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Home , Harold Shipman

Murder most medical, disposal most discreet

Brian S Hurwitz

“Indeed, all of these assassinations may be studied with been a witness to his last victim’s will.2 One patient profit by the advanced connoisseur. They are all of them described her feelings on hearing that she had been exemplaria model murders, pattern murders.”1 accepted on to Shipman’s list as “like winning the Thomas de Quincey lottery”. A relative of another patient managed to believe in his good qualities even after finding out that Shipman In , UK, an unprecedented Tribunal of had murdered his father: “I remember the time Inquiry chaired by Dame Janet Smith, a High Court Shipman gave to my dad. He would come around at the Judge, has been sitting amid the flamboyant gothic drop of a hat. He was a marvellous GP apart from the surroundings of Manchester Town Hall. After fact that he killed my father.”3 resolutions by both Houses of Parliament, the Tribunal has been charged with “receiving existing evidence and The murder of Kathleen Grundy Department of English Language hearing such further evidence as necessary” to assess Shipman had known his last victim, Kathleen Grundy, and Literature, King’s College the unlawful activities of a general practitioner (GP), for many years when he decided to kill her. Although London, Strand, London Harold Frederick Shipman, of Hyde, Greater 81 years old, she was hale and hearty, and had a busy WC2R 2LS, UK Manchester. The Inquiry has meticulously investigated social life doing voluntary work for several charities, Correspondence to: Prof Brian S Hurwitz 888 deaths in former patients of Shipman. As a GP, including Age Concern, which had offices just across [email protected] Shipman had legitimate and easy access to vulnerable the street from Shipman’s practice. When, on June 23, people in their own homes over a 23-year period, and a 1998, she attended his surgery to have her ears syringed, plentiful supply of opiates with which to kill many of Shipman arranged to call on her at home the morning them. He also had access to—indeed, he played a after to take a blood sample for a research project. routine, official part in—the civil disposal of his victims: The next day Mrs Grundy failed to turn up at a local a cardinal requirement for a perpetrator of repetitive, charity venue at which she usually served lunches, and secret homicide. concerned colleagues decided to pay her a visit. On arrival, they found her home unlocked and Mrs Grundy Dr Death on the sofa, curled up fully clothed, dead. Shipman was Despite his pleas of innocence, in January, 2000, called to examine her and reportedly said “cardiac Shipman was convicted of 15 counts of murder, and of arrest”. He then telephoned the local ’s office forging a will. He was sentenced to 15 terms of life and agreed to write out a certificate of the medical cause imprisonment. The police investigation had involved of death, stating old age as the cause. 12 exhumations and extensive enquiries into a very large In all but one respect, Mrs Grundy’s death bore all the number of deaths. The subsequent public inquiry has hallmarks of a Shipman pattern murder (panel 1). It was taken evidence on 494 cases that aroused suspicion— an unexpected death in an otherwise healthy elderly 493 deaths and an incident involving one surviving person—and found that Shipman killed 215 patients, Panel 1: A pattern murderer starting with Eva Lyons in 1975, and ending with “Shipman's patients frequently died suddenly at home, Kathleen Grundy, whom he killed in 1998. Real without any previous history of terminal or life- suspicions exist that Shipman killed an additional 45 threatening illness. Such deaths should be reported to the people but the evidence available to the tribunal was coroner. Yet Shipman managed to avoid a referral to the inconclusive. In a further 38 deaths there was coroner in all but a very few cases in which he had killed. insufficient evidence for Dame Janet Smith to form any He did this by claiming to be able to diagnose—and, view. Shipman, who never admitted to any of these therefore, to certify—the and by crimes, committed in 2003 while in prison. persuading relatives that there was no need for a post- mortem examination”. A good general practitioner? Dame Janet Smith Yet Shipman was regarded by many of his patients as a good doctor: “I genuinely thought he was a great doctor, “The poisoner fears pathology, ambulances and hospitals” very intelligent. I went to see him with different things, observed Richard Henriques QC, the chief prosecuting and he always had time to talk. You would expect to be counsel at Shipman’s trial.2 Many of Shipman’s actions— kept waiting . . . but you accepted it because you knew he advising victims’ friends and relatives that he had called an would spend time with you . . . There was a year-long ambulance when he had not, avoidance of referral wait to get onto his list: he was the most popular doctor and falsification of records, cause of death and in Hyde”, said Paul Spencer, a patient whose signature certificates—are explicable in the light of such fears. Shipman forged to make it appear that Spencer had www.thelancet.com Medicine, Crime, and Punishment Vol 364 December 2004 http://image.thelancet.com/extras/04sup_18_webversion.pdf 1

For personal use. Only reproduce with permission from Elsevier Ltd woman (79·5% of his victims were female), occurring A medical massacre soon after a home visit and administration of By the time Shipman murdered Mrs Grundy, he was diamorphine (a couple of his victims managed to get into killing at the rate of one person a week. A UK hospital; 47-year-old Renate Overton died 14 months Department of Health review compared Shipman’s after lapsing into a persistent vegetative state caused by clinical notes on patients who had died between 1974 opiate-induced respiratory arrest); friends or relatives of and 1998 with those who had died while registered with the deceased noticed the front door was unlocked similar local practices. It concluded that the number of (frequently remarked on by relatives of his other victims) excess deaths in Shipman’s practice was equal to 236 and that, on arrival, Shipman behaved in an abrupt and (95% CI: 198–277). Shipman had been present at 19% of bizarre manner. Invariably he was cold and aloof and all deaths, versus a GP presence in similar practices of seems never to have expressed any sympathy or only 1%; relatives and carers were less likely to have condolence. On one occasion he was found leaving the been present (40·1% vs 80%) at the deaths of Shipman’s house of a victim carrying her sewing machine and patients than at deaths in similar practices. Shipman’s explained to distressed relatives that the deceased patient deaths peaked between 1300 h and 1800 h: 12% died had promised it to Primrose, his wife. Uniquely, in Mrs around 1400 h (when he usually undertook home visits) Grundy’s case, Shipman had re-written her will (panel 2). versus 2% in similar practices. The proportion of Quite why Shipman chose to draft in so transparent a Shipman’s patients who died less than 30 min after his manner what can only be described as a parody of Mrs arrival was nearly three times that of similar practices.4 Grundy’s will—other than for the obvious reason of his own gain—is unknown. Although his motives are Shipman’s medical career unclear, his choice of victim may not have been: Dame After qualifying as a doctor and undertaking house jobs Janet Smith believes that some were killed because he in hospital, Shipman moved to , West found them troublesome, or because they happened to Yorkshire, in early 1974, to become a GP in a group present themselves to Shipman at a moment in time practice (panel 3). In September, 1975, he was arrested when his compulsion to kill sought expression. After the on prescription-fraud charges. He pleaded guilty to eight deaths of certain victims, jewellery and money were offences of dishonestly obtaining pethidine, and of noticed as missing, and on one occasion a cash card was forging NHS prescriptions. He asked for a further used soon after death. That Shipman was a petty thief 74 offences to be taken into account. By then he was seems quite likely; the police found a considerable thought to have unlawfully procured some 70 000 mg of amount of jewellery at his house that did not fit his wife, pethidine. He was ordered to pay a fine, to compensate but none has been claimed. the UK , and to seek treatment for his drug problem. He attended The Retreat at for treatment and by Panel 2: Kathleen Grundy’s will the time he was referred to the UK medical regulator, On the day of Mrs Grundy’s death, a will, bearing the the General Medical Council (GMC), Shipman’s signatures of two of Shipman’s patients, arrived at a firm of psychiatrists reported that he had fully recovered. In his Hyde solicitors with which she had never previously had any letter to the GMC, the consultant in charge of his care, contact. It made Dr Shipman her sole legatee, omitted any Dr Milne, wrote: “it would be to his advantage if he were mention of her daughter or grandsons, and stated that to be allowed to continue in practice, and conversely it Mrs Grundy wished to be cremated. 6 days later, the solicitors would be catastrophic if he were not to be allowed to received a letter signed by a person called Smith, informing continue in practice.”5 Shipman received a warning them that Mrs Grundy had died. Smith subsequently proved from the GMC, but he escaped erasure or suspension untraceable. from the Medical Register and was allowed to return to Mrs Grundy’s daughter, a solicitor herself, knew that her work, with no Home Office restrictions on prescribing mother wanted to be buried after her death. She had had a controlled drugs. loving relationship with her mother and was surprised and Shipman’s Todmorden partners had demanded he upset by the will. Suspecting the will to be a forgery, she leave their practice when he was arrested, and after a reported her concerns to the police and arranged for her brief spell as a clinical medical officer in Durham, in mother to be buried. When high levels of morphine were 1977, he moved to a group practice in Hyde, Greater found in Mrs Grundy’s body after exhumation a month later, Manchester, where the partners were aware of his Shipman claimed that she was a drug addict, and falsified previous drug problem and criminal conviction. This entries in her medical record to substantiate the claim. Both partnership he left in acrimonious circumstances in the will and the letter from Smith, it later transpired, had 1992, to set up single-handed practice in Hyde. been typed on Shipman’s type-writer and contained the GP’s The method Shipman used in 1974–75 to procure fingerprints, but not those of Mrs Grundy or of the two pethidine was apparently the one he continued using to apparent witnesses to her will. obtain diamorphine: over-prescription of the drug (which he frequently collected from the pharmacist

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For personal use. Only reproduce with permission from Elsevier Ltd himself) for patients who may have needed powerful analgesia, and keeping the excess to commit murder, Panel 3: Shipman’s life and career intravenously. By this means, over a 23-year period, he Born in in January 1946, Harold Frederick caused the deaths of a quarter of all the patients who Shipman was the second child of Vera and Harold Shipman, died on his list. and as a child was known as Fred or Freddie to family and friends. His parents had married in 1937, and after World War How did he get away with it? II the family lived in the 1930s red-brick Edwards Lane estate, Although some believe that medicine “has thrown up not far from Nottingham city centre. “I knew them well”, says more serial killers than all other professions put Hannah Cutler, “because I lived opposite. They never mixed together, with nursing a close second”,6 very few UK with other kids, they didn’t play in the street and when they doctors have been found guilty of murder, and only one, came home from school they stayed in the house.”2 Edward Pritchard (1825–65), both killed and effected After passing his 11+ exams, Shipman went on to High disposal by completing death certificates (on his wife Pavement Grammar School, Nottingham, an elite state and mother-in-law).7 The Shipman pattern murder school. The headmaster was a noted grammar school perfectly matched unanticipated interstices in the matrix educationalist who became director of the Institute of of controls, monitoring, and investigation that Education at the University of Nottingham. High Pavement surrounds civil registration of death and disposal of the boasted a talented staff—the novelist Stanley Middleton, dead in England and Wales. who taught Shipman English in the 1960s, later became a The many failures of these civil procedures revealed by joint winner of the Booker Prize.2 Shipman’s activities are the focus of Dame Janet At about the time Shipman took the General Certificate Smith’s inquiry. They include consideration of: Examinations at O level, his mother, Vera, had become ill —how the coronership in England and Wales is with lung cancer. Towards the end of her life, she was organised, operates, and investigates deaths; frequently visited by her GPs, who administered morphine —the dangers inherent in a system that depends, in injections for the pain. In June, 1963, when Shipman was 17, the final analysis, on cause of death certificates she died, reportedly peacefully. “I remember going to the completed by a single practitioner; house once or twice”, reports Dr Angela Campbell. “They —the ineffective monitoring of the causes of death by were a decent, hard-working, working-class family and her Registrars of Births, Deaths and Marriages, the poor slow death must have been devastating for them all.”2 level of support and training they receive, and how their 27 years later, Vera’s death was to become the focus of responsibilities to report concerns to the coroner are intense speculation on her son’s decision to embark on a discharged (Shipman marked several victims’ deaths as career in general practice, and on the role intravenous opiates due to “old age” or “natural causes”—these should have were later to play in his life and in the deaths of so many of been investigated but were not); his patients. —the failure of additional safeguards governing the Shipman went up to Leeds Medical School in 1965, married issue of cremation certificates, especially the almost Primrose Oxtoby while in his second year of studies there, universal omission, by second doctor assessors, to passed his finals, and took hospital jobs at General enquire into the circumstances of deaths beyond Infirmary. From there he moved to Todmorden, West speaking to the doctor who signed the death certificate. Yorkshire, in early 1974, to become a GP in a group practice. Dame Janet Smith believes that if cremation It was here that Shipman began to experience fits or certification had operated as originally intended, blackouts (now thought to have resulted from drug misuse) Shipman’s murders would have been detected much for which he was prescribed anticonvulsant medication by a earlier; neurologist. He was able to remain in practice with the help —the absence of public health monitoring of death of Primrose, who drove him to his home visits. rates by GP, place of death, or the proportion of certificates signed by GPs;8,9 —the failure of the GMC to place a doctor like Local knowledge Shipman (already convicted of dishonestly obtaining When Mrs Grundy’s daughter went to the police she drugs and fraud) under review and monitoring (he was had no idea that many others, over many years— subsequently referred to the GMC in 1985 for breach of friends and relatives of Shipman’s deceased patients— confidence and failure to investigate or refer a 29-year- had harboured serious concerns about the sudden old man who later died of tuberculosis, and again, some deaths of people who were not terminally ill, and about years later, for a prescription error that harmed a man his cold and aloof behaviour at the time of a death. with mental disabilities and epilepsy). Receptionists at the group practice in Hyde nicknamed Parts of all these processes, as well as deficiencies in Shipman “Dr Death”, and concerns had also restrictions on the prescribing and issuing of controlled accumulated in the minds of providers of other drugs, played a part in a systems failure to prevent a services, about both the number and pattern of deaths medical massacre. in Shipman’s practice: www.thelancet.com Medicine, Crime, and Punishment Vol 364 December 2004 http://image.thelancet.com/extras/04sup_18_webversion.pdf 3

For personal use. Only reproduce with permission from Elsevier Ltd —a local funeral director had noticed that Shipman —reform of the coronership, each enlarged district to was often present at the deaths of patients, and when he have both a medical and judicial coroner. was called to collect the bodies, many were fully clothed Among her many recommendations, one value stands with no sign of serious illness; out: decisions about the causes and circumstances of —a taxi driver who specialised in offering a service to deaths in the community should be taken out of the the elderly, to help them shop and undertake regular hands of practitioners and providers of care, and placed journeys, had noticed that a cluster of 22 of his regular within a framework that demands wide-ranging checks, customers, whom he believed were registered with inquiries, and cross-checks that will embrace Shipman, and to be in reasonably good health, had died information collected from those close to the deceased at over a 6-year period (panel 4);10 the time of their death. —a neighbouring GP who counter-signed many of the The professional response to Shipman in the UK has cremation forms on Shipman’s deceased patients had been muted. It has been argued that practical and grown suspicious and had compared the number of general lessons from the actions of a clever mass deaths in Shipman’s practice with the number murderer have little bearing on the day-to-day conduct occurring in her own.3 of GPs. On this view Shipman should be seen as a one- These concerns are not instances of hindsight: before off example: a Dr Jekyll of Hyde. But circumstantial Shipman’s arrest on murder charges, the funeral evidence suggests that Shipman was not especially director had made his concerns known to Shipman, who clever, that many of his behaviours and explanations shrugged them off; and the taxi driver had contacted a were stereotypical, and could continue only because of police detective inspector, but failed to pursue his serious flaws in an inept medical regulatory system; worries. The GP had reported her concerns to the hence, he was caught as soon as he strayed outside the coroner. medical domain into a legal one, involving scrutiny of a Dame Janet Smith intends reforms to go beyond will. Over-prescription and mis-prescription of opiates measures needed to detect homicide or criminal over decades, and the killing of 80 people when he was a wrongdoing (which are thought to be rare in UK member of a group practice should have generated medical practice), to ensure that deaths due to poor questions arising from nurse and locum access to his practice, errors, and neglect are effectively investigated. records. Clearly, no peer review or assessment of his Her proposals, so far, include: management of patients occurred. —instituting a process of certification of the fact of Structural reforms are needed, and local knowledge of death, ending the anomaly whereby only medical cause what happens at the time of someone’s death, gleaned of death is certificated in the UK; from those close to the deceased at the time of death, —ensuring that medical attendants at time of death will be at the heart of proposed reforms. Also required is will no longer decide whether or not a death is a much greater understanding on the part of the public reportable to the coroner; of the range of acceptable behaviours to be expected —taking the issuing of cause of death certificates out from medical professionals at the time of a death. of the hands of medical attendants; instead, the GP will Shipman ruthlessly overawed and manipulated supply details of the patient’s medical history and offer vulnerable friends and relatives at pivotal moments in an opinion on cause of death that can be justified; their lives. As Sam Slater, who lost both his father and —recommending that a national service to investigate sister at the hands of Shipman, put it: “Grief knocks the community deaths is set up, to investigate non- logic out of you. You are not Sherlock Holmes with a suspicious deaths on the basis of wide-ranging inquiries loved one dead. You are just numb, and that’s what of the GP and friends and relatives of the deceased, the Shipman played on with all his victims.”3 service to be charged with deciding whether a death Shipman must not be allowed to kill off the notion of should be formally reported to the coroner; this service the virtuous and humane GP.11 He has, however, to issue cause of death certificates; certainly brought forward the day when unbridled medical power and paternalism over patients and their bodies will have passed away in the UK.

Panel 4: Observations of a taxi driver epidemiologist References “If you work with old people, you expect deaths, but not the 1 de Quincey T. On murder considered as one of the fine arts. London: Philip Allan and Co, 1925. sort of number I was getting. My list of regulars was being cut 2 Whittle B, Ritchie J. Prescription for murder. London: Warner back all the time . . . it began to feel wrong, and about 3 or Books, 2001. 4 years ago I noticed all those who were dying went to the 3 Barkham P. The Shipman report. The Times, July, 20, 2002. same doctor, Dr Shipman . . . In the end I was coming home 4 Baker R. Harold Shipman’s clinical practice, 1974-1998. London: HMSO, 2001. and saying to Kath, “You’ll never guess what . . . ” and she’d http://www.dh.gov.uk/assetRoot/04/06/50/46/04065046.pdf say “Another Shipman patient?”2 (accessed Nov 5, 2004). 5 . http://www.the-shipman-inquiry.org.uk

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For personal use. Only reproduce with permission from Elsevier Ltd (accessed Nov 5, 2004). 9 Hurwitz B, Beaumont B. Monitoring deaths in general practice: a 6 Kinnell HG. Serial homicide by doctors: Shipman in perspective. simpler solution? Lancet 2003; 362: 1941. BMJ 2000; 321: 1594–97. 10 The Shipman inquiry. http://www.the-shipman- 7 Havard JDJ. The detection of secret homicide. London: London inquiry.org.uk/transcript.asp?from=a&day=176 (accessed Nov 5, MacMillan & Co Ltd, 1960. 2004). 8 Beaumont B, Hurwitz B. Is it possible and is it worthwhile 11 Baker R. Implications of Harold Shipman for general practice. keeping track of deaths in general practice: results of a 15 year Postgrad Med J 2004; 80: 303–06. observational study? Qual Saf Health Care 2003; 12: 337–42.

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For personal use. Only reproduce with permission from Elsevier Ltd