THE SHIPMAN INQUIRY Chairman: Dame Janet Smith DBE First Report Volume One Death Disguised THE SHIPMAN INQUIRY Chairman: Dame Janet Smith DBE First Report Volume One Death Disguised ‘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.’ The Honourable Mr Justice Forbes when sentencing Shipman on 31st January 2000 July 2002 © Crown Copyright 2002 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 HMSO, The Copyright Unit, St. Clements House, 2-16 Colegate, Norwich NR3 1BQ. Fax: 01603 723000 or e-mail: [email protected] Foreword The Inquiry’s Terms of Reference required me to consider the extent of Harold Fredrick Shipman’s unlawful activities but left it to me to decide how this should be done. Within a very short time, I came to realise that the only way in which to satisfy the reasonable expectations of the families and friends of Shipman’s former patients was to provide, so far as I could, a decision in each individual case in which suspicion might arise. The work of investigation and decision writing proved to be far greater than I had anticipated and has taken longer than I had hoped. I believe that this First Report provides as complete and accurate an account of Shipman’s criminality as it will ever be possible to give. Shipman breached the trust of his patients and of the communities in which he lived. He has caused unimaginable grief and distress. No one who reads this Report can fail to be deeply shocked. I would like to express my profound sympathy to those who have been bereaved by Shipman’s actions and also to those whose trust has been so callously betrayed. I wish to thank the many witnesses who have enabled the Inquiry to carry out its task. I know that, for some, the experience of providing evidence, whether orally or in writing, has been a painful one. Although the investigation of Shipman’s crimes has at times been harrowing, there is one particular respect in which it has been positively heart-warming. I want to express my admiration and respect for the way in which the people of Hyde and Todmorden care so affectionately for their relatives and neighbours. I have heard and read of countless families where a son or daughter, son-in-law or daughter-in-law, niece, nephew or grandchild cared devotedly for an elderly relation, sometimes visiting several times a day, while looking after his or her own family and children and often coping with a job. I have heard many accounts of kindness by neighbours. The completion of this First Report is an important landmark in the life of the Inquiry. It provides me with the opportunity to thank the Inquiry staff, who have worked unremittingly hard during the last 18 months. I am grateful to the administrative team, led by Andrew Griffiths and strongly supported by Oonagh McIntosh and Helen Owen. I express my admiration for, and gratitude to, Henry Palin, who, together with Ita Langan, recruited and managed a team of solicitors and paralegals. I thank the IT experts, in particular Michael Taylor, who have enabled us to cope with an enormous quantity of information without drowning in a sea of paper. I am grateful to Dr Aneez Esmail, the Inquiry’s Medical Advisor, whose help with medical issues has been invaluable. Finally, I must mention the enormous assistance I have received from Caroline Swift QC, Christopher Melton QC, Anthony Mazzag and Michael Jones, without whose indefatigable industry and considerable talents my task would have been impossible. Janet Smith July 2002 1 The Shipman Inquiry 2 CONTENTS SUMMARY CHAPTER ONE Before the Inquiry Shipman’s Professional Career: Training 7 The Move to Todmorden 7 Shipman’s Abuse of Pethidine 7 Discovery 9 Criminal Proceedings 9 A New Job 10 Possible Disciplinary Proceedings 10 The Move to Donneybrook 11 The Market Street Surgery 12 The Police Investigation of March 1998 13 The Death of Mrs Kathleen Grundy 13 Investigating Mrs Grundy’s Death 14 Widening the Investigation 15 Suspension from Practice 15 The Criminal Trial 16 The End of Shipman’s Professional Career 16 The Inquests 16 Further Police Investigations 17 The Laming Inquiry 17 CHAPTER TWO The Inquiry The Setting Up of the Inquiry 21 Terms of Reference 21 Independence 21 Starting Work 21 Deciding How to Proceed 22 The First Report 23 The Application of the Coroners Act 1988 23 Identifying the Deaths to be Investigated 24 The Deaths Investigated 26 CHAPTER THREE The Evidence and the Oral Hearings The Collection of the Evidence 29 The Arrangements for the Distribution of Evidence 31 The Opening Meeting 32 Representation 32 The Application to Broadcast 32 The Oral Hearings 33 The Oral Evidence 35 The Expert Evidence 35 Shipman’s Position 36 The Position of Mrs Shipman 36 Submissions 37 i The Shipman Inquiry CHAPTER FOUR Shipman’s Practice Todmorden 39 Donneybrook 40 Market Street 43 Residential and Nursing Homes 47 CHAPTER FIVE The Existing Procedures for Death Registration and Cremation Certification Death Registration 49 Cremation Certification 55 The Future 61 CHAPTER SIX The Medical Evidence Cardiac Causes of Death 63 Cerebrovascular Accident 67 Respiratory Conditions Causing Death 71 Cancer 74 The Presence of a General Practitioner at or shortly before a Patient’s Death 74 The Deceased’s Position in Death 76 The Collapsed Patient 79 The Diagnosis of Death 81 The Effect of Heat 82 Estimating the Time of Death 83 The Patient who Refuses to Heed Medical Advice 84 CHAPTER SEVEN Drugs Morphine and Diamorphine 87 Pethidine 96 Chlorpromazine 96 Other Types of Treatment by Injection 97 CHAPTER EIGHT Shipman’s Acquisition of Controlled Drugs Todmorden 99 Pre-Todmorden 102 Hyde 103 The Market Street Years 105 Shipman’s Time at Donneybrook 107 The Future 107 ii CHAPTER NINE The Decision-Making Process The Evidence in Individual Cases 109 Similar Fact Evidence 109 The Fifteen Convictions 110 The Significance of the Features Emerging from the Conviction Cases 111 Standard of Proof 119 Findings of Unlawful Killing 120 Decisions that the Death was Natural 120 Cases where no Decision has been Possible 120 Shipman’s Terminally Ill Victims 121 Re-registration of Deaths 122 Allegations of Theft 122 Professor Richard Baker’s Review 123 CHAPTER TEN Shipman’s Unlawful Activities: The Early Years Pontefract General Infirmary 125 Locum Work 125 General Practice in Todmorden 126 County Durham 131 CHAPTER ELEVEN Shipman’s Unlawful Activities: The Donneybrook Years The Period from 1977 to 1983 134 The Period from 1984 to 1989 139 The Years 1990 and 1991 157 CHAPTER TWELVE Shipman’s Unlawful Activities: The Market Street Years The Year 1992 159 The Year 1993 160 The Year 1994 164 The Year 1995 166 The Year 1996 168 The Year 1997 172 The Year 1998 174 CHAPTER THIRTEEN Shipman’s Character and Motivation Introduction 177 Motive 179 Other Explanations 181 Professional Reputation 181 Personal Relationships 183 Aggression, Conceit and Contempt 184 Dishonesty 186 Addiction 187 What Does This Constellation of Traits Reveal? 187 The Selection of Patients 189 The Interludes When Shipman Did Not Kill 191 Shipman’s Downfall 193 After Mrs Grundy’s death 195 iii The Shipman Inquiry CHAPTER FOURTEEN Conclusions The Numbers 197 The Typical Shipman Killing 197 The Report of Professor Richard Baker: Compatibility of Results 198 Deaths in Nursing and Residential Homes 199 Systems Failures and Tasks for Phase Two 200 The Betrayal of Trust 201 APPENDIX A ‘ The Relationship between the Findings of the Review of Shipman’s Clinical Practice and the Inquiry’s Determinations’ by Professor Richard Baker, OBE APPENDIX B Participants in Phase One of the Inquiry and their Representatives APPENDIX C Specimen Medical Certificate of Cause of Death (MCCD) APPENDIX D Specimen Cremation Forms A, B, C and F APPENDIX E Summaries of Conviction Cases APPENDIX F Chronological List of Decided Cases APPENDIX G Alphabetical Index of Inquiry Decisions iv SUMMARY 1. Shipman entered general practice in early 1974, when he joined the Abraham Ormerod Medical Practice in Todmorden. He remained there until September 1975, when his partners discovered that he had been dishonestly obtaining controlled drugs for his own use. 2. In February 1976, Shipman pleaded guilty at the Halifax Magistrates’ Court to three offences of obtaining pethidine by deception, three offences of unlawful possession of pethidine and two further offences of forging a prescription. He asked for 74 similar offences to be taken into consideration. He was ordered to pay a fine and compensation. 3. The fact of his convictions was reported to the General Medical Council, which decided to take no disciplinary action against him. The Home Office imposed no prohibition on his future dealings with controlled drugs. He was, therefore, free to continue practising as a doctor without limitation or supervision. 4. In October 1977, Shipman joined the seven doctor Donneybrook practice in Hyde. He remained there until January 1992, when he began to practice single-handed from within the same building. 5. In August 1992, he moved to new surgery premises at 21 Market Street, Hyde, where he continued to work as a single-handed practitioner until his arrest in September 1998.