SHIPMAN INQUIRY Chairman: Dame Janet Smith DBE
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THE SHIPMAN INQUIRY Chairman: Dame Janet Smith DBE Second Report The Police Investigation of March1998 THE SHIPMAN INQUIRY Chairman: Dame Janet Smith DBE Second Report The Police Investigation of March1998 Presented to Parliament by the Secretary of State for the Home Department and the Secretary of State for Health by Command of Her Majesty July 2003 Cm 5853 © Crown Copyright 2003 The text in this document may be reproduced free of charge in any format or media without requiring specific permission. This is subject to the material not being used in a derogatory manner or in a misleading context. The source of the material must be acknowledged as Crown copyright and the title of the document must be included when being reproduced as part of another publication or service. Any enquiries relating to the copyright in this document should be addressed to The Licensing Division, HMSO, St. Clements House, 2-16 Colegate, Norwich NR3 1BQ. Fax: 01603-723000 or e-mail: [email protected] THE SHIPMAN INQUIRY Chairman: Dame Janet Smith DBE The Shipman Inquiry, Gateway House, Piccadilly South, Manchester M60 7LP Tel: 0161 237 2435/6 Fax: 0161 237 2094 E-mail: [email protected] www.the-shipman-inquiry.org.uk Independent public inquiry into the issues arising from the case of Harold Shipman CONTENTS SUMMARY CHAPTER ONE Concerns Are Raised Introduction 13 The Dangers of Hindsight 14 Death Registration and Cremation Certification 14 Shipman’s Arrangements for the Signing of Cremation Forms C 16 Concerns at the Brooke Practice 16 Dr Reynolds Takes Action 19 CHAPTER TWO The Coroner Becomes Involved Dr Reynolds Informs the Coroner 23 The Coroner Informs the Police 25 The Meeting Between the Coroner and the Police 25 The Arrangements for the Investigation 27 CHAPTER THREE The Investigation Under Way The Evidence of Detective Inspector Smith 29 Detective Inspector Smith’s First Meeting with Dr Reynolds 30 The Possibility of Arranging an Autopsy 38 CHAPTER FOUR The Register Office The Request for Copy Death Certificates 39 The Issue 40 The Rival Contentions: DI Smith 40 The Rival Contentions: the Register Office Staff 42 The Search of the Registers 43 Conclusion 48 CHAPTER FIVE The Next Steps in the Investigation The First Progress Report 49 Detective Inspector Smith Collects the Certificates 49 The Significance of the Number of Deaths 50 The Death of Mrs Martha Marley 51 CHAPTER SIX The Approach to the Health Authority Detective Inspector Smith Seeks the Medical Records 53 The Relevant Health Authority Personnel 53 Detective Inspector Smith Meets Mrs Parkinson and Dr Bradshaw 54 The Records Are Put Before Dr Banks 57 CHAPTER SEVEN The Examination of the Medical Records Dr Banks’ Functions and his Knowledge of Shipman 59 Dr Banks’ Understanding of his Task 60 Dr Banks’ Conclusions 62 v The Shipman Inquiry CHAPTER EIGHT Further Enquiries What Detective Inspector Smith Probably Did from 27th to 31st March 65 What Detective Inspector Smith Did Not Do During the Same Period 67 Reporting and Supervision 67 The Lost Chance for an Autopsy 67 CHAPTER NINE Dr Banks Advises Detective Inspector Smith Detective Inspector Smith Meets Dr Banks 69 Detective Inspector Smith’s Account 69 Dr Banks’ Account 70 Mrs Parkinson’s Account 71 Were Other Topics Discussed? 71 The ‘Bad Joke’ 72 Findings 73 The Adequacy of Dr Banks’ Review of the Medical Records 75 The Outcome of the Meeting 75 Later Developments 76 CHAPTER TEN Detective Inspector Smith’s Visit to the Crematorium The Purpose of the Visit 77 The Visit 77 A Lost Opportunity 78 The Results of the Visit 80 Postscript 81 CHAPTER ELEVEN Detective Inspector Smith’s Knowledge of the Death of Miss Ada Warburton The Question to be Determined 83 The Evidence 83 Conclusion 85 CHAPTER TWELVE Mr Alan Massey Visits Shipman Background 87 The Massey Family 87 The Origin of the Concerns about Shipman 88 Mr Massey’s State of Mind in March 1998 88 Mr Massey Decides to Visit Shipman 89 Conclusion 91 CHAPTER THIRTEEN The End of the Investigation Two Weeks Pass 93 Detective Inspector Smith Meets the Massey Family 93 Detective Inspector Smith Proposes to Close the Investigation 95 Detective Inspector Smith’s Second Visit to Dr Reynolds 96 Detective Inspector Smith Speaks to the Coroner 97 vi CHAPTER FOURTEEN Internal Enquiries by the Greater Manchester Police Chief Superintendent Sykes Speaks to Mr Postles 101 August 1998 102 November 1998 103 December 1998 105 The Police Decide to Record What Had Happened in March/April 1998 105 The Ellis Report 108 The Evidence Initially Submitted to the Shipman Inquiry 115 The Stelfox Report 115 Findings 117 CHAPTER FIFTEEN An Analysis of Dr Banks’ Role Finding a Benchmark 119 Concerns about Shipman’s Failure to Report Deaths to the Coroner 121 Concern about the Common Features 124 Signs of Substandard Care 125 Findings 126 Dr Banks’ Suspension and the Disciplinary Proceedings Against Him 130 CHAPTER SIXTEEN Conclusions Who Was to Blame? 133 What Would the Outcome Have Been? 135 The Greater Manchester Police Internal Investigation 137 Recommendations to the Greater Manchester Police 138 Final Thoughts 139 APPENDIX A Notes made by Detective Inspector Smith in his daybook during the course of the March 1998 investigation APPENDIX B Computer spreadsheet created by Detective Inspector Smith in March/April 1998, setting out information obtained from the copy death certificates and from the Dukinfield crematorium APPENDIX C Notes made by Mrs Janet Parkinson, formerly Consumer Liaison Manager of the West Pennine Health Authority, in March and April 1998 APPENDIX D Chart compiled by Dr Alan Banks, Assistant Director of Primary Care and Medical Adviser to the West Pennine Health Authority, from information contained in 14 sets of general practitioner records examined by him on 26th –27th March 1998 APPENDIX E Participants in Stage One of Phase Two of the Inquiry and their Representatives vii SUMMARY Introduction 1. On 31st January 2000, Harold Fredrick Shipman was convicted of the murder of 15 patients and of forging the will of one of them. His trial was the culmination of an investigation which began in July 1998 into the death of Mrs Kathleen Grundy. 2. Shipman had, however, been the subject of an earlier police investigation. On 24th March 1998, Dr Linda Reynolds, a principal of the Brooke Practice, which practised from premises opposite Shipman’s surgery, reported to Mr John Pollard, HM Coroner for the Greater Manchester South District (‘the Coroner’), her concerns, and those of her partners, about the number of Shipman’s patients who were dying and the circumstances of their deaths. At the request of the Coroner, a confidential investigation was carried out by the Greater Manchester Police (GMP or ‘the Force’). That investigation was conducted by Detective Inspector (DI) David Smith under the supervision of Chief Superintendent (CS) David Sykes. 3. DI Smith concluded that there was no substance in Dr Reynolds’ concerns and his investigation ended on 17th April 1998. After that time, Shipman killed three more patients before his arrest. They were Mrs Winifred Mellor, Mrs Joan Melia and Mrs Grundy. After Shipman’s trial, there were concerns about the thoroughness with which the first police investigation had been carried out and whether, if it had been conducted differently, Shipman’s course of killing could have been stopped earlier and the lives of three of his victims saved. 4. In the course of hearings which took place between May and July 2002, the Inquiry conducted a detailed examination of the evidence relating to the March 1998 police investigation. This Second Report records my findings as to what occurred during this investigation and provides my opinion as to whether or not, in performing their duties, the conduct of the various public servants involved fell below the standard which the public is entitled to expect. Dr Reynolds Makes her Report 5. When Dr Reynolds made her report to the Coroner, she mentioned two particular grounds for concern. First, she told him that she knew that Shipman, who was a single-handed practitioner, had signed 16 cremation Forms B in the previous three months, whereas the Brooke Practice, with a patient base of 9500, had had only 14 patient deaths during the same period. Shipman had a patient list which was approximately one-third the size of the Brooke Practice list. Moreover, the figure of 16 cremations within his practice would not include: - deaths which had occurred in hospital - deaths followed by burial - deaths certified by the coroner - deaths where Shipman had asked a doctor other than one from the Brooke Practice to complete Form C. 1 The Shipman Inquiry 6. The effect of these factors was that, if Shipman’s practice followed the usual pattern, those cremations which members of the Brooke Practice were aware of were likely to represent no more than about 21% at most of Shipman’s total deaths during the relevant period. Given the fact that Shipman had a patient list which was approximately a third the size of that of the Brooke Practice, it is apparent that the disparity between the number of deaths of patients in Shipman’s practice and in the Brooke Practice was potentially very large indeed. It was this disparity which concerned Dr Reynolds and the other members of the Brooke Practice. 7. The second cause of concern was the presence of features which appeared to characterise the deaths, namely that the deceased persons were elderly women who had been found dead at home, apparently alone, fully dressed. They did not appear to have been ill. Shipman often found them dead. These features were unusual. It is more common for deaths to be more or less equally distributed between men and women.