Summary of Autopsy Report for Diana, Princess of Wales

On August 30, 2007, CBS Evening News obtained a copy of Spencers 40-page autopsy report and ran a
television piece titled, "Was there time to save Diana? New revelations on the 10th anniversary of Princess
death raise questions".

Stanley Zydlo, MD, a prominent American emergency physician from Northern Illinois and pioneer in
pre-hospital trauma systems dating to their origin in the late 1960s and early 1970s, said in an interview
with a CBS reporter that
at least 70 minutes were lost in the field during Diana, Princess of Wales
prehospital care.
When a patient has unstable vital signs (blood pressure, pulse, respirations) following
multiple trauma, rapid transport to a surgeon in a hospital is imperative to find and stop the source of
haemorrage, he said. In Diana's case, the bleeding was from a torn pulmonary vein in her chest.

Diana was a 36-year-old unrestrained (no seatbelt) female back-seat Mercedes automobile occupant in a
motor vehicle accident who sustained blunt chest and probably head trauma at
12:25 am on August 31,
1997. The first witnesses on the scene found her sitting on the floor of the back seat with eyes open and
mumbling indistinct phrases.  The first physician on the scene,a physician with the private medical service
SOS Medecins, called the SAMU de Paris switchboard operator, which is the normal routine. Personnel
with Sapeurs-Pompiers, a military firefighting service run by the civil defense component of the French
Ministry of the Interior, apparently arrived within seven minutes of the crash (
12:32 am) and began
administering treatment. Fifteen minutes after the motor vehicle crash (
12:40 am), the first SAMU medical
intensive care unit (MICU) arrived with its on board physician, probably an anesthesiologist but possibly an
anesthesiologist-designated/trained general practitioner.

The French SAMU physician said in a deposition that Diana, Princess of Wales was crying out. When he
could not reassure her, he started an intravenous drip in her arm and at
12:45 am infused intravenous
midazolam (Versed) and fentanyl, an opioid analgesic 80 times more potent than morphine, to "calm her

"There is a particular propensity for apnea [slow breathing] when even very small doses of midazolam are
given in conjunction with fentanyl," write emergency medicine experts Reichman and Simon. "Midazolam
may cause hypotension [low blood pressure] that is related to the dose [how much drug is administered]
and to the rate of administration [how fast the drug is pushed into the catheter inserted into the vein]. This
effect is more likely to occur in hypovolemic [low blood volume inside the circulatory system from, say,
internal hemorrhage or dehydration] patients or elderly patients", Reichman and Simon note with caution.

After administering the drugs and beginning to extract the patient from the car, the SAMU physician noted
that Diana went into cardiac arrest [her heart stopped beating].  He performed endotracheal intubation
[inserted a tube into her windpipe to open and maintain her airway], placed her on a respirator [to ventilate
her lungs with oxygen through the tube in her windpipe], and performed external cardiac massage to
reestablish her cardiac rhythm.  There apparently was no appreciation for the seriousness of her internal
blunt injuries. The SAMU team
spent about 30 more minutes (around 12:50 am [after the cardiac
arrest] to 1:19 am) tending to Diana in the tunnel.

At 1:19 am, the SAMU team contacted the SAMU de Paris medical dispatcher to request permission to
take her to a hospital four miles away. The medical dispatcher called the hospital to assess for ICU bed
availability, which was normal procedure.  The SAMU system prides itself on limiting time in hospital
emergency departments, to the extent they then existed in France, and transporting critically injured trauma
patients directly to anesthesia-run ICUs or directly to the surgeon-run operating rooms if a surgical lesion is
suspected by the SAMU physician-anesthesiologist. Emergency departments at the time were not
equipped to deal with critically injured patients!

1:29 am, the hospital agreed to the SAMU medical dispatchers request. Thus, by the time the SAMU
medical dispatcher had finalized the decision for the SAMU ambulance to proceed to the hospital, Spencer
had been at the scene
bleeding internally into her chest for 64 minutes (12:25 am-1:29 am). The
"golden hour" was used up, but she was still alive, attesting to the potential survivability of her injuries.

Sancton writes, "Then the ambulance drove her at a snails pace to Pitie-Salpetriere hospital, 6.15
kilometers away. At that time of night, it would normally take five or 10 minutes to do that drive along the
riverfront expressway but Diana's driver, applying standard French emergency procedures, drove extremely
slowly so as not to subject the fragile patient to shocks and bumps. As a result, it took them some
minutes to make the drive
, and the ambulance stopped within a few hundred yards of the hospital to treat
a sharp drop in blood pressure".  Thus Diana, Princess of Wales arrived to within about 1000 feet of the
hospital at
2:06 am, 101 minutes after the accident.

The on-duty physician at Pitie-Salpetriere hospital who admitted her said that she arrived alive and with a
cardiac [heart] rhythm.  "Though she had no serious external injuries, X-rays indicated internal
haemorraging that was compressing her right lung and heart. Within 10 minutes of her arrival, the patient
again suffered a cardiac arrest, prompting the doctors to inject large doses of epinephrine directly into the
heart, and to perform an emergency thoracotomy [opening up the chest cavity to find and suture the wound]".

"According to testimony of the chief surgeon on duty that night, the operation revealed that the source of the
haemorraging was a single lesion, which he described as a partial rupture of the left pulmonary vein at the
point of contact with the left atrium. The tear was sutured and the haemorraging was stopped. Despite
nearly two hours of manual internal massage, and the application of electroshocks, it was impossible to
reestablish a heartbeat.
The patient was declared dead at 4 a.m. August 31st 1997.

"At a press conference one hour later, the doctors read a five sentence communiqu that cited an important
wound in the left pulmonary vein as the source of the internal bleeding that killed her. The communiqu made
no specific mention of other lesions. Nor did the French coroners report, which listed the cause of death as
internal hemorrhaging due to a major chest trauma and a phenomenon of deceleration which caused a
rupture of the left pulmonary vein".

During the CBS interview in 2007, Dr. Zydlo could not say whether Diana, Princess of Wales "definitely
would have survived", given her injuries. He did say, however,
the 70-minute pre-hospital delay
"certainly took away all of her chances".
"No official from the French emergency system would
comment on Diana's treatment for this report [the CBS report] but in 2002, five years after her accident, the
French emergency guidelines were changed," said the CBS reporter, although she gave no reference for
the statement. "Today, a patient with the same the unstable blood pressure would be rushed to a hospital",
she said, anxiously!

Several SAMU organization and practitioner causes facilitated Diana, Princess of Wales death:

1.     Administration of midazolam and fentanyl, which may have contributed to or even caused the cardiac
arrest, given her internal injuries and perhaps state of (de)hydration after a boat cruise in the hot
Mediterranean. The cardiac arrest necessitated the tracheal intubation, placement of Spencer on a
respirator, and external cardiac massage.

2.     Failure by the SAMU physician to consider internal haemorrage as a source of the patients (recurrent)
hypotension [low blood pressure].

3.     Failure of the SAMU organization to train SAMU physicians to suspect internal hemorrhage as a
source of a patients hypotension [low blood pressure].

4.     Failure of the SAMU physician to insert a chest tube to check for internal chest bleeding as a source of
her low blood pressure. See reference 1- the SAMU organization states that in-field tube thoracostomy and
even autotransfusion [reinfusing a patients blood back into the patient] are taught.

5.     SAMU organization policy of prolonged stabilization and diagnosis at the scene of the injury, rather
than quick assessment and stabilization and rapid transport.

6.     SAMU system requirement for on site SAMU physician to await permission from SAMU medical
dispatcher who must await permission from receiving hospital ICU physician to transport a critically ill
multiple trauma patient.

7.     SAMU policy of slow ambulance transport to facilitate a pleasant experience for the patient and avoid
exacerbating existing injuries.

8.     The implausible state of French emergency departments in 1997.

9.     Failure of SAMU organization to involve surgeons, emergency medicine physicians, and others health
professionals in multidisciplinary development and application of pre-hospital trauma patient care protocols.

10.  Failure SAMU organization transparency in sentinel events, such as Spencer's death. Failure to divulge
information persists.

11.  Failure of the French government/medical community to communicate with the international public
about the care received by Diana, Princess of Wales in Paris.

12.  Failure of the French government/medical community to communicate to the international public what it
has done to reduce the probability of future pre-hospital sentinel event occurrences.


Diana, Princess of Wales would probably have survived had bystanders rescued and transported her by
private vehicle to the nearest hospital.

Avoid being injured in road traffic accidents in France!