CAROLINE WEATHERILL MEMORIAL LECTURE 2014

A LITANY OF EXHUMATIONS

1 As you will all be aware the wall between heaven and hell which was liable to be maintained jointly fell into disrepair. St Peter asked the Devil to contribute to the cost of the necessary repairs but the Devil refused to pay anything. St Peter said to him if you don`t agree to contribute we will sue. Oh, said the Devil, and where are you going to find a lawyer. It may well be that the Isle of Man Law Society had a similar difficulty in finding a lawyer. So you have me.

2 It is an enormous pleasure to be asked to speak to you today and to do so in memory of Caroline Weatherill who died so tragically in 2006, shortly after giving birth to twin daughters. She was only a young woman and it was a life that was far too short. She had been admitted as an advocate in 1997 and during her articles had married Lawrence. She had quickly established herself as a very effective, well motivated and doughty advocate. She was a delightful funny and clever woman and had well-deservedly earned the respect of colleagues and clients alike. She will continue to be missed and mourned by her family and by a great many people who had good reason to be glad of and be grateful for her life.

3 Last year`s speaker was Lord Neuberger. Unfortunately I could not come but I note that he stayed at Government House and that there was a magnificent dinner for him there. When this evening I return to my room at the Sefton Hotel after dining at a local Italian restaurant I will remember that, although in fairness to the Law Society I should add that where I am staying and eating are my own choices. In fact Lord Neuberger and I have much in common. We both went to the same college at the same university at the same time. He read chemistry and then became a merchant banker but then moved on. I read law and became a barrister. The rest they say is history. I had thought of entitling this lecture `From the sublime to the ridiculous` but I know that Lord Neuberger would object to the word `sublime`.

4 Many of you will know that I am a serial collector of unusual part-time jobs. My adult children often say to me that I would find it easier if I had one proper job but I remain unconvinced. And so it is that, apart from my role here I am also, like most of you, a practising advocate and I am the Chancellor of the Dioceses of Carlisle and . And although it would be tempting to address you on the subject of the rule of law and the role of the modern advocate [which I had initially contemplated doing], I think that will have to await a lecture from someone more erudite than myself and I am going to talk about some of my experiences in my other day jobs.

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5 Now you need to know that most decisions I make as Chancellor involve church buildings but the most interesting part of the jurisdiction relates to the law of exhumation, with which you will no doubt all be intimate. Hence the title of my lecture : `A litany of exhumations`.

6 So it was that I conducted my first Consistory court in a beautiful little church near Kendal over 10 years ago. The facts were these. Some years ago the husband had died and was buried in the churchyard. A few weeks before a lady - not related to him - had died and was buried, by mistake [a mistake on the part of the gravedigger], in the same grave. The parish priest, on behalf of the surviving wife who had hoped to be buried with her husband, sought a faculty to exhume the lady and re-inter her in a nearby grave. Although, for inexplicable reasons such application was opposed, all was going well and the gravedigger had admitted that it was his fault, but then in his closing submissions the advocate for the deceased lady suddenly announced ` ... and there are the two Human Rights Act points`.

7 At this point my heart sank. `What are they?` I timidly asked. I was told that the first point was the right to family life enshrined in Article 8(1) of the Convention. With as much tact as I could muster, I pointed out that the lady was dead and that in such circumstances the right to family life was a concept somewhat difficult to understand. The advocate agreed. I suggested that there must be some well established jurisprudence on this issue. He agreed ... but did not produce any. I suggested that this was not a point which was likely to succeed.

8 Somewhat emboldened I asked what the second point was and was told that it was the right to the peaceful enjoyment of possessions enshrined in Article 1 of Protocol 1 of the Convention. I asked who owned the lady`s body. I got no answer. I observed again that there must be cases on this. He agreed … but again did not produce any. It will come as little surprise that that point too was lost.

9 If there is a moral to this story it is that indiscriminate reliance on Convention rights when you have not done your homework merely serves to irritate the trial judge.

10 I could tell you of many other exhumation cases where initially the real case is never revealed to you. For example the old man who complained that when his wife died and he was ill, his children had arranged for his wife to be buried in a churchyard of their choosing which he believed was inappropriate and would not allow him to be buried with her in due course. It seemed such a sad story. Of course in due course the children were served with the application. The response of his daughter was to point out that the father had not revealed his current address and of course the facts came spilling out. He had abused the daughter over a number of

2 years, it had all come to light when she was older, and then he had been prosecuted, convicted and, notwithstanding his age, he was now serving a lengthy prison sentence. Since all this had come to light the parents had separated and the daughter suggested to me that the last thing that the mother wanted was to be buried with the father. I did not need much persuasion that such was the case.

11 There are sometimes very sad cases. Some years ago there were floods in north Cumbria. One day I received a telephone call saying that the churchyard adjacent to the river was being eroded and coffins were tantilisingly dangling almost into the river. Of course such applications were swiftly granted.

12 And there was the woman whose skeleton was found in a cellar in Bolton. She was wearing jewellery. Although she had died many years before [with her skeleton was a newspaper the date of which gave some clue] all attempts to identify her failed and she had been buried in a common grave. Subsequently there was an attempt made at facial reconstruction which gave rise to an application by the Chief Constable who wished that she be exhumed so that DNA tests could be carried out after a family from Liverpool had come forward believing that this was their mother, who left when suffering from alcoholism. The jewellery was similar to that which the Deceased had owned. In due course DNA established that this was the missing woman and she was returned to her relatives for re-burial.

13 Finally there was the case of the so-called . This was an application to exhume the remains of three men who had all died on the same date. That is very unusual. The cause of death was expressed to be by judicial . They had been hanged because they had been convicted of murdering a policeman during the Fenian riots in Manchester in 1867. To my surprise their remains were interred in a local cemetery.

14 The facts were that on 18 September 1867 these three men were part of a group of 30-40 Fenians who successfully attacked a horse-drawn police van transporting two arrested Fenian leaders. Two others were convicted of murder. One, an American citizen, was reprieved on the eve of his execution because of the intercession of the United States Government. The other`s appeal succeeded because the evidence was considered to be unsatisfactory.

15 The three remaining men were publicly hanged on a temporary structure built on the wall of New Bailey Prison in Salford on 23 November 1867 in front of a crowd of about 10,000. It is recorded that the spectators were `well supplied by the gin palaces of Deansgate and the portable beer and coffee stalls`. According to one of the three catholic priests who attended the men:

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`A crowd of inhuman ghouls from the purlieus of Deansgate and the slums of the City ... made the night and early morning hideous with the raucous ... strains of `Champagne Charlie`, `John Brown` and `Rule Britannia`. No Irish mingled with the throng. ... They had obeyed the instructions of their clergy. Throughout Manchester and Salford, silent congregations with tear stained faces ... assembled for a celebration of early Mass for the eternal welfare of young Irishmen doomed to die a dreadful death that morning.`

16 I might add that the executioner William Calcraft was reportedly nervous of executing Fenians because of threats he received. He was also described as `particularly incompetent` and `notoriously unable to calculate the correct length of the rope required for each individual hanging`. It was said that frequently he had to rush below the scaffold to pull the victim`s legs to hasten death.

17 I am sure that it was not the finest hour of any judicial system. Lest you think that this never happened in our modern world you might want to read the judgment of the Privy Council in the Bahamanian case of Reckley v Minister for Public Safety and Immigration in 1997. It is interesting because the Privy Council debate whether the royal prerogative of mercy is amenable to judicial review and decide that a man sentenced to a mandatory sentence of death has no right to make any representations to the Committee which exercises the royal prerogative of mercy. You will also discover that the hapless Reckley had the particular misfortune to be represented by me, a few months before my appointment here. I might add that Reckley was executed within an hour of the conclusion of the hearing before the Privy Council. Ironically in a subsequent decision in 2001 - Lewis v Attorney General of Jamaica - the Privy Council agreed that Reckley had been wrongly decided. But it was somewhat late for Reckley.

18 But - returning to the Manchester Martyrs - why, I hear you ask, was I considering an application to exhume the remains of men who had been hanged some 140 years ago. Well, as was the then practice, each of the deceased was interred within the prison precincts and some time after the New Bailey Prison was closed in 1868 their remains were re-interred in the newly constructed Strangeways Prison, now HM Prison Manchester. You may remember that many years later in 1990 there was a prison riot which lasted 25 days, caused considerable damage and led to the extensive rebuilding of the prison.

19 It transpires that in February 1991 during the rebuilding of Strangeways Prison the remains of 60 prisoners who had been executed and buried within the prison grounds were exhumed, their remains subsequently cremated and placed in separate unnumbered and unidentifiable caskets and interred in a single grave at Blackley cemetery in Manchester. Eventually I had to refuse the application because I could not be satisfied which of the caskets related to each of the three hanged men.

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But for that I would probably have granted the applications. So it was that these three men were denied the state funeral in Dublin which had been planned on the assumption that I would grant the applications.

20 However during the course of my enquiries I sought to ascertain from the Prison Governor, the Home Office and the Department for Constitutional Affairs what had happened. I met with either no response or a somewhat guarded response. Of course I recognise that these were times when Anglo-Irish relations remained somewhat fraught. Eventually I was shown correspondence between the Home Office and a prominent Republican on the subject and discovered the truth which was the exhumations had taken place without any attempt being made to contact any relatives of any of these persons and in a shroud of secrecy. The last person to be hanged at Strangeways was on 13 August 1964 - less than 27 years before - and it is inconceivable that there were not living relatives who could have been contacted.

21 From these matters you will no doubt understand that I enjoy what I do. I also enjoy sitting in this jurisdiction although I note that I am very seldom, if ever, allowed to do anything on my own. Of course I enjoy the Isle of Man, even though I am not fond of cats or kippers or even motor cycles. I am agnostic to the Island`s fairies but delight in the concept of three legged men which I need to stress are not the same thing.

22 By contrast the Metropolitan Borough of Tameside in Greater Manchester is an odd place. It lacks any real charm or culture. It has a run down theatre but no art gallery or music. Recently the market hall was burnt down. It straddles the former Lancashire and Cheshire boundaries and has not much to commend itself, ... save that I was born and brought up there and my mother still lives there.

23 It is the place where in the early 1960s Ian Brady and Myra Hindley lured a number of young children to their inevitable brutal death and buried their bodies on the bleak nearby Saddleworth Moors. Hence the title `the Moors Murderers`. I can remember when I was a teenager reading in the local paper - the Ashton under Lyne Reporter - stories of children who were missing. Uncharitably some of us thought that they had run away from home. And I went to university to read law just after the dreadful trial in Chester Crown Court when Brady and Hindley were convicted.

24 Not far away - years later - someone lured Lesley Mohlseed as she was on her way to buy a loaf of bread from the local shop for her mother. She too was buried by someone on the Saddleworth Moors. Her convicted killer [Stefan Kishko] served 16 years before being acquitted by the Court of Appeal, after DNA evidence provided conclusively that he could he could not have raped and killed her. So much for Tameside.

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25 Having been called to the English Bar, I returned to practice from chambers in Manchester. My very first brief was - surprise, surprise in Tameside - in the Dukinfield Magistrates` Court near to where I was born. I was terrified and I am not sure who was more frightened : me or my careless driving client. But I knew deep down that I would be ok.

26 The Magistrates` clerk was a man with an enormous moustache who happened to the father of a friend of mine and I knew that he would look after me. And he did. Then I was not to know that some 30 years later I would be party to a process where I would be trawling through the medical records of his deceased wife - my friend`s mother - in an investigation as to whether her death had been a natural one.

27 Over 30 years later - on 13th January 2004 - Harold Frederick Shipman committed suicide in Wakefield Prison by hanging himself. He had shown no remorse. It is said that he had committed suicide at that time so as to ensure that his wife Primrose received a pension for his many years of valued service to the NHS. By that time the precise nature and extent of his service to the NHS was being uncovered. He was my friend`s mother`s doctor - whom she admired so much - and the awful truth is that he murdered her.

28 Having obtained his medical degree about the same time as I graduated, between 1971 and 1974 Shipman worked at Pontefract General Hospital. He became a general practitioner in early 1974 : initially for a short time in Todmorden and for most of his life in Hyde. Throughout his career as a general practitioner he enjoyed a high level of respect within the communities in which he worked. In Hyde he was extremely popular with his patients, particularly his elderly patients and was regarded by many as the best doctor in Hyde. Even as a sole practitioner, he had a huge waiting list of those who wanted to be a patient in his practice. He was implicitly trusted and some patients gave him a front door key so that he could let himself in.

29 In July 1998 one of his patients, Mrs Kathleen Grundy, died. Shortly before her death Mrs Grundy made a will. It read thus :

`I give all my estate, money and house to my doctor. My family are not in need and I want to repay him for all the care he has given to me and the people of Hyde. He is sensible enough to handle any problems this may give him. My doctor is Dr H F Shipman.`

30 That will was sent to a firm of solicitors in Hyde whom Mrs Grundy had never used before and shortly after her death a friend named Smith [who did not

6 exist] informed the solicitors of Mrs Grundy`s death and how they might contact her surviving daughter.

31 All this came as a surprise to Mrs Grundy`s daughter who was a practising solicitor and had conducted any necessary legal work on her mother`s behalf and who in 1986 had drawn up her mother`s will by which Mrs Grundy had made her daughter the sole beneficiary to her substantial estate. Not unnaturally she suspected that her mother`s recently executed will had been forged.

32 That will had been forged by Shipman and he had subsequently killed her. Surely he must have known that her solicitor daughter, who was on excellent terms with her mother, would call for a police investigation. That investigation led to the exhumation of Mrs Grundy and finding of diamorphine in her body. A forensic document examiner expressed the opinion that the signatures of the witnesses to the will were forgeries and that the will itself had probably been typed on the typewriter seized from Shipman`s surgery.

33 Shipman was arrested and charged with Mrs Grundy`s murder. The investigation was rapidly widened to include the deaths of very many other patients. Further bodies were exhumed from local cemeteries. Forensic tests were carried out. Shipman was arrested and in due course charged with 15 murders.

34 When interviewed by the police Shipman retained his composure and was confident to the point of demonstrating arrogant superiority. At times he treated the police with contempt and never expressed any sympathy with the relatives of the deceased. As to Mrs Grundy`s death he explained the finding of diamorphine in her body on the basis that she must have taken heroin and claimed that for some time he had suspected her of being a drug addict. This of course was completely untrue.However he could not account for the presence of diamorphine in other bodies. But when confronted with computer evidence of false entries to justify the death of one of those patients he faltered ... only to be rescued by his solicitor asking for a break in his interview. Thereafter he merely said `no comment`. In some sense he remained in control throughout.

35 At Preston Crown Court Shipman pleaded not guilty to all charges. On 31st January 2000, following a lengthy trial, Shipman was convicted of murdering all 15 of his patients : all of them were women. To explain why diamorphine had been found in their bodies, Shipman`s defence was that they must have been drug addicts. When he was sentenced to 15 terms of life imprisonment the judge, Mr Justice Forbes, said this :

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`None of your victims realised that yours was not a healing touch. None of them knew that in truth you had brought her death, death which was disguised as the caring attention of a good doctor.`

36 The trial judge recommended to the Home Secretary that Shipman should spend the rest of his life in prison. But rumours abounded locally as to how many more of his patients who had died had been his victims. Although the Director of Public Prosecutions announced that no further criminal proceedings would be instituted against Shipman, there was a local outcry because it was suspected that he had killed very many others. There were demands that there should be a public inquiry. The Government originally decided that there should be a private inquiry but after a successful judicial review of that decision, it gave in to such demands and there was a public inquiry.

37 So it was that the Shipman Inquiry, chaired by Dame Janet Smith, was established in January 2001. I was involved in that inquiry about which I will say more later.

38 What was the end result ? After an Inquiry which lasted for 4 years, Dame Janet concluded that between 1972 and 1998 - a period of 23 years - Shipman had killed no fewer than 218 - and probably 263 - of his patients. His oldest victim was aged 93 and the majority of his victims were elderly but, on occasions, he killed younger people. The youngest was only 41 although, very unusually, he was in the advanced stages of a terminal illness and Shipman hastened his death.

39 Most of his victims were women : 171 were women and 44 were men. Generally women live longer than men so that there are more elderly women than elderly men living alone. Since Shipman`s typical victim was an elderly person living alone, he found most of his potential victims among his female patients. But when the opportunity presented itself he killed men too.

40 Most of his patients were not ill immediately before their death. Many were not expecting Shipman to call at their homes when he did. Many women were dressed in their outdoor clothes and shoes, resplendent in their recently applied make up when they were found dead. They had not intended to die : they had intended to go out shopping. But Shipman had called and somehow persuaded them to have an injection. No one survived to repeat his explanation for so doing. But whatever he said, he gave them a lethal dose of an opiate, usually diamorphine.

41 Now my older daughter [a pharmacist] informs me that a relatively small dose of diamorphine is ideal if you have had a heart attack but a large dose will inevitably kill you. But how did Shipman amass the amount of drugs for his substantial lethal doses ? After all you can only lawfully obtain drugs on

8 prescription. Surely somebody would check what a doctor obtained on prescription? Apparently not.

42 But why did no one notice that so many of Shipman`s healthy patients were dying so suddenly ? There must be standard mortality rates and if a substantially higher proportion of a doctor`s patients were dying, surely this would be picked up on a computer. Apparently not.

43 But why did no one notice that Shipman was present at the time of death so often when it is well recognised by doctors that general practitioners are not normally present at the exact time of death ? Apparently it usually happens only once or twice in a general practitioner`s career. Very ill people frequently die in hospitals or hospices. If they die at home they are usually surrounded by the paraphernalia of illness. That did not happen with Shipman`s patients.

44 And, given that Shipman`s patients frequently died suddenly at home without any previous history of terminal or life-threatening illness - the very sort of cases which are required to be reported to the coroner - why were most of these deaths not referred to the coroner, who could have ordered that there be a post mortem examination and toxicology tests . The answer was that Shipman claimed to be able to diagnose and certify the cause of death and persuaded relatives who trusted him that there was no need for a post mortem examination.

45 These were some of the questions the Inquiry sought to answer.

46 That Shipman was able to repeatedly kill for so long and so frequently is all the more remarkable when you consider the increasing numbers of his murders. 3 in April/May 1972, 1 between 1974 and 1976, 71 in the next 15 years between 1977 and 1992 and 143 in his last 6 years of practice. 1 Patient in 1992, 16 in 1993, 11 in 1994, 30 in each of 1995 and 1996 and 37 in 1997. Finally in the first 3 months of 1998 he murdered 15 patients. It was at that time that there was a covert police investigation into the deaths of Shipman`s patients. It concluded [mistakenly] that there was no legitimate suspicion against Shipman.

47 Shipman went on to kill three further patients [the last being Mrs Grundy whose will he forged] before he was finally caught.

48 At the end of Shipman`s trial it was revealed that almost 25 years before, when he was a very young doctor in Todmorden, he had pleaded guilty at the Halifax Magistrates Court to 3 offences of obtaining pethidine by deception, 3 offences of unlawful possession of pethidine and 2 offences of forgery of prescriptions. He asked for 74 similar offences to be taken into consideration. He was fined and ordered to pay compensation. The fact of his conviction was reported to

9 the General Medical Council who - you may think surprisingly – decided to take no disciplinary action against him. The Home Office decided to impose no prohibition on his further dealings with controlled drugs. The case was not untypical at that time. Therefore from 1977 he was free to continue to practise as a doctor without any limitation or restriction. After his trial there were many who asked how that could have been allowed to happen.

49 When in her First Report Dame Janet revealed her assessment of the shocking enormity of Shipman`s culpability, many asked a further question : how it could be that Shipman`s repeated murder of his patients had escaped the notice of the authorities responsible by general practitioners such as him, when, particularly with the benefit of hindsight, there were warning signs that all was not well.

50 Dame Janet`s Second Report examined the conduct of a police investigation into Shipman which took place in March 1998 which failed to uncover his criminality and allowed him to murder his last three victims. That was the part of the Inquiry in which I appeared representing the local Registrars of Birth Deaths and Marriages and the local Crematorium. I have never before spent hours searching through death certificates and crematorium records.

51 But how did that investigation begin and why did it fail ? It all began with a local general practitioner, Dr Linda Reynolds, who practised from premises opposite to those of Shipman. The background to it all was that most of those whom Shipman murdered were cremated and that before a cremation can be authorised a second doctor must confirm the cause of death and the cremation documentation must be checked by a third doctor employed at the crematorium. Frequently Shipman asked a doctor in Dr Reynold`s practice to be the second doctor who confirmed the cause of death.

52 I digress for a moment of black humour. My son [a doctor] says that amongst doctors the fee paid to the second doctor who briefly looks at the deceased and confirms the cause of death before a cremation can take place is called `ash cash`. In their early stages of medical training, his medical friends relied on receipt of `ash cash` rather than using cash machines.

53 On 24th March 1998 Dr Reynolds spoke to the coroner. She raised two concerns.

54 Firstly, she believed that an unusually excessive number of Shipman`s patients were dying. She knew that in the previous 3 months Shipman [a sole practitioner] had had at least 16 of his patients who had died and been cremated [no doubt other patients had died hospital or had been buried and not cremated]

10 whereas her own practice [with three times the patients of Shipman] had only had about 14 deaths of patients in the same period.

55 Secondly, she related the concerns of a local undertaker. Firstly, most of the deaths were of females : whereas it was more common for deaths to be equally distributed between men and women. Secondly, most of those who had died did not appear to have been ill and died apparently alone : whereas most deaths at home occur after a period of illness, with the patient confined to bed and relatives and friends in attendance. Finally, Shipman was often either present at the time of the death or found the patient dead : that is very uncommon.

56 Not surprisingly the coroner contacted the police and a Detective Inspector was appointed to carry out discreet enquiries. After carrying out an investigation for 24 days that officer concluded that there no substance in Dr Reynolds concerns. It is apparent that Shipman became aware of the investigation and its conclusion and he went on to kill 3 more patients. I offer some brief highlights as to what went wrong with that investigation.

57 Firstly, the officer`s general approach seems to have been that he did not believe that a trusted doctor could be killing his patients and that he was not prepared to entertain such a conclusion in the absence of convincing proof. Such an approach may accord with the burden and standard of proof in a criminal trial but you may not think that it is a good starting point for a police investigation.

58 Secondly, although Dr Reynolds told him of her belief that Shipman was killing his patients, either deliberately or through lack of care, he did not take her concerns seriously. When she said that two of Shipman`s patients were at the local undertakers and would be available for post mortem examination, he led her to believe that he would ask the coroner to authorise post mortem examinations but in fact he did nothing. If he had done so it is likely that diamorphine would have been detected. The officer did not ask Dr Reynolds to explain Shipman`s apparently excessive death rates or ask about the unusual circumstances of the deaths. Until Shipman was convicted there are many who thought that Dr Reynolds was over- reacting. By the time that Shipman was convicted Dr Reynolds, who had retired through ill-health, was in the last stages of a terminal illness and she died shortly thereafter.

59 Thirdly, the officer went to the Tameside Registry Office to obtain all the entries in the registers of deaths relating to deaths certified by Shipman. In the previous 6 months Shipman had certified 31 deaths. Although the officer only went away with 20 certificates [there was an issue before the Inquiry as to how that happened] he made no attempt to understand the significance of the number of deaths or the comparative death rates reported by Dr Reynolds.

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60 Fourthly, the officer visited the offices of the West Pennine Health Authority. He wanted someone to check the medical records. A doctor did examine those records but failed to recognise features within them which tended to support the concerns which had been identified to him.

61 By then the officer had decided that there was nothing further to investigate. Although he visited the Dukinfield Crematorium, he asked no questions about the system of cremation certification and did not ask to see any of documentation or registers. He went to see the undertakers [who had contacted Dr Reynolds] but did not ask them to elaborate their concerns nor did he ask to see any records.

62 The investigation was closed. Amazingly, the officer made no check on the police national computer to ascertain whether or not Shipman had any previous convictions. He probably just assumed he would have none. Of course he was wrong. Had he discovered them it would surely have raised the index of suspicion of any reasonable police officer. So it was that, notwithstanding a general practitioner raising concerns, a police investigation found no cause for concern about Shipman, leaving Shipman to kill three more patients.

63 But I need to stress that although the wrong conclusion was reached because of human error on the part of a number of honest and well-meaning individuals who became caught up in Shipman`s web of criminality, there were also systematic failures which included the following.

64 Firstly, the system of death certification had no real teeth, in that the second doctor [the ash cash doctor] who confirmed the cause of death usually saw himself as a rubber stamp.

65 Secondly, the doctor who certified the cause of death [in this case Shipman] could simply fabricate the background circumstances to the death in documents which were never seen by relatives who had they seen them would have immediately corrected them and aroused suspicion.

66 Thirdly, the system of death registration seemed to be more about ensuring that the coroner was troubled as little as possible and that post mortem examinations were authorised in as few cases as possible.

67 Fourthly, there was a climate in which no one seriously contemplated that a doctor might kill his patients.

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68 Finally, nobody undertook any statistical analysis, however rudimentary, as to whether the number of patient deaths of any given doctor was significantly higher than the norm to trigger an investigation, however modest, as to why that should be.

69 What remains a complete mystery is why he killed. In her report Dame Janet Smith said this :

`Shipman's forgery of Mrs Grundy's will was hopelessly incompetent and the arrangements he made for its delivery were bound to excite suspicion. The psychiatrists find it hard to believe that Shipman really thought he could get away with forging the will and killing the testator. I agree. If he did, he had lost touch with reality. It is possible that he had begun to think he was untouchable. He had got away with so many killings and was still idolised by many of his patients. ...

The psychiatrists suggest that Shipman might have had mixed subconscious motivations in forging the will before killing Mrs Grundy. He might have felt an overwhelming need to stop killing. He might have been, as it were, 'throwing himself to the gods'. Either his plan would succeed and he would leave Hyde and run away with the money, or he would be caught. Either way, the killing would be stopped. ...

It seems to me that, in forging Mrs Grundy's will and killing her, Shipman must have been raising a flag to draw attention to what he had been doing. I think it likely that the conflict between whatever drove him to kill and his fear of detection … must have driven him to the edge of breakdown. … No longer in touch with reality, I think he might then have devised a fantasy plan, by which he could obtain Mrs Grundy's money, run away and stop being a doctor. The killings would cease. This plan, rationally considered, was bound to fail, but it would offer him a fantasy future and a way to stop himself from killing. Whether he needed to end the killings only because he feared detection or whether there were other psychological needs, I do not know. But I think that the intolerable tension between his drive to kill and his need to stop lay at the root of this fantasy. That is the best explanation I can offer for the final event. `

70 Both Mrs Kathleren Grundy and died prematurely : as did my friend`s mother who was killed by Shipman.

71 In conclusion I have but one question for you. If Shipman had not forged Mrs Grundy`s will and aroused the suspicions of her solicitor daughter, do you think that he would he still be practising and treating his patients in Hyde ?

72 I add only this. Mrs Grundy died on 24th June 1998. 12 days later Shipman obtained a 100 mgs of diamorphine - a very substantial quantity - from a patient who 13 had cancer. He did not use it to kill before his arrest but the very fact that he obtained it may make you ponder as to whether he intended to do so when the opportunity next arose.

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