant difference of scientific opinion on a major issue, these arguments will not be discussed.

Finally the triumvirate states that it emphatically does not come to a conclusion about the question of which point of view is the most correct one in scientific terms. It is sufficient to note that there are relevant differences in scientific opinion that were not - and therefore insufficiently - addressed in the investigation and prosecution of Mrs. de B.

SUMMARY

The Triumvirate answered six questions in this report. Firstly it was considered whether or not it was correct that only possibly inexplicable or suspicious deaths were investigated where Mrs. de B. was potentially involved, and whether other deaths of which it was ascertained that she was certainly not involved were discarded as irrelevant. The Triumvirate concludes that in the first phase of the investigation- the death of baby A.Z- Mrs. de B. was considered a suspect - and the only suspect - far too quickly.

In the second phase of the investigation, where a number of deaths and reanimations within the JKZ deemed suspicious were considered, the Triumvirate is convinced that the police and the public prosecutors were focused on reviewing the case with an open and objective approach. The Triumvirate can understand that - taking into account the JKZ director's charges - the focus was initially on the ward where Mrs. de B. worked and on the period during which Mrs. de B. worked in the JKZ. Once this investigation did not yield any direct evidence, for instance statements of witnesses that saw Mrs. de B. perform any life threatening acts, an insufficient eye was given to alternative scenarios.

The Triumvirate therefore concludes that, during the investigation of incidents in the KJZ, the choice to focus the investigation on the ward where Mrs. de B. worked and the period in which she worked there, was unjustifiably maintained. With this choice - criticised by the Triumvirate - as a given, the Triumvirate has found no further evidence that deaths which were ascertained not to involve Mrs. de B. were discarded as irrelevant.

The second question the Triumvirate answered concerned the experts consulted. Who were they and why were they specifically asked to report. The Triumvirate answered this question pertaining to those experts relevant to the answers required for other questions and only to the extent to which this did not mean giving an opinion on a legal decision.

The Triumvirate concludes that the reasons behind why a certain expert was consulted over another, had no structural research into the specific qualities of the person consulted as its basis. Relatively arbitrary arguments such as chance knowledge of (the name of) a person played an important part. A system of certification of experts and the establishment of a register would offer the start of a solution for the future. This thought is not new and important steps have already been taken towards it.

A third aspect the Triumvirate considered is the initial information provided to the statisticians who were consulted, and on which their work was based. Was that correct and complete? The Triumvirate has concluded that of those who reported in the area of statistics, only Prof. Elffers performed calculations with the data provided by the police and/or public prosecutors. Others who reported in this area only reported on the findings of Prof. Elffers.

In the opinion of the Triumvirate the question as to whether or not the involvement of one and the same nurse in a large number of deaths and reanimation was a matter of chance played a role from the very start of the police investigation. This aspect, which was stated as a "gut feeling" by the Public Prosecutor already played an important role in the JKZ director's statement. This continued up to and including the evidence produced by the Public Prosecutor in court.

The Triumvirate has concluded that the three reports by Prof. Elffers lack an initial/ starting protocol or paragraph stating exact and complete definitions. There is no definition of what is considered a reanimation, what exactly a shift is and what is taken to be the time of an incident. This, in the opinion of the Triumvirate, has immediate and direct bearing on the question of complete and correct starting information. The Triumvirate takes complete information in this context to mean: the type of information on the basis of which an expert can undertake a valid and reproducible calculation. The Triumvirate concludes that the lack of definitions of several important concepts means that starting information was incomplete.

Furthermore, although the concept of �incident� was defined it was not used consistently. The term incident referred only to those cases where reanimations were done; therefore it only referred only to successful reanimations and non-successful reanimations. Deaths of patients when no attempt to reanimate was made were outside of this definition and therefore could not be counted as incidents. When reviewing the RKZ, the numbers only referred to deaths; any successful reanimations were not included in the calculations. The Triumvirate has noted that in five of the six deaths in the RKZ the dossier did not provide the information as to whether or not reanimation was attempted. In several patients there was a policy not to attempt reanimation. When looking at the definition of the term �incident�, these cases should therefore not have been included in the calculations. Since they were, the Triumvirate concludes that the term �incident� was not used consistently. The starting information was therefore a incomplete from a statistical viewpoint.

The Triumvirate also determined that the meaning of the term �reanimation� did not appear to be defined and that there is no guarantee as to the completeness of the registration of reanimations. Due to the lack of a definition of this term and the fact that there is no certainty about the number of reanimations, the Triumvirate concludes that the starting information was not unambiguous and from the statistical point of view incomplete and (possibly) incorrect.

In his third report Prof. Elffers performed a recalculation with the omission of one case within the JKZ (because it was not mentioned in Prosecution documents). This introduced a different component into the calculations: since it change to concern reanimations that the public prosecutor deemed were sufficiently incriminating to warrant charging Mrs. de B. The Triumvirate deems the introduction of this component detrimental to the reliability of the statistical calculations.

The Triumvirate has also concluded that the function of the work of Prof. Elffers changed from a guiding instrument for the police to potential evidence and that this occurred without formal or conscious decision. The public prosecution has indicated by way of the Public Prosecutor that, in the quest for the greatest possible transparency the public prosecution decided to include Prof. Elffers' reports in the dossier. Since the Judge is entirely free in selection of evidence this means that there was from the start a risk that it would attain that function. Moreover in their evidential deposition the Advocate-Generals insisted on using the report and statement of Prof. Elffers as evidence at Court. Since the reports in no way exonerate Mrs. de B. the Triumvirate is of the opinion that since it concerned (at least in his first report) only guiding information, nothing would have prohibited leaving the reports out of the dossier. The way the public prosecution used the reports negates their original function.

The fourth question that was asked of the Triumvirate is that of the starting information provided to the medical experts consulted: was that information correct and complete? The Triumvirate answered this question through consultation with the six experts and concludes that there is no indication that they were provided with incorrect information. However, three of the experts consulted did not have access to complete information in the phase of the criminal case against Mrs. de B. although two of them were provided with extra information during the Appeal. It is certain that Prof. De Wolff did not receive one specific report. After having received this report he does not come to a different conclusion.

The sixth and final question is whether relevant differences of scientific insight in Digoxin tests were sufficiently included in the investigation and prosecution of the person concerned. The Triumvirate concludes that a report on concentrations of Digoxin in the blood and tissue of a patient that died September 4 2001 was not sent on to the public prosecution until two years after it arrived at the NFI. This report, made by a laboratory in Strasburg, France, arrived only a few days after the court's decision. The expert of the NFI decided not to send it on immediately, as it was no longer relevant in his opinion. After all, the investigation was formally closed and there was no longer a case.

The Triumvirate is of the opinion that this was not correct. There are no indications that the test results from Strasburg were kept behind by the NIF in bad faith. But the utmost transparency is paramount, especially in a case such as the one against Mrs. de B., which concerns a suspect that has always denied their guilt. The decision as to whether or not the report was exonerating was not up to the NIF expert. The Triumvirate is of the opinion that the report should have been brought to the attention of the process parties immediately on its receipt.

Where it concerns the contents of the case - were relevant differences of scientific insight into the Digoxin tests (and their interpretations) sufficiently considered in the case?

The Triumvirate has concludes as follows: Between the petitioner on the one hand and Prof. De Wolff and the expert of the NIF on the other hand there is a difference of opinion as to whether concentrations of Digoxin found in the body of the patient after death, indicate a toxic administration when taking into consideration post mortem redistribution. Since the petitioner is not a toxicologist the decision was made to consult a foreign expert in the area of Digoxin. This was Prof. Koren, toxicologist and pharmacologist, at the University of Toronto in Canada.

He stated amongst other things: "in conclusion, I'm of the opinion that every attempt to interpret the post mortem level as proof of poisoning (inadvertently or on purpose) is incorrect and, in all honesty, quite shocking. The idea that a professional in health care is imprisoned because of such an incorrect interpretation would be absolutely unacceptable.

Without making a statement on which is the most correct statement scientifically the Triumvirate concludes that relevant differences in scientific insight into the Digoxin problem in the case against Mrs. de B. were taken into account insufficiently. At the same time the Triumvirate notes that the public prosecution is not to blame, since Mrs. de B.'s defence also, on the basis of amongst other things a report from an expert appointed at the proposal of the defence, was of the opinion that there was Digoxin poisoning.

IN CONCLUSION

This report has concluded that in the case against Mrs. de B. in the investigation and prosecution as well as in the presentation of evidence in court, there were deficiencies. The Triumvirate states that it realises that an investigation such as this one can be hectic. That under such circumstances mistakes are sometimes made is understandable and - taking into account the size of the police investigation - perhaps even unavoidable.

However the Triumvirate is of the opinion that the shortfalls found were at least partly of a fundamental nature. The Triumvirate is of the opinion that the investigation was suspect-focused too soon and that there was not enough consideration given to possible alternative scenarios. There was also very little critical treatment of the results of statistical calculations which were also given a different function to that originally intended.

The police investigation started in September of 2001 and continued into the summer of 2002.

This translation of the report is an ongoing process , it will be added to as and when it is completed.

Words and/or phrases in italics are still under review as to their exact translation and will be corrected in time.

Disclaimer: these pages are a partial translation of web pages at http://www.luciadeb.nl
The translation is "a work in progress", and www.luciadeb.nl is a moving target. Suggestions for corrections and improvements are welcome.

Copyright: original Dutch texts: Metta de Noo.
English translation: Marty Hirst, Carole Edrich, Corine Judkins, Michaela Wouters

"Grimbergen" Report

Committee Evaluation Closed Criminal Cases

Report of the triumvirate in the case against Mrs. de B.