Qualityin Primary Care 2004;12:5- 11 # 2004 Radcli¡ eMedicalPress

Researchpapers ©Last seenbeforedeath ©:theunrecognised clueintheShipmancase GuyHoughtonMA MB FR CGP GPAdvisor,BirminghamPublicH ealthH ub,and SeniorPar tner,Gree nbank Surgery,HallGreen, Birmingham,UK

ABSTRACT Therehave beenvery few mortality surveys at 8% ofpatients wereseen alive on the day ofdeath, in individual practice level.This lackof robust com- comparison with Dr Shipman actuallyin attend- parative informationis oneof the reasons why the anceat almost 20% ofhis patients’deaths. fullextent of HaroldShipman’ s possible murderous Althoughthese areonly the results ofa single activities wentunrecognised until Richard Baker practice study, theyo ¡era benchmarkfor further undertookhis comprehensive study as apart ofthe comparative data collectionto deŽne patterns of o¤cialShipman Inquiry. mortality inthe community.They also suggest only This review looksat 752 deaths over11 years ina minormodiŽ cations to the notiŽcation of cause of singlesuburban Birmingham practice. Inaddition death procedures areneeded to identifyanother to recordingthe age and sex ofthe patient, and the Shipman. placeand cause ofdeath, the extra, previously unrecorded,parameter ofwhen the generalpracti- Keywords:cause ofdeath, last seenbefore death, tionerlast saw the patient alivewas included.Only placeof death

Introduction formfor the notiŽcation of cause ofdeath asks when the certifyingpractitioner last saw the patient before death, there have beenno studies lookingat the The discovery ofthe fullextent of Dr HaroldShip- signiŽcance of this statistic. Therewould have been man’s murderous exploits has highlighted the lackof noindication forthe Registrar ofBirths and Deaths to corroborationof general practitioners’ (GPs’ ) evid- have recognised the di ¡erencebetween the certiŽcates encein death certiŽcation. As aresult ofthe Shipman issued inhospital, wherethe certifyingdoctor might Inquiryled by Dame Janet Smith, there have been beexpected to have seenthe patient onthe day of proposals forchanges indeath certiŽcation in the death, and ingeneral practice whereit is much less United Kingdom and inthe roleof the coroner. 1 likely. Suggestions includethe conceptof amedical coroner, As apart ofthe Shipman Inquiry,Richard Baker the needfor signatures oftwo independentpracti- had to performan exhaustive analysis ofthe patterns tioners, death registers with greater epidemiological ofdeath among Dr Shipman’s patients inorder to scrutinyand automatic referralto the coronerof any demonstrate the likelihoodof unnatural death. Not case wherethe doctor is the onlyperson present at the onlydid hehave to go through clinicalrecords, moment ofdeath. 2–5 surviving cremationcertiŽ cates, and data obtained Althoughroutine information from death certiŽ- fromthe registration ofdeaths concerningDr Ship- cates is enterednationally into O ¤cefor Population man’s patients, but healso had to collectcomparative Censuses and Surveys (OPCS) statistics, there remains data fromother generalpractices inthe localityof verylittle available practice-speciŽ c data. Recent Todmorden. As aresult hewas ableto show three studies ondeaths ingeneralpractice have beencon- features related to the possibility ofunlawful killing: cernedwith placeand cause ofdeath, particularly concentratingon quality issues inpalliative and 1the twofold increasein the percentageof deaths terminalcare and lookingto reduceavoidable factors between1 pm and 7pm (55% ofShipman’ s associated with premature deaths. 5–7 Althoughthe patients against 25% ofthose ofother doctors) 6 G Houghton

2the threefoldincrease in deaths taking placewithin 2sex (male,female) halfan hour of the onset ofsymptoms (60.4% 3placeof death (home,hospital, nursinghome, against 22.7% respectively) hospice, away/other –includingin street, onholi- 3the 20-fold increasein the numberof deaths day etc) actuallyattended bythe GP. Dr Shipman was 4cause ofdeath: principal cause oncertiŽ cate of present at onein Ž ve ofall his patients’deaths notiŽcation of cause ofdeath (summarised inthe (19.5%) as compared with less than oncein 100 followingcategories): (0.8%) forother practices. 8 . vascular, includingischaemic heart disease, stroke, thromboembolicdisorders Bakerand his colleagueshave suggested anumberof . cancer,to includeall malignant processes and furtherparameters fora system ofmonitoring deaths leukaemias ingeneral practice. 9 So, inview ofthis lackof . respiratory, usuallybronchopneumonia or published data ondeaths ingeneral practice, Idecided chronicairways obstruction to review ourown practice mortality statistics to see . murder/suicide if anycould be used simply to identifypotential . other, comprising: Shipman situations. –infection(septicaemias) –trauma (usuallyfractured neckof femur) –renal(acute or chronicrenal failure) –alimentary(gastrointestinal bleeding) Method –neurologicaldisorders (e.g. Parkinson’s dis- ease ormotor neuronedisease) Over the last 11 years, sincewe started to use . old age computerised patient data routinelyfor clinical and . unknown administrative purposes at GreenbankSurgery, Ihave 5last seenbefore death byGP memberof practice kept anadditional paper recordof details ofall patient (onday ofdeath, within 7days, within 2weeks, deaths, whether at homeor in hospital. These details within 4weeks, within 8weeks, within 12 weeks, werenoted at the time ofcompleting the frontof the morethan 12 weeks before). LloydGeorge envelope when the health authority The data wereentered onto a simple Excelspreadsheet requested returnof a patient’s records, following and the results correlatedusing pivot tables. o¤cialnotiŽ cation of death. We area fourpartner training practice insuburban Birmingham. The practice population has beenrela- tivelystable with anannual turnover until recently of Results 8% and alist size which is increasingfrom 6600 to 7200. The practice proŽle has tended to ahigher than average proportion ofelderly, with 9% between65 Inview ofthe marked discrepancy betweenDr and 74 years ofage and 11% over75. Newregistrations Shipman’s presenceat the point ofdeath compared arereducing this at the same time as increasingthe with the other Todmorden GPs, Iconcentratedon the Asianethnic minority to morethan 20%. Interms of analysis ofpatients actuallyseen at homeby a GPon deprivation, wereceive 455 additional Jarman pay- the day ofdeath. The results aresummarised inthe ments, 400 at levelJ1, 50 at J2 moderate and Žve at J3 tables. Tables 1and 2show the overalldemography of high-leveldeprivation. age/sex and place/cause ofdeath ofall the 752 patients Therewas acumulative total of752 deaths overthe inthe practice. Tables 3, 4, 5and 6allrelate to the 11 calendaryears. The year-on-yearŽ gures arewithin correlationsbetween when patients werelast seenalive variation limits expected byPoisson calculation.The and their sex, age at death, and placeand cause of most recentcomparable overall data werepublished death. by Holden et al,who collateddetails of1263 deaths Just 61 or8% ofall patients dying wereseen by a GP fromfour practices inSt Helensbetween 1992 and onthe day ofdeath. Elevenof these patients were 1996.5 Their demographic mortality details werevery actuallycertiŽ ed dead at the hospital, three inthe similar to those at GreenbankSurgery although there hospice and afurtherfour in nursing homes, which is agreater numberof very elderly people in Hall Bakerfound to bea safe havenfrom Dr Shipman’s Green. nefariousactivities. Seventeenpatients died at home Icollatedthe followinginformation, where avail- ofknown cancers: although the presenceof such able,about everypatient’ s death: conŽrmed pathology does notnecessarily exclude a hastened death, friends and relatives arelikely to be 1age ofpatient inage bands (under50, 50–59, 60–69, involvedas carers. We areleft with atotal of26 70–79, 80–89, 90+ years) patients seenalive by a GPat homeon the day of The unrecognised clue in the Shipman case 7

Table 1 Age/sexmortality data at Greenbank Surgery( n)

Sex

Ageband (years) Female Male Total % Cumulative %

Under 50 18 22 40 5 5 50–59 11 29 40 5 10 60–69 42 41 83 11 21 70–79 87 106 187 25 46.5 80–89 141 128 269 36 82 90+ 101 27 128 17 100 Total 399 (53%) 353 (47%) 752 100

Table 2 Cause/placeof death ofpatients at Greenbank Surgery( n)

Placeof death

Cause Not AwayHome Hospital Nursing Hospice Total known home

Unknown 4 4 9 18 2 37 Alimentary 1 3 14 18 Cancer 2 1 40 97 6 52 198 Septicaemia 3 13 1 1 18 Renalfailure 2 15 17 Murder 4 4 Neurological 8 15 8 1 32 Old age 14 2 5 21 Respiratory 15 70 9 94 Suicide 3 2 1 6 Trauma 1 1 9 11 Vascular 1 13 110 162 10 296 Total 7(1%) 23 (3%) 211 (28%) 416 (55%) 41 (5.5%) 54 (7%) 752

death, who werecertiŽ ed as dying frompotentially onthe day ofdeath: Ihave notthe recordeddetails of uncorroboratedcauses overan 11-year period. whether the doctor was actuallypresent at the time of Twentypatients werecertiŽ ed as dying ofvascular death, but the Todmorden study and memorysug- causes, two ofrespiratory causes and fourof old age. gests that the expected numberwould be less than This means that, forour practice, we arelooking at sevenover the 11 years orrather fewerthan oneper three cases ayearin which aGPattended the patient year. 8 G Houghton

Table 3 Lastseen/ sexdata for patients at Greenbank Surgery( n)

Sex

Last seenalive Female Male Total Cumulative %

Onday ofdeath 36 25 61 8 Within oneweek 118 108 226 38 Within 2weeks 52 44 96 51 Within 4weeks 60 72 132 68.5 Within 8weeks 65 46 111 83 Within 12 weeks 26 21 47 89.5 Morethan 12 weeks 38 32 70 99 Not known 4 5 9 1 Total 399 (53%) 353 (47%) 752 100

Table 4 Lastseen/ age data for patients at Greenbank Surgery( n)

Ageband (years)

Last seenalive Under 50–59 60–69 70–79 80–89 90+ Total Cumulative 50 %

Onday ofdeath 2 4 6 13 21 15 61 8 Within 1week 6 6 19 69 81 45 226 38 Within 2weeks 4 8 10 19 38 18 97 51 Within 4weeks 6 4 20 39 46 16 131 68.5 Within 8weeks 9 10 12 27 40 13 111 83 Within 12 weeks 1 1 9 11 18 7 47 89.5 More than 12 11 5 5 12 25 12 70 99 weeks Not known 1 2 2 1 2 1 9 1 Total 40 (5%) 40 (5%) 83 (11%)188 (25%)271 (36%)127 (17%) 752 100

Conclusions medical attendant ofa patient forseveral years, which is morelikely in the contextof a single-handed GP. However,it appears that the initial doubts and Much has beenmade ofthe fact that the current concernsexpressed byneighbouring practitioners system ofdeath certiŽcation failed to identifyDr about the frequencyof cremations, and the under- Shipman’s falsiŽed notiŽcation of cause ofdeath in takers’surprise at the numberof patients dying fully so manypeople for so long.It is certainlytrue that clothed inthe afternoonwere disregarded sinceit was there is alackof corroborative evidence of cause of feltinconceivable that adoctor might besystem- death, particularlywhen one doctor has beenthe sole aticallykilling his patients. Althoughwe nowknow The unrecognised clue in the Shipman case 9

Table 5 Lastseen/ placeof death for patients at Greenbank Surgery( n)

Placeof death

Last seenalive Not AwayHome Hospital Nursing Hospice Total known home

Onday ofdeath 43 11 4 3 61 Within oneweek 1 90 104 21 10 226 Within 2weeks 17 65 4 10 96 Within 4weeks 1 7 25 84 3 12 132 Within 8weeks 1 5 14 72 3 16 111 Within 12 weeks 1 1 8 32 3 2 47 Morethan 12 weeks 2 9 13 42 3 70 Not known 2 1 6 9 Total 7(1%) 23 (3%) 211 (28%) 416 (55%) 41 (5.5%) 54 (7%) 752

Table 6 Lastseen/ cause of death data for patients at Greenbank Surgery( n)

Cause

Last seenalive VascularCancer Respiratory Other Murder/ Old age Total suicide

Onday ofdeath 22 22 10 1 6 61 Within 1week 94 47 31 37 11 226 Within 2weeks 36 30 13 17 1 96 Within 4weeks 52 42 17 18 2 132 Within 8weeks 39 38 10 21 2 1 111 Within 12 weeks 25 10 4 8 47 Morethan 12 weeks 26 5 9 22 8 70 Not known 1 4 4 9 Total 296 (39%) 198 (26%) 94 (12.5%) 131 (17.5%) 10 (1%) 21 (2.5%) 752

this was the case, we must take carenot to beovertaken have beenexpected to appreciate the signiŽcance of bythe extremeconverse that thereforeall doctors the ‘last seenbefore death’ question on the notiŽcation must betreated as if theyare likely to bepotential ofcause ofdeath form. What is neededis some form murderers. ofcorroboration or formalnotiŽ cation that another Bakerhas shown that Dr Shipman was present at doctor has seenthe patient –perhaps within the 20% ofallhis patients’dying at home. Inour practice previous two weeks –and is inaposition to conŽrm fewerthan 6% ofpatients certiŽed as dying intheir the cause ofdeath. This should bereinforced by the homes wereseen alive on the day ofdeath, letalone informalenquiries made bythe registrar at the time of with oneof us inattendance. AsIpointed out inthe registration. Anyremaining doubts must ofcoursebe introduction,until now, a registrar ofdeaths couldnot notiŽed to the coroner. 10 G Houghton

Evenif allour 26 deaths at homehad beenpassed on 2Frankel S,Sterne Jand Davey SmithG. Mortalityvari- to the Coroner’s O ¤ce,this is fewerthan halfof the 59 ationsas a measure ofgeneral practitioner performance: that wehad to notifywhen the patient had notbeen implicationsof the Shipman case. British MedicalJournal seenby a GP within the two-week period beforedeath. 2000;320:489. It is interesting to notethat there werean almost 3Pinder D.Monitoringthe death rates ofgeneral practi- tioners’patients in a single health authority. Journal of equivalentnumber of 25 who died at homeand had PublicHealth Medicine 2002;24:230–1. notbeen seen in the two-week period but had been 4MulkaO and Logan A.Death –usuallya naturalout- seenwithin fourweeks. If certiŽcation within amonth come,not a crime. British Journalof GeneralPractice wereto beallowed with the possibility ofa named 2003;53:73. seconddoctor who couldbe contacted incase ofdoubt 5HoldenJ, O’DonnellS, Brindley Jand Miles L.Analysisof ordisquiet, there may beno further burden on the 1263 deaths infour general practices. British Journalof currentregistrar and coronersystems. GeneralPractice 1998;48:1409–12. Iwouldsuggest that wholesalechanges arenot 6KhuntiK. Referral for autopsies: analysisof 651 con- necessaryin the aftermath ofthe Shipman a ¡air, if secutive deaths inone general practice. Postgraduate wecontinue to collectand publish simple routinedata MedicalJournal 2000;76:415–16. with su¤cientscientiŽ c rigour to identifyand chal- 7HoldenJ and TathamD. Placeof death of714 patientsin anorthwestgeneral practice 1992–2000: anindicator of lengepossible abnormalpatterns ofbehaviour. More quality? Journalof ClinicalExcellence 2001;3:33–5. studies arerequired to conŽrm the wider applicability 8SmithJ. The Shipman Inquiry. TheFirst Report Appendix and generalisabilityof our practice data. Ihave A–TheRelationship betweenthe Findingsof the Reviewof supplied the comparative tables betweenHall Green Shipman’s ClinicalPractice and the Inquiry’s Determina- and St Helensin Appendix 1 so that anyinterested tions byProfessor RichardBaker, OBE. London: Crown practitioner cancompare his orherindividual prac- Copyright, 2002. www.the-shipman-inquiry.org.uk tice statistics with published data. 9Baker R,JonesD and GoldblattP. Monitoringmortality rates ingeneral practice after Shipman. British Medical Journal 2003;326:274–6. ACKNOWLEDGEMENTS

This study was apart ofa programme ofwork CONFLICTSOF INTEREST commissioned bythe Birmingham PublicHealth Hub.GH was entirelyresponsible for design, data None. collection,analysis and writing ofthe paper, but wouldlike to thank Professor Richard Bakerfor his ADDRESS FORCORRESPONDENCE assistance inthe initial discussions. Dr GuyHoughton, 102 Delius House,Symphony Court, Birmingham B16 8AG, UK. Tel:+44 (0)121 REFERENCES 689 5727; email: [email protected] 1 Smith J. TheShipman Inquiry .London: CrownCopy- right, 2002. www.the-shipman-inquiry.org.uk Accepted 8October 2003 The unrecognised clue in the Shipman case 11

Appendix 1

Comparativemortality datain Hall Green and St Helens

Age and sex Total Age band Male Female Total (years)

Hall Green 752 0–54 37 24 61 (8%) 55–74 117 91 208 (28%) 74+ 199 284 483 (64%) Total 353 (47%) 399 (53%) St Helens 1263 0–54 66 37 103 (8%) 55–74 285 220 505 (40%) 74+ 273 382 655 (52%) Total 624 (49.5%) 639 (50.5%)

HallGreen list size 7000, over11 years; St Helenslist size 30 790, over40 months

Placeof death Place Hospital GP care Hospice Other n n (%) n (%) n (%) n (%)

Hall Green 752 415 (55) 252 (33) 54 (7) 30 (4) St Helens 1263 733 (58) 482 (38) 11 (1) 37 (3)

Cause ofdeath Major cause Vascular Malignancy Respiratory Other n n (%) n (%) n (%) n (%)

Hall Green 752 296 (39) 198 (26) 94 (12.5) 164 (22) St Helens 1263 553 (44) 351 (28) 172 (13) 187 (15)