By the time she was admitted to hospital, Nahkira Harris had no discernible blood pressure. Despite massive blood and plasma transfusions, despite the desperate attempts of doctors to revive her, she never regained consciousness.
Nahkira was nine years old. She died not from a rare or incurable disease but from simple diabetes - and from the confusion and bad communication that surrounded her.
The tabloids and the courts said it was her parents' fault. Beverley and Dwight Harris were described as extremist vegan Rastafarians, crazed homeopathic nutcases and just plain cruel. Rumours spread that they had taken Nahkira to Africa for tribal medicine and given her homeopathic remedies rather than let her take insulin.
After a trial last month in which they were accused of gross negligence in the handling of their daughter's condition, Beverley and Dwight were convicted of manslaughter. The authorities said they prevented Nahkira receiving insulin, but the couple say they had no objection to the drug and simply wanted someone to discuss it with them before their daughter embarked on a life of daily injections. What really happened may never be fully known. There is no doubt, however, that someone let Nahkira down.
Dwight Harris, 32, describes himself as a moderate Christian although he also adheres to Rastafarian teachings and is a vegetarian - a lifestyle he encourages in his five other children. He also tells them to filter their water and avoid additives, but he is not opposed to modern medicine and he had never resorted to homeopathic remedies before Nahkira fell ill in December 1991.
Dwight is in Lincoln prison serving two and a half years; Beverley, 34, is free, but with an 18-month suspended sentence. Last week she and her children moved into a new home in Nottingham.
On 14 December 1991 Nahkira, a lively child who liked dancing and baking cakes, was feeling unwell. Her father immediately took her to see Dr Naomi Phillips, their GP, who suspected diabetes and made an appointment for her to have blood tests at the Queen's Medical Centre, Nottingham. These confirmed that she was a diabetic, and four days later the Harrises took her to the paediatric department at Queen's to find out what to do next.
At this point communications began to break down. At the hospital they spoke to Dr Shirley-Anne Derrick, who was just beginning her 32nd hour on duty. The Harrises wanted to know about insulin: was it made from animal products? Was there an alternative? Could it be tested in Nahkira's blood outside her body, because she had a number of allergies? All these questions were later linked to a religious zealotry that did not exist. Hospital staff insist that Dwight had vowed not to give Nahkira insulin, but he denies this. Being a Rastafarian does not preclude the taking of insulin or modern medicines.
The exhausted Dr Derrick did what she could, eventually telling the Harrises quite simply that without insulin, Nahkira would die. The family say she made this assertion in front of the child. Nahkira burst into tears; the Harrises asked to see a consultant. It was 4.30pm; they were told to return at 8pm. They signed a 'discharged against medical advice' form and took their daughter home for a meal.
When they returned - without Nahkira - they found that no appointment had been arranged with Dr Derek Johnston, the consultant in charge of the paediatric team. The couple were late (the hospital says they were one hour 45 minutes late), although they had telephoned to say they would be. The paediatric registrar on duty, Dr Stephanie Anne Smith, was not available. The Harrises, bewildered and angry, were told to go home.
'Later we were accused of not getting treatment for Nahkira, but we did try,' Beverley says. 'We have no objections to insulin and there is nothing in our beliefs that would have prevented Nahkira taking it. We just wanted someone to talk to us about it first.
'No one at any point told us that Nahkira needed insulin now. We knew diabetes was something she was developing, but she was nine and had been fine. We thought insulin was something she would need eventually.'
Dwight went back to see the GP, Dr Phillips, on 23 December. He asked for another appointment to be made - but not with Dr Derrick. Dr Phillips said she could not interfere in the choice of doctor; no further appointment was made. Between 18 and 20 December both the hospital and the Nottinghamshire social services department had been trying to find the family, but they complained later that they had not been told about Dwight's visit to Dr Phillips on the 23rd.
Dr Johnston, the paediatric consultant, had learnt of the problem with the Harrises and asked Margaret Hosking, a community diabetic nurse, to contact the family. She went to their home on 20 December but the Harrises were staying with a friend nearby because a business venture had collapsed and their electricity had been cut off. The authorities wrongly assumed the family had gone to ground.
A social worker, Parminder Soar, was dispatched to try to contact the family. Her speciality was racial affairs, but she does not appear to have been told that Nahkira was in imminent danger. She left a note that puzzled the Harrises: 'Hello] I am a black social worker and I work at the Queen's Medical Centre. I was asked to become involved because I too am black: although I am Asian I do understand and face the racism we all do as black people.' She went on to say she understood why the Harrises were angry with the hospital.
Dwight and Beverley, who collected mail from their home each day, ignored that letter but they did respond to a note left by Ms Hosking - Dwight left a message on her answerphone later that day, a Friday, but nothing was done.
The Independent has obtained confidential minutes of a case conference held in February 1992 after Nahkira's death. These show that Ms Hosking felt she had done all she could, particularly since Dwight had left no details of where he could be contacted. (It was obvious, however, that he had received her note at the family home in Radford.)
The minutes say that tracing the Harrises 'was taking up a lot of time and she did not think it was her job to trace the family further . . .' She thought involving the police would be 'too confrontational'. At the trial, she said that Dr Johnston agreed she had done all she could and should stop looking. The social workers closed the case on 6 January, even though Nahkira was supposed to be desperately ill.
At the case conference, Dr Johnston said he had told David Sheard, the group principal social worker, that Nahkira's condition was 'potentially life-threatening' and said it might be necessary to invoke the Children Act, under which an emergency protection order could give the authorities the power to find Nahkira, take her into care and administer whatever treatment was necessary.
The minutes show that Mr Sheard denies the Children Act was ever discussed. In an addendum to the minutes, he adds: 'I also noted that the parents were told if she didn't receive insulin she would die, but that no indication re time scales was given to them.'
It is common ground that the urgency of the need for immediate treatment was not conveyed to the Harrises.
Beverley says: 'We didn't know what we could do next. We had been to the hospital twice, and we were sent away without seeing anybody, we had replied to the special nurse's note and we had been back to our GP, but we still didn't have another appointment.
'We thought it must be a question of waiting for an appointment to come through and in the meantime a friend suggested we try homeopathic remedies.'
Misha Norland, a homeopath based in Devon, suggested the Harrises give Nahkira syzygium, a remedy popular in India but less effective than insulin. It served only to mask Nahkira's symptoms, making her appear well when in reality she was becoming dangerously ill. Dr Phillips had given the Harrises a bundle of urine sticks to check Nahkira's urine/sugar level daily. According to Beverley, the readings were normal.
In court it was alleged that Nahkira had lost nearly one-third of her weight during the six weeks between the diagnosis and her death. But the record of her weight on 18 December was missing, so a nurse submitted a 'recollection' of about 30kg (4st10lb). Nahkira's corpse weighed 23kg (3st9lb), but family friends say her normal weight was around 25kg.
The prosecution argued that Dwight and Beverley must have seen their daughter wasting away; her parents said she lost a little weight, but they put that down to a new, carefully monitored diet.
On 31 January Nahkira developed what looked like flu. Beverley and Dwight took her to see Chris Hammond, a GP who was also a homeopath. He noted that she appeared to be slipping into a coma and, after talking to the parents about her condition, arranged for her to be taken to hospital for insulin. But Nahkira slipped deeper into her coma on the way to the hospital and did not recover.
The coroner asked the police to investigate after Dr Johnston, the head paediatrician at Queen's, wrote to him to say Nahkira's death was entirely avoidable. This was the conclusion the jury reached, laying all the blame on the parents.
It may be argued that they failed Nahkira in some way, but they have to live with that. Were they bad parents? Tony Normington, Nahkira's headmaster at the Elms primary school, told the court they were excellent and loving parents, if anything a little 'over-protective'. Their MP, Alan Simpson, believes they have been made scapegoats for the failures of the hospital and the social services.
'I don't believe the Harrises were bad parents,' he says. 'They may have made some poor judgements, but the mechanisms were there to avoid putting them in the position where they could make those judgements. The hospital, which knew more than the Harrises about how ill Nahkira really was, and the social services had the power to seek an emergency protection order, but they did not do so.
'The Harrises were convicted for supposedly being negligent. But if they failed that child, they were not alone.'