Qualityin Primary Care 2004;12:5- 11 # 2004 Radcli¡ eMedicalPress Researchpapers ©Last seenbeforedeath ©:theunrecognised clueintheShipmancase GuyHoughton MAMB 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 dene patterns of o¤cialShipman Inquiry. mortality inthe community.They also suggest only This review looksat 752 deaths over11 years ina minormodi cations to the notication 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 notication 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- signicance 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 certicates encein death certication. 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 certication 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 perform anexhaustive 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 cremationcerti cates, and data obtained Althoughroutine information from death certi- 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-speci 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 oncerti cate of present at onein ve ofall his patients’deaths notication 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 further parameters 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 home orin 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¤cialnoti 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 increasing from6600 to 7200. The practice prole 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, we receive455 additional Jarman pay- the day ofdeath. The results aresummarised inthe ments, 400 at levelJ1, 50 at J2 moderate and ve 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-year 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 actuallycerti 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: conrmed 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 werecerti 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 werecerti 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