Christopher Rogers, the coroner/pathologist was an intriguing witness. So laid back as to be almost laid out, he was rather languid, pedantic, and unflappable. But he was clear and convincing, and sure that Jackson did not self-administer propofol.
Most devastating to the defence was Dr Elon Steinberg, highly expert cardiologist, and very authoritative on normal professional standards of care. He seemed to irritate the judge, though, being a bit condescending and smug, with a little grin, and lecturing to the jury. He outlined so many ways in which Murray's conduct was grossly outside any normal professional standards of practice, and severe negligence. The judge has been distinctly less impressive in this phase, tolerating messy cross-examination by Flanagan which wouldn't be accepted in many other courts.
Examples of Murray's gross negligence
1. Propofol is not used to treat insomnia, for sleep or psychiatric indications. Flanagan didn't like this, and wanted to claim support from a single study in Taiwan that used a smaller dose and shorter transfusion (2 hours for 5 nights, not all night for 2 months) of propofol in a small group of insomniacs. As it was only published a year after Murray's activity, it can hardly support what he did, and is still highly experimental. Flanagan seemed to want to imply Murray was a bold experimenter, but this would have needed a properly designed study, a number of patients, and the approval of a University Ethics Committee.
2. Any treatment, let alone one that is at best experimental and off-label, must have written informed consent to prove that the patient had understood a detailed explanation of the risks, benefits and alternatives. Flanagan wanted to imply that this had been achieved in friendly, but unrecorded and informal chats with Jackson. Of course that is inadequate. There's a broad principal in such medical matters, that if it wasn't written down, it didn't happen. Flanagan apparently wants us to accept (without Murray even taking the risk of testifying) that everything Murray may say happened, did happen. Not good enough.
3. Murray failed to keep any, let alone adequate medical records, which are required by normal standards of care, and for many good reasons. He can't rely on his own memory or expect his self-serving claims to be assumed to be true.
4. Propofol should never be used at home, and many aspects of how it was given in Jackson's home were severely negligent breaches of normal practice. None of the routinely required equipment was present, and each absence was a separate act of negligence. There should have been a pulse oximeter with an alarm, IV drip equipment with automated controls, an automated blood pressure cuff (measuring BP at least every 5 minutes, without requiring the doctor to stop other activities to make the measurement) ; and ECG monitor, proper Oxygen equipment (the oxygen cylinder in the room was empty, but nobody has explained when or how it was emptied- Murray didn't refer to using it); suction equipment (as there is a significant risk of the patient regurgitating stomach contents); an endotracheal tube, a defibrillator; and a range of essential drugs.
5. Anyone intending to give propofol anywhere should never do this alone (responses to the drug are unpredictable, and there's an unusually small range between slightly sedated and coma) - there should have been assistance, from another doctor, perhaps a nurse, and not just anyone, but someone with a minimum of formal training in resuscitation. You never leave a patient alone when you have given propofol.
6. Above all, Murray ridiculously failed to call 911 to get urgent help, delaying this for some 20 minutes or more, by which time his patient was beyond help. Flanagan tried to argue about how long this would have taken --- yet Murray had time to call others (and not even to ask them to call 911) and later to run downstairs to speak to the cook and again fail to ask them to call 911.
One is left wondering what the defence case will now be. Anyone claiming to be a genuine expert would find it really hard to contradict any of the evidence of the prosecution experts.
Interestingly, it appears that the judge has decided to have the prosecution finish their case on Thursday and then have Friday as a holiday, with the defence starting their case on Monday. If so, this is advantageous to the prosecutors, as it leaves the jury free over the weekend to remember their case, before being distracted by the defence.
(Professor M.A. Simpson, Health24, October 2011)
6 facts on propofol