Shipman Report -Chapter 8- Shipman's Acquisition of Controlled Drugs

The First Report > Death Disguised > Chapter 8 - Shipman's Acquisition of Controlled Drugs Shipman's Acquisition of Controlled Drugs 8.1 The evidence relating to Shipman's acquisition of controlled drugs is relevant to the Inquiry in two ways. First, it is necessary to consider whether and, if so, by what means, Shipman was able to obtain the drugs required to kill all those persons for whose deaths I have found he was responsible. 8.2 Second, the Inquiry will in due course examine the procedures for prescribing, dispensing, collecting, delivering, storing and disposing of controlled drugs and the monitoring of those procedures and consider whether the safeguards currently in place afford adequate protection for the public or whether they require strengthening. The quantity of drugs which Shipman managed to obtain, and the degree of ease with which he was able to acquire them, will obviously be highly relevant factors in any assessment of the adequacy of the present systems of monitoring and control. Todmorden Pethidine 8.3 The events leading up to Shipman's convictions for drugs offences in 1976 have been described in Chapter One. The evidence gathered by the police and Home Office inspectors relating to Shipman's acquisition of drugs came from the controlled drugs registers kept by the Todmorden pharmacies, in particular the pharmacy of Boots the Chemists. Each pharmacy would have kept several drugs registers, one for each type of controlled drug. The Inquiry has not succeeded in tracing the registers for this period and, indeed, it seems likely that they were destroyed many years ago. 8.4 From the contemporaneous documents kept by the Home Office, it is clear that, whilst in Todmorden, Shipman obtained pethidine (and, on occasions, Pethilorfan) injections by two different methods. First, he repeatedly signed written orders or requisitions for the drugs, representing that they were for the use of the Abraham Ormerod Surgery whereas, although some of the drugs thus obtained may have been used for practice purposes, the vast majority were taken by him for his own use. Up to July 1975, Shipman accounted for the drugs obtained in this way by recording their purchase in the controlled drugs register kept in the surgery, but he maintained no proper record of the supply of the drugs to patients. This was no doubt because, in reality, he was not supplying the drugs to patients, but using them himself. When asked about that omission during a meeting with Home Office inspectors and the police in July 1975, Shipman claimed that he was unaware of the requirement to make a record of supply. After that meeting, and a subsequent one when the statutory requirements were fully explained to Shipman and his partners, Shipman kept no records at all of his purchase or supply of pethidine. During the period of his practice in Todmorden, Shipman obtained over 30,000mg pethidine by written orders 'for practice use'. 8.5 Second, Shipman presented prescriptions for the drugs at local pharmacies, purporting to be collecting the drugs on behalf of the patients in whose names the prescriptions were made out; in the event, the patients received very little, if any, of the drugs prescribed. For this purpose, Shipman selected patients who were suffering, or had suffered from conditions which might require treatment by pethidine. One such patient received only one of the seventy or so 100mg ampoules which Shipman had 'prescribed' for him. Before presenting a prescription, Shipman would forge the signature of the patient on the back, claiming exemption from prescription charges, and giving the clear impression that he was authorised by the patient to collect the drug on his or her behalf. 8.6 The first pethidine obtained by Shipman on requisition (a total of twenty 100mg ampoules) was collected by him from the Boots pharmacy on 8th April 1974, a very short time after his arrival in Todmorden. Thereafter, he continued to obtain drugs in increasing quantities until the time of the discovery of his wrongdoing in September 1975. In both August and September 1974, he obtained ten 100mg ampoules of pethidine on requisitions for the practice. This rose to twenty 100mg ampoules in October and thirty in November. In that month, he presented his first prescription for pethidine in the name of a patient; he later admitted that that patient had received no more than five doses out of the total of about five hundred ampoules obtained in his name over a period of ten months. 8.7 Fifty of those ampoules were obtained in December 1974, and the amounts of pethidine acquired by Shipman continued to increase. In May 1975, Shipman obtained 15,000mg of the drug in the name of one patient. Even after Shipman's meeting with Home Office drugs inspectors and the police in July 1975, he continued to obtain large amounts of pethidine. Four days after that meeting, he collected a further ten 100mg ampoules on requisition for the practice and, during August, he acquired seventy 100mg ampoules, most in the name of another patient who, he later admitted, received none of them. On Saturday, 27th September (two days after Dr Dacre had discovered what Shipman was doing, but before Shipman was aware of that fact), he obtained ten 100mg ampoules of pethidine and, on Monday, 29th September, the very day when he was challenged by his partners about his abuse of pethidine, he had obtained a further ten ampoules of pethidine and ten ampoules of Pethilorfan on requisition, all ostensibly for practice use. 8.8 At the meeting with his partners on 29th September 1975, Shipman admitted that he had been abusing pethidine. He subsequently told a Home Office drugs inspector, Mr Donald McIntosh, and the police that he had been taking the drug for about 18 months (i.e. from about May 1974), having begun the habit shortly after joining the practice in Todmorden, when he found that he did not get on with his partners and became depressed. In fact, as I have said, he first obtained a supply of pethidine in early April 1974. 8.9 Shipman's claims that he obtained the pethidine for his own use are supported by the fact that, in November 1975, when he was interviewed at The Retreat, Mr (then Detective Sergeant) George McKeating observed that the veins on Shipman's arms (and, he claims in a later statement, on his legs also) had collapsed. With hindsight, it is apparent that the 'blackouts' from which Shipman suffered in 1975 were in fact convulsions precipitated by his pethidine abuse. Shipman's partners also reported that, when confronted with their discovery, Shipman's first response was to ask them to help him to continue to obtain pethidine to feed his habit, a request which they, of course, refused. 8.10 At the time of his interview with the Home Office drugs inspector and the police in November 1975, Shipman claimed to have been taking 600 to 700mg pethidine a day before he was detected; if this were true, his consumption could well have accounted for the amounts of the drug which he is known to have obtained. In a statement made to the police in 1998, Mr McKeating observed that, at the time when he met Shipman in November 1975, he suspected that he had been injecting larger quantities of pethidine than he was admitting. Interestingly, he also said this: 'All his veins had collapsed, something I would have expected to see on an addict of at least five years standing, making me suspect that his habit was longer than he admitted' . 8.11 The Inquiry has considered the possibility that, by November 1975, Shipman may have been seeking deliberately to overstate the amounts of pethidine which he claimed to have taken, in order to conceal the fact that he was also using the drug to kill. A note in the Home Office files, made on 14 th November 1975 following a discussion with Dr Hugo Milne (the psychiatrist to whom Shipman was first referred), suggests that Shipman had first told Dr Milne that he was taking about 300mg pethidine a day, rather than the larger amount (600 to 700mg) he later claimed. Unfortunately, Dr Milne's contemporaneous notes have not survived and there is no other reference in the documents to the amounts of pethidine which Shipman was using in 1974 and 1975. Even if the Home Office note accurately reflects what Shipman said to Dr Milne, it is quite possible that, at that early stage after his detection, Shipman was seeking to underestimate the extent of his drug problem. It is impossible to be sure. Nor is it possible to be sure precisely how much pethidine Shipman acquired during his time in Todmorden. The Home Office documents mention other prescriptions which were dispensed, but of which no records survive, so that the total amount of pethidine obtained is likely to have been greater (although probably not by a great deal) than it has been possible for the Inquiry to calculate. Although it is not possible to calculate accurately the amount of pethidine acquired by Shipman during his time in Todmorden, nor the extent of his personal use, I do not think that he was using the drug to kill his patients. Other Controlled Drugs 8.12 There is no direct evidence in the contemporaneous documentation from the Todmorden years about any enquiry into Shipman's acquisition of any other type of controlled drugs, for example morphine or diamorphine; there were, however, records of his obtaining twenty ampoules of 30mg morphine sulphate injections on signed order for the practice in February and March 1975. This suggests that the controlled registers which would have recorded his acquisition of morphine were searched. 8.13 It seems virtually inconceivable that the Home Office and police would have examined in detail Shipman's history of obtaining pethidine without also considering his use, or possible abuse, of other controlled drugs. This view is confirmed by the statement of Mr McKeating, who has told the Inquiry that his investigations covered all controlled substances, including diamorphine, pethidine and morphine. He correctly recalls that those investigations revealed that Shipman had received some supplies of morphine. Mr McKeating also remembers Shipman observing at The Retreat (although this does not appear in the transcript of the interview) that he had tried morphine on a few occasions but did not like it and had stopped taking it. Mr Eric Lloyd-Jones, former pharmacist and manager of the pharmacy at Boots the Chemists, Todmorden, recalled in his Inquiry statement that the Home Office drugs inspector had investigated Shipman's obtaining of diamorphine as well as of pethidine. There is no mention in any of the contemporaneous documents of any concern about Shipman's acquisition of diamorphine. 8.14 There is, therefore, no evidence that Shipman unlawfully obtained diamorphine whilst in Todmorden, and his obtaining of morphine appears likely to have been limited to the two occasions referred to above. Nevertheless, the quantity of morphine which he did obtain would have been sufficient to kill several people. Pre-Todmorden 8.15 The fact that Shipman began to obtain pethidine so soon (within six weeks) after his arrival in Todmorden must raise the possibility that he had acquired the habit of taking the drug whilst he was at Pontefract General Infirmary, possibly in the Obstetrics and Gynaecology Department, where the drug was widely used. Pethidine was also frequently used in other departments for the relief of post-operative pain. On the occasion of his first interview with the Home Office inspectors and the police, in July 1975, Shipman told his interviewers that he had taken pethidine once at a party when he was a student, but had never had taken it since. That was, of course, a lie. He made no mention of taking the drug in Pontefract. 8.16 The Inquiry has obtained a statement from a retired consultant who formerly worked in the Obstetrics and Gynaecology Department at Pontefract General Infirmary, Mr Peter Howe. He has described the procedure in force in the department, whereby a record of each dose of pethidine supplied for use was entered by the pharmaceutical staff into the controlled drugs record kept on the ward; the drug then had to be signed out for use by two registered midwives. Mr Howe was not aware of any problem of doctors or nurses abusing pethidine, or any other drugs, at the time when Shipman was in his department. The Inquiry has obtained a limited amount of information from nurses employed at the hospital in the early 1970s; they also say that Shipman would not have been able to obtain access to controlled drugs at the hospital. Dr Doreen Belk, one of Shipman's contemporaries at Leeds University and at the hospital in Pontefract, recalls that, when administering an injection, there was invariably a nurse present who checked the contents of the phial with him. 8.17 Other doctors who worked at the hospital at the same time as Shipman are not so sure that it would have been impossible to obtain drugs illicitly, although they were not themselves aware of any specific problem of drug abuse, by Shipman or any other doctor, at that time. Dr John Turner, a consultant physician under whom Shipman worked immediately after he qualified, has told the Inquiry that he believes that, in general, it is relatively easy for a member of the resident medical staff in any hospital to acquire drugs, if he or she is minded to do so. This could be done by prescribing the drug for a patient, then appropriating it, and/or by colluding with the nursing staff. Dr Philip Gordon, who worked with Shipman for a short time on the paediatric team, recalls an occasion when his own general practice took on a doctor who, unknown to them, was a drug addict. That doctor told Dr Gordon how, when working in hospital (not at Pontefract), he would prescribe a pethidine injection for a patient; he would then administer half of the injection to the patient and keep half the contents of the syringe for himself. This method is reminiscent of those employed by Shipman to obtain controlled drugs whilst he was practising in Todmorden and, later, in Hyde. 8.18 Whilst it is possible, therefore, that the systems designed to prevent drug abuse at the hospital were thought to be foolproof, it seems likely that this was not in fact the case. It is quite possible that, unknown to Mr Howe and to those other doctors and nurses who have been contacted by the Inquiry, Shipman was able to obtain pethidine illicitly whilst at Pontefract, just as he was able to do for almost 18 months in Todmorden before he was finally detected. 8.19 Mr McKeating's comments about the state of Shipman's veins would support the suggestion that his pethidine abuse had started before his arrival in Todmorden. A comment made by Shipman during his meeting with the police and two Home Office inspectors in July 1975 may also be significant. The notes of that meeting contain these words: 'Referring to the prevalence of Pethidine in the orders ( i.e. Shipman's orders made on behalf of the practice ) he said that he had a preference for using Pethidine whilst his partners preferred ( i.e. preferred to prescribe ) other drugs…He stated that he had acquired this preference whilst working as a doctor at a hospital in Pontefract' . 8.20 Whilst this conversation took place within the context of the drug which Shipman preferred to prescribe, it may well be that the 'preference' which he had acquired in Pontefract was for using, rather than prescribing, pethidine. Hyde 8.21 There is no evidence that Shipman continued to abuse drugs after his departure from Todmorden. Neither his employers in Durham, nor his colleagues at the Donneybrook practice, saw any sign of a continuing problem. Both would have been conscious of the possibility of a relapse by Shipman into his former habit, so might have been expected to look out for telltale signs, particularly at first. By the time of his move to Hyde, Shipman was driving again and there was no repetition of the convulsions from which he had suffered previously. 8.22 Shipman had resolved that he would not keep a controlled drugs register, nor, officially at least, any controlled drugs 'in his bag' for his emergency use in the course of his practice. At least one of Shipman's partners at the Donneybrook practice was aware of this intention but others, for example, Dr Geoff Roberts, apparently were not. The Inquiry's Investigations 8.23 The Inquiry has obtained the controlled drugs registers from nine pharmacies situated in and around Hyde. The registers must be retained by pharmacies for two years after completion but, in fact, the registers made available to the Inquiry extend back much further than that. 8.24 The Inquiry initiated a number of investigations in an attempt to discover whether Shipman had any other sources of supply for controlled drugs, over and above the nine pharmacies referred to above. One possibility which occurred to the Inquiry team was that Shipman may have collected opiates (for example, in syringe drivers) on behalf of patients from the Tameside General Hospital pharmacy and diverted them for his own use. However, the chief pharmacist at the hospital has told the Inquiry that the situation would not arise whereby a general practitioner would personally collect controlled drugs from the hospital pharmacy on behalf of one of his patients. 8.25 On examining the controlled drugs registers for the various pharmacies, the Inquiry team noted that, in the 1990s, Shipman had a small number of patients who were drug addicts and for whom he prescribed methadone. Methadone is a morphine derivative which can, in certain circumstances, be used for pain relief. It is also used in the treatment of drug addicts. Although methadone injections are available, they are only available in certain tightly controlled circumstances and cannot be prescribed by general practitioners. Shipman prescribed methadone in oral form. Enquiries of Mrs Ghislaine Brant, pharmacist at the Norwest Co-op Pharmacy, revealed that Shipman never collected methadone on behalf of patients and that it was not delivered to his surgery, but was dispensed direct to the patient. There does not, therefore, appear to be any possibility that Shipman used methadone to kill. 8.26 The Inquiry was also anxious to ascertain whether there were any other local pharmacies from which Shipman may have obtained drugs. However, enquiries of his former colleagues and staff revealed no evidence that Shipman obtained drugs from sources other than the local pharmacies already investigated. The possibility cannot be entirely ruled out that he visited pharmacies further afield and obtained supplies of opiates under some pretext, even under a false name. However, there is no evidence at all that he did so and it does not seem to me that, bearing in mind the quantities of diamorphine which he was able to obtain within the immediate locality, he would have had any reason to seek supplies from other sources. Diamorphine 8.27 Although prescriptions issued by Shipman were on occasions dispensed by other pharmacies, the bulk of the drugs prescribed by him were supplied by the Norwest Co-op (formerly Battersby's) Pharmacy, which was situated next door to Shipman's Market Street surgery and close to the Donneybrook Surgery. The controlled drugs register for the Norwest Co-op Pharmacy does not extend back beyond 1991 and none of the other pharmacies whose registers go back further dispensed any diamorphine injections prescribed by Shipman prior to 1991. The Market Street Years 8.28 Although he did not move to the Market Street premises until August 1992, Shipman began to practise single-handed in the preceding January from rooms within Donneybrook House. It was during his time there that he prescribed for one of his patients two 30mg ampoules of diamorphine, which were dispensed on 16th March 1992. The patient concerned subsequently transferred doctors and has since died; the Inquiry has not investigated his death, which was plainly unconnected with Shipman. However, the patient's medical records have been obtained and reveal no record of his having been prescribed diamorphine in March 1992, nor evidence of any condition which would have justified such a prescription. It seems, therefore, that Shipman obtained the drug for his own purposes. 8.29 The first recorded supply of diamorphine prescribed for a patient of Shipman after his move to the Market Street premises was on 22nd February 1993, when a prescription for one 30mg ampoule of diamorphine was dispensed in the name of Mrs Louisa Radford from the Norwest Co-op Pharmacy, Market Street. From that time until August 1993, a curious pattern of prescribing emerged. On 14 occasions, a prescription for one 30mg ampoule of diamorphine was dispensed, in the names of 13 different patients. The two prescriptions for the same patient were almost three months apart. It is clear, therefore, that the prescriptions did not form part of a course of the drug, yet a single ampoule of 30mg of diamorphine could have no therapeutic use on its own, since it would be likely to be fatal to a morphine-naïve individual, particularly if elderly. It would be theoretically possible to use part of an ampoule and reserve the rest for future use but this would give rise to difficulties in calculating the correct dosage and would have little point when smaller ampoules were readily available. At trial, Shipman's explanation for his use of 30mg ampoules was that he was in 'the bad habit' of prescribing 30mg diamorphine; he said that he would use what was necessary and dispose of the rest by squirting it down the sink. As I shall explain in Chapter Twelve, in reality, it now seems clear that, during 1993, Shipman was using 30mg ampoules of diamorphine to kill, replenishing his stock as and when necessary. 8.30 From November 1993, Shipman's pattern of obtaining diamorphine changed. Mr Raymond Jones, who was suffering from terminal cancer, began to receive large amounts of diamorphine by way of a syringe driver. Following his death, Shipman took possession of two or three boxes (i.e. twenty or thirty 100mg ampoules, possibly more) of diamorphine. He did not return them to the pharmacy from where they had come for destruction. I therefore assume that he kept them for his own purposes. 8.31 Between May 1994 and April 1995, Shipman prescribed another thirty five 100mg ampoules of diamorphine powder in the name of four patients to whom it was never administered. In July 1995, Shipman removed a large quantity (probably 1100mg diamorphine) from a patient's home, following the patient's death. He pretended that he took the drugs for 'disposal'. In reality, it is clear that he retained the drugs; four ampoules of the diamorphine prescribed for that patient were found by the police when they searched Shipman's home on the day of his arrest over three years later. 8.32 Shipman used the same method of obtaining diamorphine on the deaths of several further patients between September 1995 and April 1998. On 6th June 1996, he collected twenty 500mg ampoules and twenty 100mg ampoules of diamorphine (i.e. 12,000mg diamorphine in all) on behalf of a patient who died on that date; none of that diamorphine was delivered to the patient's home and it is clear that Shipman kept it. A small part of this consignment of drugs was found at Shipman's home on the day of his arrest over two years later. Assuming a fatal dose of about 30mg diamorphine, this stockpile of 12,000 mg diamorphine would have been sufficient to cause the death of approximately 360 people. 8.33 In addition, Shipman continued to write prescriptions for diamorphine which was neither needed nor used by the patients on whose behalf he purported to obtain it. However, the total quantities became larger, usually 1000mg a time, sometimes more. The 30mg ampoules which he had previously favoured were never used after 1993; instead, he changed to 100mg ampoules, even 500mg ampoules on one occasion. 8.34 At his trial, Shipman put forward a number of explanations to account for the prosecution evidence that he had obtained large quantities of diamorphine in the manner described. I do not propose to deal in detail with his evidence on the topic, which was completely unconvincing. Suffice it to say that, whilst he had to concede that he had failed to comply with the statutory requirements relating to controlled drugs on occasions, he denied that he had ever obtained diamorphine for his own purposes. In my view, it is clear that he did and that the jury accepted that he did. 8.35 It is also clear that, even on the basis of the medical records kept by Shipman, there must have been occasions when he was carrying diamorphine which he had not obtained by lawful means. The records reveal, for example, that he administered diamorphine without a prescription to Mrs Violet Bird and Mrs Jose Richards in 1993, Mrs Renate Overton in 1994 and Mr Peter Ovcar-Robinson in 1995. The Inquiry has also learned that he administered diamorphine to a member of the Market Street practice staff who attended the surgery unannounced and in great pain in December 1997. From her evidence, it seems that diamorphine must have been on the surgery premises at that time. 8.36 After November 1993, it is not possible to relate the individual ampoules of diamorphine obtained by Shipman to the deaths which he caused. However, I am quite certain that the amounts of diamorphine, which the available evidence reveals that Shipman was able to obtain after that time, would have been more than sufficient to cause all the deaths which I have found that he perpetrated, right up to that of Mrs Kathleen Grundy in June 1998. Morphine and Pethidine 8.37 In his clinical audit, Professor Baker pointed out that no entries for morphine or Cyclimorph injections were found in any of the controlled drugs registers of the various pharmacies whose registers he inspected, although Shipman had noted, in his medical records, that he had administered those drugs to several of his patients. Examination of the medical records revealed that all those patients identified by Professor Baker as having received injections of morphine or Cyclimorph had died shortly after the administration of the injection. Those patients were Mr Frank Halliday and Mrs Nellie Bardsley in 1987, Mr Harry Stafford in 1988, Mrs Mary Dudley in 1990 and Miss Mary Andrew, Mrs Edna Llewellyn, Mr Charles Brocklehurst and Mrs Amy Whitehead in 1993. Where the controlled drugs registers survive, no record of a prescription for morphine or Cyclimorph injections can be found for any of these patients. I have little doubt that the reason for the absence of such records is that the injections administered were in fact lethal doses of diamorphine. 8.38 There is no evidence from the controlled drugs registers examined by the Inquiry that Shipman was prescribing or obtaining unusually large quantities of morphine (whether in tablet or any other form) or pethidine during the 1990s. Shipman's Time at Donneybrook 8.39 As I have already mentioned, the Inquiry has no information about Shipman's acquisition of controlled drugs from the Norwest Co-op Pharmacy prior to October 1991. However, having seen the methods by which he was able to obtain large quantities of pethidine in Todmorden, and the very similar means which he was using to acquire diamorphine in the 1990s, I have no difficulty at all in inferring that, whilst at Donneybrook, Shipman was using in the same way dishonest methods to obtain opiates (probably diamorphine) as he did before and after his time there. I refer further to this subject in Chapter Eleven. The Future 8.40 It is apparent that Shipman was able to obtain very large quantities of controlled drugs illegally and without complying with any of the statutory requirements of record keeping. When he was in Todmorden, Shipman's illegal acquisition of pethidine quickly came to the attention of the authorities. While in Hyde, he was able to acquire strong opiate drugs for over 20 years by a variety of illegal means, none of which attracted the attention of the police, the Home Office Drugs Inspectorate or any other authority. In Phase Two, Stage Three, the Inquiry will examine how this could have happened and will seek to devise improved systems of control which will prevent such abuse in the future. © Crown Copyright 2002 View Shipman Report Table of Conents Chapter 9 - The Decision-Making Process

Shipman Report - Chapter 7 - Drugs

The First Report > Death Disguised > Chapter 7 - Drugs Drugs 7.1 At his trial, Shipman was convicted of the murder of 15 of his patients; toxicological tests on the bodies of nine of those patients had revealed evidence of morphine toxicity. The prosecution case was that Shipman had killed each of his victims by administering a lethal injection of morphine or diamorphine. 7.2 Evidence about the properties and effects of morphine and diamorphine was given to the Inquiry by Professor Henry McQuay. Professor McQuay is a doctor of medicine and a Fellow of the Royal College of Anaesthetists. He is the Professor of Pain Relief at the University of Oxford and an Honorary Consultant at the Oxford Pain Relief Unit. He has considerable experience in the use of morphine and diamorphine and has published basic scientific and other works on the topic. He gave evidence for the prosecution at Shipman's trial. 7.3 Professor McQuay provided for the Inquiry a report dealing with the properties, use, effects and therapeutic and toxic dosages of morphine and diamorphine. He also gave written answers to supplementary questions put by the Inquiry legal team and provided an additional report, dealing with the effects of morphine and diamorphine administered by different routes and the timing of the effects of the drugs when delivered by those routes. He gave oral evidence to the Inquiry on 21st June 2001. 7.4 Professor Kevin Park is Professor of Pharmacology at the University of Liverpool. He has more than 20 years' experience in research in drug metabolism and in the mechanisms of adverse drug reactions. He and Professor McQuay provided a joint report with Dr Grenville focusing particularly on chlorpromazine (Largactil), but also dealing with other drugs which might have a depressant effect on the respiration or central nervous system. 7.5 As a general practitioner, Dr Grenville has experience of prescribing and administering opiates and of the issues relating to their use, and he also gave evidence to the Inquiry on that topic. Morphine and Diamorphine 7.6 Diamorphine is twice as potent as morphine, when given by intravenous injection; however, once introduced into the body, diamorphine is very rapidly changed into morphine. It is not, therefore, possible to say, as a result of toxicological tests alone, whether any morphine found on testing was originally administered as morphine or diamorphine. In Shipman's case, the overwhelming likelihood is that, during his years in Hyde, diamorphine was his drug of choice. This is apparent from the available evidence about Shipman's acquisition of controlled drugs during the 1990s, which will be discussed in Chapter Eight. 7.7 Professor McQuay explained that morphine works by binding to the receptors which carry messages of pain to the brain. Although it has the same chemical constituents as morphine, diamorphine's different structure means that it cannot bind to the receptors and has to break down into morphine in order to be able to do so. The process of change from diamorphine to morphine takes only about 30 seconds. Dr Grenville pointed out that morphine also has euphoriant and vasodilatory effects, which can be helpful in treating certain conditions. 7.8 Whether administered as morphine or diamorphine, the morphine has to be transported in the bloodstream to the brain and the spinal cord, where the receptors are situated. The quickest way to achieve this is by intravenous injection, i.e. administration straight into the bloodstream. Alternatively, the drug can be administered by intramuscular injection, which is much slower because the morphine has to pass from the muscle to the bloodstream before being carried to the receptors. If the drug is taken orally, then it is absorbed from the intestines into the bloodstream, before passing round to the brain and the spinal cord, and this takes longer than either the intravenous or the intramuscular route. The timing of the effects produced by the administration of morphine and diamorphine by different routes is compared at paragraphs 7.29 to 7.36. The Side Effects of Morphine and Diamorphine 7.9 One of the two most important unwanted side effects of morphine and diamorphine is respiratory depression; the other is addiction. Morphine, when administered, has the potential to slow the rate of breathing and, ultimately, to stop breathing altogether. This must be taken into consideration when deciding whether to prescribe morphine or diamorphine and, if so, how much to prescribe. If a patient is in acute pain, respiratory depression is less likely to occur, since the potential of morphine to stop breathing is combated by the pain itself. If a person has no pain or distress when the drug is administered (for example, if he or she is taking the drug for 'recreational' purposes), there is no opposition to the potential to depress respiration and breathing is liable to become slower. Euphoria will also occur very rapidly. If a patient already has a condition causing respiratory depression, such as chest disease, the further depressant effect of the drug on the patient's breathing may easily give rise to danger. Other side effects of morphine, usually evident when a patient is first started on the drug, are dizziness, constipation and nausea. 7.10 Morphine injections are delivered ready-mixed as a transparent liquid in little glass pots called ampoules; they are available in a variety of strengths. They are administered by drawing up the contents of the ampoule into a syringe by means of a needle. Diamorphine comes in powder form, also in an ampoule, and has to be mixed with sterile water for administration as an injection. The water is drawn up from an ampoule into a syringe and then squirted into the powder ampoule. The diamorphine solution is then drawn back into the syringe ready for injection. Diamorphine is easy to dissolve, so only a little liquid (about 1 to 2ml for a 10mg ampoule of diamorphine) is required. With an intramuscular injection, the smaller the volume used, the less uncomfortable the injection. Diamorphine is supplied in 5mg, 10mg, 30mg, 100mg and 500mg ampoules. 7.11 An intravenous injection is most commonly administered into the large vein in the crook of the elbow, the next most favoured site being a vein on the back of the hand. The most usual sites for an intramuscular injection are the buttock, the big muscle on the outside of the thigh or the deltoid muscle in the upper arm. The Use of Morphine and Diamorphine in the Treatment of Severe Acute Pain or Distress 7.12 Dr Grenville described the circumstances in which he would use morphine and diamorphine for the treatment of severe acute pain, for example, after severe trauma, or for the pain of a heart attack. He would also use the drug to alleviate distress caused by left ventricular failure, a condition not characterised by pain. He told the Inquiry that he usually uses morphine in the form of Cyclimorph, which also contains cyclizine (a drug which prevents sickness). He carries for this purpose two ampoules of Cyclimorph 15, each of which contains 15mg morphine. Dr Grenville has had to administer Cyclimorph on only four occasions in his career, two of which were emergencies which occurred when he was off duty. In recent years, the use of morphine and diamorphine by doctors in acute circumstances arising in the community (as opposed to hospitals) has reduced, due to the greater role played by trained paramedics in the treatment of heart attacks and other acute conditions. 7.13 Dr Grenville emphasised that it is important to use the drug in the minimum quantities required to give pain relief; in other words, the drug is titrated against the patient's problem, be that pain or distress. This is best done by injecting the drug intravenously, so that it passes straight into the bloodstream and rapidly moves to the brain and spinal cord, where it exerts its effects; those effects can be observed as the drug is administered. Dr Grenville described this process: 'So you inject the drug into the vein very, very slowly and you observe the patient as to what effect it is having upon them. By observing a patient, you can tell how much pain they are in; whether their pain is being relieved; whether life is becoming easier for them. You are also observing the patient to watch for the onset of unwanted effects, such as sedation or respiratory depression. It is always a question of titrating the dose against the problem for which you are using it' . 7.14 Dr Grenville uses a long, narrow, low volume insulin syringe so as to achieve greater control over the dose and aims to inject about 1mg morphine a minute. 7.15 Dr Grenville went on to make the point that the intravenous route is to be preferred, because titration is possible. With the intramuscular route, there is no possibility of titrating and it is necessary for the doctor to decide beforehand how much of the drug he or she is going to give. The only circumstance in which Dr Grenville would inject morphine intramuscularly would be, he said, if he had to give an opiate to a patient in severe pain and he could not get venous access because the veins were collapsed or for some other reason. 7.16 As to the effects of the drug, Dr Grenville said that the first effect was likely to be the euphoriant effect but, in a patient with severe pain, an intravenous injection will very quickly start acting to help the pain and it is necessary to ask the patient to report any differences which he or she may notice as the drug is delivered. In the case of acute left ventricular failure, the patient will be distressed with rapid, laboured breathing and, probably, secretions. The aim of the injection is to try to ease the patient's distress and panic and thus reduce the production of adrenaline and other hormones. Opiates also have a vasodilatory effect which might reduce the pooling of blood in the lungs. In this case, morphine would be used in conjunction with a large intravenous dose of a diuretic. 7.17 An injection could also be given subcutaneously; if this is done as a 'one-off', which would not be usual, it could be given anywhere on the body under the skin, most likely on the thigh, the stomach or the chest wall. The Use of Morphine and Diamorphine in the Treatment of Chronic Severe Pain 7.18 Subcutaneous injections are usually administered over a period of time, using a butterfly needle, which is placed under the skin on the chest wall or on the abdominal wall, and held in place by two 'wings' taped onto the surface of the skin. Such injections are used in the management of persistent, severe pain, usually as a result of cancer. 7.19 Both Professor McQuay and Dr Grenville gave evidence about the use of strong opiates in relieving pain caused by terminal conditions. They described how the patient's pain is managed by using progressively stronger pain-relieving drugs, usually in tablet form. When strong opiates are introduced, they are often in the form of slow-release morphine tablets, which are designed so that the morphine within the tablets is absorbed slowly into the bloodstream over 24 hours; thus, if the tablets are taken regularly, a constant level of the drug within the bloodstream is maintained, the aim being to keep the drug at a level whereby the patient is pain-free. Often, a patient can be maintained on an oral opiate, such as morphine, for a long time – for months, even years. If breakthrough pain is experienced, this should be dealt with by giving a single dose (a 'bolus' dose) of the drug by some convenient means, often an oral morphine solution. However, breakthrough pain is an indicator that the current regular dose of oral medication is inadequate and should be increased so that the pain is effectively controlled. 7.20 When a patient with a terminal illness becomes unable to swallow, opiates have to be administered by a route which does not involve swallowing, most usually by the subcutaneous route using a syringe driver attached to a butterfly needle. A syringe driver is a pump, into which a standard-sized syringe will fit. It is designed to drive home the plunger of the syringe over the course of a 24 hour period. By making up the solution of the opiate to be put into the syringe in different quantities, the drug can be delivered to the patient at different rates. As the rate is increased, the level of the drug in the patient's bloodstream increases and that level can be titrated against the degree of pain experienced by the patient. If a syringe driver is in use, any breakthrough pain is best dealt with by an intravenous injection although, once again, the occurrence of breakthrough pain may signify the need to reassess and increase the dose of the drug being delivered through the syringe driver. Syringe drivers have been a common method of treating a patient who is unable to swallow for the last 20 to 30 years, according to Professor McQuay, although Dr Grenville said that they have become more widespread in the community (as opposed to hospital) over the last 10 to 15 years. The first use, known to the Inquiry, of a syringe driver among Shipman's patients was in November 1993; it is, however, possible that one or two had been provided to other patients before that time. The Appropriate Dose of Morphine or Diamorphine 7.21 Both Professor McQuay and Dr Grenville gave evidence about the doses of morphine and diamorphine, which would be appropriate in various different circumstances. 7.22 Dealing first with the relief of acute pain, for example after a heart attack or an operation, Professor McQuay stated that the standard adult dose would be 10mg morphine or 5mg diamorphine, repeated four hourly as necessary, administered intramuscularly. If injecting intravenously, he would give about half those quantities and probably, he said, with some caution. That would be the amount of the drug which would be given by way of 'pre-med' to a patient before undergoing an operation. 7.23 Dr Grenville observed that the dose of morphine usually required in circumstances of acute pain by a previously healthy, opiate-naïve adult patient is extremely variable, but the commonest range would be 5 to 10mg morphine or 2.5 to 5mg diamorphine by the intravenous route. If constrained to give an intramuscular injection, he said that he would probably give 5mg morphine and observe the effects, hoping that the patient was not a person who was particularly susceptible to morphine and aware that, if the dose given proved inadequate, he could always give a further dose. Dr Grenville said that the maximum amount of morphine he had ever needed to use in circumstances of acute pain was a full ampoule of Cyclimorph 15, i.e. 15mg morphine. 7.24 Where a patient has protracted chronic pain, such as that produced by cancer, the average daily dose of oral morphine is, according to Professor McQuay, about 120mg, although the dose can be much larger – in rare situations up to 2 to 3g per day. If a change is then made to subcutaneous delivery (because the patient cannot swallow), but the pain has not increased, then the dose will be reduced to between a third and a half of that being given orally. In other words, morphine delivered by the subcutaneous route is generally considered to be between twice and three times as potent as morphine delivered orally. Professor McQuay explained that, in practice, the change from the oral to the subcutaneous route often occurs towards the very end of life, at a time when the pain is escalating, so that a simple conversion is not appropriate. In that event, it is usual to start with the equivalent of the current oral dose, giving 'extras' as necessary and then calculating, by reference to the number of extras, the appropriate daily dose. Professor McQuay estimated that about 30 per cent of patients requiring subcutaneous morphine need more than 200mg morphine per day. 7.25 Professor McQuay told the Inquiry that previous exposure to morphine frequently has the effect of increasing a patient's tolerance to the drug, resulting in more being needed to achieve the same level of pain relief. The effect of the drug is also subject to factors such as age, size and state of health. In general, the older the patient is, the greater the effect of a given dose of morphine. All these factors have to be taken into account when determining the dose of morphine or diamorphine to be used. The effect of the drug is also influenced by the speed at which it is delivered; maximum effect would be achieved by giving the contents of a syringe by the intravenous route very quickly. Excessive Doses of Morphine and Diamorphine 7.26 Both Professor McQuay and Dr Grenville were asked to identify the dose of morphine and diamorphine which they believed was likely to be fatal in a morphine-naïve patient. Professor McQuay pointed out that the task was a difficult one, since the aim of doctors was to avoid giving such a dose if possible; the answer to the question cannot be found in any textbook and, in any event, would vary according to the patient's age, size and state of health, together with other factors. However, his best estimate was that 60mg morphine or 30mg diamorphine, given over one minute to a fit adult who had not previously been exposed to strong opioid drugs, would be fatal. The most he has ever administered himself was 30mg morphine intravenously over ten minutes, titrated to control very severe pain arising from a trauma suffered by a very large (and presumably fit) man in the course of cross-country skiing. 7.27 Professor McQuay said that he would expect a dose of 30mg diamorphine, given intravenously over five minutes or less, to put a fit, normal person, not habituated to the drug, to sleep and eventually stop their breathing. Dr Grenville was a little more conservative in his views. He said that he would expect, on the basis of his own experience of giving therapeutic doses, that a dose of 20mg diamorphine or 40mg morphine would prove fatal. He would reduce those amounts by half in an elderly, small, ill or frail patient. He said that a smaller dose could produce long-term coma with brain damage, without necessarily causing death by total cessation of respiration. 7.28 The risk of coma and brain damage is illustrated by the circumstances of two of the deaths for which I have concluded that Shipman was responsible. In the case of Mrs Alice Gorton, who died on 10th August 1979, Shipman plainly believed that she was dead when he summoned her daughter to the house. Shortly after the daughter's arrival, however, Mrs Gorton was heard to groan loudly. She survived in an unconscious state for a further 24 hours or so. Whilst Mrs Gorton was elderly, she was also a large woman and I have found that Shipman injected her with a dose of diamorphine which was not sufficient – possibly because of her size – to kill her immediately, but was enough to render her unconscious and to cause her death from brain damage or bronchopneumonia, or as a result of a combination of the two. I have also found that, on 18th February 1994, Shipman injected Mrs Renate Overton with sufficient diamorphine to cause unconsciousness from which she never recovered. It is not clear whether Shipman used less diamorphine on this occasion than was his habit or whether Mrs Overton, being only 47 years old, was a more robust subject than most of his elderly patients. Whatever the cause, she survived in a persistent vegetative state for 14 months. The Timing of the Effects of Excessive Doses of Morphine and Diamorphine 7.29 Professor McQuay produced a report dealing with this topic, with which Dr Grenville has signified his agreement. Dr Grenville has also commented on the timing of the effect of the drugs in the context of the specific deaths about which he has given evidence. 7.30 If a fit adult with no previous experience of opioid drugs were given 30mg diamorphine intravenously over one minute, Professor McQuay said that he would expect breathing to stop within one minute and death to ensue within five minutes, because of lack of oxygen to the brain. The patient would be incapable of moving from the position in which he or she had been injected and would be unlikely to vomit. Larger doses would, Professor McQuay said, have the same effect. 7.31 Professor McQuay observed that he was unable to predict with precision the effects of an intravenous dose of less than 30mg diamorphine. He said that, after any dose over 5mg, the patient would be aware that something had happened, would be aware of feeling strange and drowsy and, if he or she tried to move about, would probably be nauseated and vomit. Professor McQuay observed that a dose of 20mg could well prove fatal in an elderly, unfit and opioid-naïve person. Dr Grenville said that a patient to whom a fatal intravenous injection was administered would rapidly become unconscious and would be unaware that he or she was dying; he drew a parallel with the anaesthetic given before an operation, after which the patient usually falls asleep and is aware of nothing else until the effects of the anaesthetic wear off. 7.32 An intramuscular injection takes longer to work and the effects are less predictable. The effect of an intramuscular injection of 30mg diamorphine would be maximal between 30 and 60 minutes after its administration. The degree of the effect would also be slightly less than for the same dose delivered intravenously, since absorption of the drug would be less complete. Nevertheless, Professor McQuay would expect a 30mg intramuscular dose of diamorphine to be fatal in an opioid-naïve person. Because of the slower absorption, it is possible that there would be a period of time after administration of the injection when the patient would be able to walk and talk. As the drug began to take effect, the patient would feel nauseated and might vomit, particularly if he or she were trying to move about. Although an onlooker may not notice any immediate effect, by a period of 15 minutes after the injection – and certainly by 30 minutes after – it would be clear that 'something strange' was happening. The general proposition, confirmed by Dr Grenville when giving his evidence in the case of Mr Samuel Mills, is that, if a person is going to die as a result of an intramuscular injection of opiates, he or she will do so within about an hour of its administration. 7.33 The oral route is the slowest and the onset of the effects of a dose of 60mg tablets of morphine (i.e. the equivalent of 30mg diamorphine) would, according to Professor McQuay, be 30 to 45 minutes after its ingestion; again, there would be a period of normality before the patient began to feel nauseated and act strangely. This would probably be evident by 45 minutes after ingestion, certainly by 60 minutes. The 'lucid interval' would be increased further if the oral morphine were given in a slow-release formulation; the onset of the effects would then be delayed to 11 / 2 to 2 hours after administration. Dr Grenville stressed that different people have a different susceptibility and, in the case of frail and elderly patients, the onset of the effects of the drug could be quicker than the estimates set out above. 7.34 Professor McQuay has described how, if a needle is placed in a vein in order to deliver an intravenous injection, it can slip out of the vein so that fluid which had been intended to go into the vein is instead extravasated, i.e. it goes outside the blood vessel and into the tissues around the vein. The injection thus becomes subcutaneous but the timing of the effect will, Professor McQuay said, be similar to that for an intramuscular injection. In order to avoid the risk of giving an extravasated injection, the injector usually checks, by intermittent pulls on the syringe plunger, that there is a back flow of blood which shows the needle is still in the vein. However, a needle can come out of the vein if the recipient or the injector moves position or the needle shifts. There can be problems also with small, very mobile veins which are sometimes present after excessive weight loss; also, many elderly people have veins with calcified walls, which are difficult to penetrate. The veins may also have collapsed or be difficult to find, for example in a person who is obese. 7.35 If a needle comes out of the vein and part of the drug is extravasated, Dr Grenville said that the effect produced by the injection is likely to be significantly slower than if it had been delivered intravenously. He said: 'If it became extravasated, then you may be looking at the effects within a few minutes up to maybe tens of minutes, depending upon the patient's condition and the amount of the dose that is being given, how much was given intravenously, how much was extravasated; there would be all sorts of factors. Clearly, I have to say it is something I have no experience of' . 7.36 If the dose administered were of such a size as to be fatal, Dr Grenville said that, as with an intramuscular injection, there may be a period during which the patient might be able to move around, albeit feeling unwell, dizzy and perhaps sick, before lapsing into unconsciousness and death. Double Effect 7.37 Professor McQuay and Dr Grenville gave evidence about the phenomenon known as 'double effect', whereby the administration of a dose of opiates sufficient to relieve a patient's pain might also have the effect of reducing the patient's respiratory drive to such a degree that the patient's life is shortened. Dr Grenville pointed out that, as well as considering the effect of the drug on respiratory drive, a doctor must also consider the fact that, if the patient's pain is not relieved, he or she may become distressed and exhausted and thus the patient's life may be shortened anyway. 7.38 Dr Grenville explained that it was necessary, when deciding on the amount of the drug to give and the rate at which it should be delivered, to balance the need to relieve pain against the risk of depressing respiration. This is likely to be more difficult when the patient is close to death and suddenly experiences a degree of breakthrough pain, necessitating a dose of pain relief, which may reduce the patient's respiration to the extent that he or she cannot continue. He stressed that this was likely to arise at the very end of life and that any shortening of life was likely to be by hours only. 7.39 Dr Grenville said that good medical practice when using opiates in these circumstances was for the doctor to ensure that the patient's death was as pain-free as possible and that he or she was kept comfortable and did not die distressed. However, it is not lawful to administer doses of opiates which are primarily intended to hasten death and which are more than the doctor honestly believes is required to alleviate pain. 7.40 Professor McQuay acknowledged the problem with terminally ill patients. He said that the technique in these circumstances is to titrate the dose against the response. If the patient is conscious, he or she can indicate whether the drug has had any effect in relieving pain; even if the patient is comatose, signs such as grimaces, sweating or a rise in pulse rate can indicate continuing pain. Obviously, the unconscious patient is more difficult to assess. Professor McQuay said that he could not be certain whether the giving of a dose of opiates sufficient to relieve distress in a desperately ill patient with a short time to live might also have the effect of shortening life by a brief period. In those circumstances, he would have to make a value judgement as to the appropriate dose against the background of the previous doses received by the patient. 7.41 When giving evidence about the death of Mrs Mary Ogden, Dr Grenville referred to the direct and indirect results of an intramuscular administration of opiates to a patient who was approaching death. On the one hand, the injection could have the direct effect of depressing respiration and causing death; in that event, he would expect death to occur within an hour of administration of the drug. He distinguished this situation from that of the indirect result of the injection, which he described thus: '…in the real situation of a patient who is really ill and really needs analgesia, you could envisage the situation, and, indeed, it occurs, where they require a dose of morphine or diamorphine which is very large but may not be sufficient to cause death of itself but may be large enough to cause temporary respiratory depression which then allows, in a very debilitated patient at death's door ( sic ) , to develop a terminal bronchopneumonia and to that extent one could describe the bronchopneumonia as a direct result of the morphine injection and that is a different timescale. So this really is the difference between a real-life situation of the type that I have seen and the sort of thing that happened or may have happened when Shipman was involved'. 7.42 Dr Grenville confirmed that, if the opiate were the primary cause of death, death would occur within about an hour. However, the dose of opiate might be a contributory cause of a death taking place more than an hour later. 7.43 The Inquiry has investigated a number of cases in which it has been suggested, or suspected, that Shipman administered opiates in a quantity designed to hasten death, rather than merely to relieve pain. However, in many of these cases, it has been impossible to make any assessment of the amount of medication given. Shipman's medication records were frequently inadequate, so that even when the general practitioner records are available, it is often impossible to tell from them what or how much medication was prescribed and/or administered. The exception to this is those cases of terminally ill patients on syringe drivers where the district nurses' records of drugs received and administered are still available; those records are of a generally high standard. However, Shipman's failure to record the drugs administered and the fact that he is known to have been in illicit possession of large quantities of opiates, together with the lack of availability of any records at all in the early years, make it very difficult to assess the nature and quantity of drugs administered to some of the patients whose deaths have been considered. Pethidine 7.44 In his answers to the supplementary questions put by the Inquiry, Professor McQuay explained that pethidine is a synthetic strong opioid painkiller, the effects and uses of which are similar to those of morphine. Like morphine, it acts on the receptors which transmit messages of pain to the brain. Also, like morphine, pethidine is addictive and produces various side effects, including respiratory depression, retention of urine, palpitations and convulsions. Because of the risk of these latter effects, pethidine is not generally used for the long-term relief of chronic pain. Instead, it is used to treat acute pain, usually where not more than ten doses are likely to be required. 7.45 Pethidine can be administered by injection or in tablet form. A usual dose would be 100mg given intramuscularly, repeated four hourly as necessary. Professor McQuay estimated a lethal dose to be of the order of 500mg for a fit opioid-naïve person. Administering a dose of that size would have considerable practical difficulties. In the 1970s, pethidine was supplied in ampoules containing 50mg of the drug in 1ml water or 100mg in 2ml water. Therefore, a lethal dose would entail the administration of five of the larger ampoules, containing a total of 10ml liquid. It seems unlikely, therefore, that Shipman can have used pethidine to kill. 7.46 The timing of the effects of the administration of pethidine by different routes would be similar to those for morphine and, as with morphine, the degree of effect would depend on a number of factors, including age. High or repeated doses give rise to the risk of convulsions. Chlorpromazine 7.47 The proprietary name for chlorpromazine is Largactil. Chlorpromazine is an anti-psychotic or neuroleptic drug, which has been in use for more than 25 years. It can be used to manage agitated states in the elderly and, since it suppresses nausea and potentiates the effects of other centrally acting depressant drugs, it has been much used in the treatment of the pain of terminal illness. It exists in tablet, elixir and injectable forms. 7.48 Dr Grieve, one of Shipman's partners in Todmorden, confirmed to the Inquiry that the doctors there used injectable chlorpromazine in the treatment of terminally ill patients, such as Mrs Lily Crossley, and there are references also to its use by Shipman during the Hyde years. 7.49 In 1974 to 1976, ampoules of chlorpromazine for injection contained either 25mg in 1ml of solution or 50mg in either 2ml or 5ml of solution. The recommended dosage was 25 to 50mg, to be repeated every 6 to 8 hours. Smaller dosages would be appropriate in the case of small, elderly or frail patients. The March 2001 British National Formulary refers to ampoules containing 25mg chlorpromazine in 2ml of solution. 7.50 The solution is given by deep intramuscular injection, into either the buttock or upper arm. It has irritant properties which would make intravenous injection painful and, to all intents and purposes, impracticable. While a massive overdose of chlorpromazine might be capable of directly causing death (for example, by inducing fatal cardiac arrhythmia), such an overdose would involve the injection of a substantial volume of fluid and I do not think that Shipman would ever have chosen to kill a patient by this method. 7.51 On the other hand, a smaller overdose of chlorpromazine could have an indirect lethal effect in very much the same way as might be achieved by a sublethal dose of morphine or diamorphine. A dose of 100mg chlorpromazine is not a lethal dose, but could contribute to a patient's death. The mechanism would be by suppression of the respiration, or of the protective cough reflex, of a frail person, especially where that person already had a chest infection or history of chronic obstructive pulmonary disease. Depending on the circumstances of the individual and the dosage given, death might ensue by this indirect mechanism after anything between a small number of hours and several days. The patient would go into a deep sleep quite soon after the giving of the injection, a sleep from which he or she might well not wake if death followed as an indirect result of the injection. 7.52 Other drugs exerting a comparable depressant effect on the respiration or central nervous system would include the anxiolytics, hypnotics and some of the more sedating anti-depressants and anti-histamines. Other Types of Treatment by Injection 7.53 In the course of considering individual cases, I have come across other suggested types of treatment by injection. When giving evidence in the case of Mrs Hannah Jones, Dr Grenville said that, in 1985, the best treatment available for a severe asthma attack was an intravenous injection of aminophylline or terbutaline, and it is quite possible that Shipman legitimately treated Mrs Jones with such injections some months before she died. Both drugs carried a risk of causing fatal irregularities of the heartbeat, but such problems, if they occurred at all, would follow immediately after the injection, when the patient would go into cardiac arrest. Dr Grenville also alluded in that case to the giving of an intramuscular injection of a steroid. In considering the case of Miss Florence Taylor, Dr Esmail told me that, in the early 1980s, intravenous injections of salbutamol might have been given in similar circumstances and with similar possible side effects. 7.54 I should mention, for the sake of completeness, that there were undoubtedly occasions on which Shipman gave a lethal injection of diamorphine but purported to have given something else. So, in the case of Mrs Eileen Crompton, Shipman purported to give an intravenous injection of benzylpenicillin, whereas I am sure that he gave a lethal injection of morphine or diamorphine. 7.55 In the next Chapter, I will consider the means by which Shipman was able to acquire controlled drugs. © Crown Copyright 2002 View Shipman Report Table of Contents Chapter 8 - Shipman's Acquisition of Controlled Drugs

Shipman Report Chapter 6 - The Medical Evidence Pt II

The First Report > Death Disguised > Chapter 6 - The Medical Evidence Pt II


The Effect of Heat

6.92 Once the circulation has completely ceased, cooling of the body starts. Dr Grenville explained that the rate at which cooling occurs depends on the ambient temperature, and on the presence or absence of insulating material such as clothing. As Dr Grenville observed:

'A naked body in a cold environment cools very much more quickly than a fully clothed body in a warm environment, say, with the gas fire on' .

6.93 Similarly, obese people cool less rapidly than very thin people, because their body fat itself acts as an insulating material. As a rough guide, Dr Grenville said that, in the absence of clear reasons for cooling to be delayed, he would expect the hands, certainly the fingers, to be cool to the touch within an hour or so of death.

6.94 In a significant number of cases where I have found that Shipman killed, the deceased person has been found in a room in which the fire, usually a gas fire, has been turned to an unusually high setting, making the room extremely warm. It is clear that Shipman was responsible for this, but why he did it is less clear. The effect of the increased heat would be to delay the process of cooling of the body after death. Increased heat would also, as Dr Grenville explained in the course of his evidence relating to the death of Mrs Charlotte Bennison, speed up the onset of rigor mortis and bring forward the time when rigor mortis wears off. Low temperature, on the other hand, could be expected to delay the onset of rigor mortis. It is clear that Shipman was aware of the effect of heat on the onset of rigor mortis, as he correctly explained to Mrs Nadya Williamson, the wife of Mrs Bennison's nephew, why rigor mortis had set in earlier than might have been expected.

6.95 It seems likely that the high incidence of bodies found in overheated rooms resulted from efforts by Shipman to make it difficult for others accurately to estimate the time of death. Sometimes, the fact that the body was still warm when found might suggest that death had occurred more recently than was in fact the case, and might, therefore, serve to increase the apparent time interval between an earlier visit by Shipman and the death. On other occasions, the early onset of rigor mortis might lead people to believe that the death had occurred significantly earlier than was in fact the case. In any event, any attempt accurately to estimate the time of death would be made more difficult, if not impossible, by the presence of excessive heat.

6.96 The Inquiry legal team has investigated another possibility, namely, that heat might have the effect of speeding up the metabolism of morphine and that Shipman, knowing this, might have been attempting to minimise the chance of morphine being found in his victims' bodies, should toxicological tests be ordered. Professor Kevin Park, Head of the Department of Pharmacology and Therapeutics at the University of Liverpool, has advised that, after death, hepatic metabolism cannot influence blood levels of morphine; keeping a deceased's body in hot conditions is not, therefore, likely to speed up the metabolism of morphine. It is, of course, possible that Shipman mistakenly believed that it would have this effect, although the Inquiry has no positive evidence of this. On balance, it seems likely that his motive in leaving his victims in overheated rooms was to foil any attempts to assess accurately the time of death.

Estimating the Time of Death

6.97 In many cases, Shipman purported on cremation Form B to estimate the time of death, sometimes claiming to be able to do so from the temperature of the body and, on other occasions, specifying an exact time of death without giving any factual basis for his assertion. Dr Grenville emphasised that the timing of death is an extremely difficult and complex procedure, usually carried out by forensic pathologists. One such forensic pathologist, Professor Helen Whitwell, MBChB FRCPath DMJ(Path), registered medical practitioner, Professor of Forensic Pathology at the University of Sheffield and Consultant Pathologist to the Home Office, gave evidence to the Inquiry about three deaths after which there had been post-mortem examinations. She observed when giving evidence about the death of Mrs Pamela Mottram:

'...essentially the time of death is one of those huge mysteries of forensic pathology' .

Professor Whitwell went on to say:

'…the general rule, even with most deaths, is the best evidence is when they were definitely last positively seen alive and then known when they were found dead ( sic ) . There are lots of complicated equations and things that one can use, but they essentially are not of much use apart from very exceptional circumstances' .

6.98 Dr Grenville said that he does not himself possess the skills necessary to estimate time of death and would not attempt to do so. He is, however, aware that it is mandatory to record the core temperature, usually by obtaining a rectal temperature. The ambient temperature must also be measured, and careful observations noted about the deceased's clothing or covering and those signs which wax and wane after death, such as rigor mortis and post-mortem lividity. There is no evidence that Shipman ever obtained or recorded such information in cases where he estimated the time of death with apparent confidence, nor is there any evidence that he possessed the skills necessary to make such estimates of time.

The Patient who Refuses to Heed Medical Advice

6.99 Dr Grenville was asked how a general practitioner should deal with a patient who has a serious medical condition but refuses admission to hospital, or other necessary treatment. This was a situation in which Shipman claimed frequently to find himself, often with a patient who had suffered signs suggestive of an evolving stroke or transient ischaemic attack, or who had suffered, or may have suffered, a heart attack, or who had a chest infection or bronchopneumonia. Shipman's solution to this problem was, usually at least, to leave the patient at home, without arranging any immediate care, and without seeking the assistance of relatives to change the patient's mind; he would then tell the patient 'tluk' , i.e. 'to let us ( the surgery ) know' if he or she had a change of mind or had deteriorated.

6.100 By contrast, Dr Grenville said that it was 'incredibly rare' for a patient to refuse to take such advice. If the initial reaction is negative, the doctor must explain carefully the reasons for the advice given. In the face of a continued refusal to accept his advice, he said that he would ask the patient whether there was a relative, friend or neighbour to whom he could speak, in the hope that the patient would accept the joint advice of himself and that other person. If he still met with no success, he would make a most detailed note of what had happened, and ask the patient to sign a declaration that he had advised the patient to go to hospital and explained the risks associated with failing to take that advice. The effect of requesting a signature is, he says, to make it clear to the patient that the doctor is serious, and also to protect the doctor in the event of a complaint or litigation in the future.

6.101 Dr Grenville said that he had not had to resort to obtaining a signature from a patient refusing to be admitted to hospital, but he had had to do so where a patient was refusing treatment which he definitely believed was in the patient's best interests. In the event that he was forced, contrary to his own judgement, to leave a patient at home rather than have him or her admitted to hospital, he said that he would want to try to arrange for the patient to be observed on a more or less continuous basis, whether by family, the district nursing service or Social Services. In an extreme case, the National Assistance Act 1948 could be used, although this takes time and is usually resorted to in the case of a person living in chronically poor conditions, rather than someone suffering a serious life-threatening illness.

6.102 In an extreme case, a doctor may have to override a patient's wishes. In the case of Mrs Mary Coutts, Dr Grenville said that, had she been suffering from bronchopneumonia which was plainly life-threatening, a reasonable doctor might have been justified in ignoring any weak protests that she might have raised about not going into hospital and in simply overriding her and getting her into hospital for treatment.

6.103 Most of Shipman's patients had been registered with him for years, had the utmost confidence in his medical abilities and trusted him implicitly. In reality, it is highly unlikely that they would have resisted his attempts to persuade them of the need for hospital admission, particularly if they were as ill as he described. Even those who were genuinely unwilling to be admitted, such as Mrs Elizabeth Battersby, would have been unlikely to maintain their opposition once their relatives were informed and lent their support to Shipman


© Crown Copyright 2002

View Shipman Report Table of Conents

Chapter 7 -Drugs

Shipman Report - Chapter 6 - The Medical Evidence

The First Report > Death Disguised > Chapter 6 - The Medical Evidence

The Medical Evidence

6.1 Much of the expert medical evidence upon which I have drawn when making my decisions was given to the Inquiry by Dr John Grenville. In this Chapter, I propose to summarise the important features of his evidence.

6.2 Dr Grenville is a doctor of medicine, a diplomate of the Royal College of Obstetricians and Gynaecologists and a member of the Royal College of General Practitioners. He has been a principal in general practice since 1981; he was a full-time practitioner until 1992 and has worked on a half-time basis ever since. He has been secretary of the Derbyshire Local Medical Committee since 1984 and was a deputy police surgeon to Derby Constabulary from 1982 until 1985. He is a clinical complaints advisor to the Medical Defence Union, in which capacity he regularly advises general practitioners at committees and tribunals when complaints are made against them. He advised the police throughout their investigation into Shipman's activities and provided witness statements in connection with 97 deaths. He also gave evidence for the prosecution at the criminal trial and to the Coroner at some of the inquests.

6.3 Dr Grenville provided the Inquiry with a detailed report dealing with issues of general application to the deaths being investigated, and attended to give oral evidence (his 'generic evidence') about those issues on 22nd June 2001. In addition, he provided a report on cases potentially involving the double effect of opiates and a further report, dealing with eight deaths where the delayed effects of morphine or diamorphine had been considered. He has also provided to the Inquiry 108 individual reports in connection with 92 deaths and attended to give oral evidence relating to some of those deaths on 23rd and 24th July, on 12th , 13th , 14th and 19th November and on 7th December 2001. Most recently, he prepared a (joint) report on chlorpromazine and other drugs with similar potential effects.

Cardiac Causes of Death

6.4 Shipman frequently certified cardiac causes of death, most often coronary thrombosis and left ventricular failure. Dr Grenville explained in simple terms the mechanisms giving rise to these conditions.

Myocardial Infarction

6.5 What is commonly known as a 'heart attack' is properly termed a myocardial infarction. The pumping action of the heart is produced by contractions of the muscles within the wall of the heart, which are co-ordinated by electrical activity within the cells of the heart wall. Oxygenated blood, which is necessary for the electrical and muscular activity of the heart wall, is supplied by means of blood vessels, known as the coronary arteries. These arteries are, according to Dr Grenville, particularly susceptible to the build-up of fatty deposits (known as atheroma) within them, producing a condition called coronary atherosclerosis.

6.6 As a coronary artery becomes occluded by atheroma, the blood flow through it decreases and the amount of oxygen getting to the heart wall beyond the occlusion also decreases. This can cause pain in the chest (and sometimes the upper abdomen, neck, left shoulder and arm) on exertion; this pain is known as angina. Angina is relieved by rest, which reduces the amount of oxygenated blood required by the heart, or by anti-anginal medication such as glyceryl trinitrate (GTN) spray or tablets. Many angina sufferers lead normal lives, suffering attacks of angina but knowing what to do in order to relieve the pain when they occur, and some live with angina for very long periods of time. Sometimes, the angina deteriorates and the patient suffers episodes of angina even at rest. The patient is then at high risk of suffering a heart attack at any time.

6.7 Not everyone who suffers from atherosclerosis – even to a significant degree – experiences angina. Furthermore, although most patients who suffer a myocardial infarction have suffered angina for some preceding period (often a long period), some patients suffer myocardial infarctions without any previous history of angina.

6.8 When the blood flow beyond an occlusion becomes critical to the point where there is insufficient oxygen to allow the heart to continue pumping, the muscle beyond the occlusion dies; this is known as a myocardial infarction. The cause of the infarction is occlusion of the coronary artery, which is known as a coronary thrombosis. Thus, the terms 'coronary thrombosis' and 'myocardial infarction' are used interchangeably – even by doctors.

6.9 If the section of heart muscle which dies is large enough, the heart is unable to continue pumping efficiently or, if the electrical activity of the heart is interfered with to the extent that control of the pumping mechanism is no longer co-ordinated (known as ventricular fibrillation), the heart stops pumping blood. Once this happens, the oxygen supply to the brain is compromised and unconsciousness follows within a minute or two, followed by death within five to ten minutes, unless treatment is successfully instituted.

6.10 According to Dr Grenville, myocardial infarction produces pain similar to angina, but usually much more severe, described as a crushing sensation or a tight band around the chest, often accompanied by sweating, shaking and vomiting. It cannot be relieved by rest or by anti-anginal medication. Short-term relief from pain can be achieved by the administration of a small dose of an opiate (see Chapter Seven), but the priority is to secure admission to hospital, preferably to a coronary care unit, for thrombolysis (the so-called 'clot-busting' treatment) and any other supportive treatment that may be necessary. Whilst thrombolysis is a treatment that has become available relatively recently (since the early 1990s), admission to hospital was the accepted way of managing an acute myocardial infarction even before that time. If the patient suffers a cardiorespiratory arrest, the appropiate treatment is resuscitation: see paragraphs 6.76 to 6.85.

6.11 The ease with which a myocardial infarction can be diagnosed is variable; sometimes the medical history and classic signs make it obvious to an attending doctor. At other times, where a patient has atypical pain, diagnosis can be more difficult. According to Dr Grenville, the doctor should look for other possible causes of the pain but should always err on the side of caution. If the symptoms might be those of a heart attack – that is, if a heart attack is within the differential diagnoses – Dr Grenville said that, in his view, hospital was where the patient should be. When asked about the value of an electrocardiogram (ECG) in diagnosing myocardial infarction, Dr Grenville said that it would not necessarily be diagnostic, since a patient having an infarction can have a normal ECG at the time, even where an ECG taken later would confirm the occurrence of the heart attack. Moreover, if the patient is obviously having a heart attack at home, the doctor does not want to waste time linking him or her up to an ECG in order to confirm what is already evident.

6.12 Once in hospital, tests can be performed which are diagnostic of myocardial infarction. For example, heart muscle which has been damaged releases an enzyme into the bloodstream and this can be measured. If, over a period of about 48 hours, the level of the enzyme rises and then falls again, that is diagnostic of a myocardial infarction.


Heart Failure

6.13 Dr Grenville went on to describe the various types of heart failure which can occur. Heart failure happens when the heart is beating, but not sufficiently strongly to maintain the normal circulation of blood through the rest of the body. This can be caused by a number of factors, including infarction of the heart muscle and hypertension, which is sustained long-term high blood pressure.
6.14 Dr Grenville explained that the ventricles are the main pumping chambers of the heart. The right ventricle pumps blood from the heart through the lungs; the blood then returns to the left side of the heart and the left ventricle pumps blood around the rest of the body. The deoxygenated blood comes back into the right side of the heart, completing the cycle. The left ventricle is larger, stronger and more prone to problems than the right ventricle.
6.15 Acute right ventricular failure is commonly caused by pulmonary embolus, which occurs when a blood clot moves from a vein in another part of the body, usually the leg, to the lungs, and blocks the blood circulation there; the right ventricle is then unable to pump blood through the lungs.
6.16 Acute left ventricular failure is often associated with myocardial infarction. This can occur when the damage to the muscle wall of the left ventricle is sufficient to impair the ventricle's ability to pump blood through the body, but not so severe as to stop it pumping altogether. Acute left ventricular failure can also occur as the end point of chronic heart failure (also known as congestive heart failure: see paragraphs 6.20 to 6.23), whereby the heart compensates for long-term problems which are being experienced in pumping blood through the heart, by developing hypertrophy or enlargement of the left ventricular wall. This enables the heart to maintain an adequate circulation around the body in the short term, but there comes a point when the compensatory mechanism is suddenly inadequate and an acute left ventricular failure ensues.
6.17 When acute left ventricular failure occurs, the blood from the left ventricle is not pumped out into the rest of the body, but the right ventricle continues to pump blood into the left side of the heart, thus causing the lungs to become congested and resulting in rapid accumulation of blood in the small blood vessels of the lungs. The pressure in these small blood vessels increases and they leak fluids into the air spaces of the lungs, causing sudden, very severe breathlessness. Air cannot be moved into the air spaces of the lungs, because they are full of fluid; as a consequence, blood no longer circulates, so death ensues, due to lack of oxygenated blood to the vital organs.
6.18 The severe breathlessness of acute left ventricular failure is usually accompanied by the appearance of foam – often bloodstained, producing a frothy, pale pinkish fluid – at the mouth and nose. The mechanism of death in acute left ventricular failure is analogous to drowning or suffocation, and the patient is usually extremely distressed. He or she will often try to get more air to relieve the feeling of suffocation, by loosening clothing or opening doors and windows. Dr Grenville said that he had seen patients with acute left ventricular failure 'a couple of times' in general practice and no more than six times in hospital, and he confirmed that such patients became very distressed. The condition is not, however, characterised by pain.
6.19 Despite the absence of pain, acute left ventricular failure can be treated by slow intravenous injection of morphine or diamorphine, in order to reduce the patient's distress and panic, and thus reduce the production of adrenaline and other hormones that would otherwise be released into the bloodstream and make the situation worse. Opiates also have a vasodilatory effect, which might reduce the pooling of blood in the lungs. In addition, large doses of a diuretic should be given intravenously, thus causing fluid to be removed from the bloodstream by the kidneys. This reduces the amount of fluid in circulation, which in turn reduces the amount of work which the heart has to do. Dr Grenville observed that, in a case of acute left ventricular failure, he would probably give the diuretic before the opiate and, if not then, immediately afterwards. Although acute left ventricular failure is a rare condition, he carries a diuretic with him when on duty, for the purpose of treating the condition if he encounters it. Acute left ventricular failure can cause death within two or three minutes of onset or, if the failure is less severe, over a period of minutes to an hour or so.
6.20 Reference has already been made to congestive heart failure and its cause: see paragraph 6.16 above. If congestive heart failure is present, then, because of deficiencies in the heart's pumping mechanism, blood collects in various organs of the body, usually the liver and lungs, where there are a lot of blood vessels. The organs become congested and increase in size; there is often a decrease in the organs' efficiency and, in the case of the lungs, fluid in the lungs can be heard by listening to the chest, where crepitations (soft crackling sounds) will be audible. Another area which becomes congested is the legs, which develop oedema and become large and swollen. There are other causes of oedema of the legs, usually resulting from problems with venous circulation, but the symptom is commonly associated with congestive heart failure. In severe cases of heart failure, fluid can leak through the skin of the legs, sometimes causing ulceration, with the attendant risk of septicaemia. Treatment for congestive heart failure includes diuretics. The administration of an opiate would not usually be appropriate treatment for congestive heart failure.
6.21 Other signs that would point to a diagnosis of congestive heart failure are gradually increasing shortness of breath (although other conditions, such as emphysema or asthma, may also cause this) and an enlarged liver (caused by blood backing up there) without any obvious cause. There may also be an irregularity of the heart rate. Dr Grenville referred to a particularly common irregularity, atrial fibrillation, where the heart beats irregularly but not sufficiently to keep going as effectively as it should. Such an irregularity can be indicative of congestive heart failure. Sometimes, a patient with severe congestive heart failure will develop a particular sort of sallow appearance, and cyanosis (a bluish discolouration of the skin resulting from an inadequate amount of oxygen in the blood). Congestive heart failure carries a poor prognosis, even with treatment, and Dr Grenville described how the condition can deteriorate so as to lead to death, which will usually be by way of acute left ventricular failure. Because congestive heart failure is frequently associated with coronary atherosclerosis, patients suffering from congestive heart failure sometimes die of a myocardial infarction.
6.22 When looking for signs of congestive heart failure, a doctor would usually listen to a patient's heart sounds and look for an increase in jugular venous pressure (JVP); the jugular vein is a vein in the neck, close to the surface of the skin, and situated just above the heart; it drains into the right atrium of the heart. If the pressure of blood in the heart is raised, the blood in the jugular vein backs up and can be seen and measured by the number of centimetres that the column of blood can be sustained above the sternal notch in the middle of the chest. Any increase in JVP above zero is an indicator of congestive heart failure.
6.23 Dr Grenville has observed, when giving evidence about some of the individual deaths, that Shipman tended to over-diagnose congestive heart failure, usually on the basis of the presence of ankle oedema, which he appeared to treat as virtually diagnostic of the condition. Once he had diagnosed congestive heart failure, he continued to treat the patient for it on an indefinite basis, often not reducing the medication prescribed, even when the condition seemed well controlled. When giving evidence about the death of Mr Samuel Mills, Dr Grenville said:

'…once he made ( the ) diagnosis, he was very keen to review patients, either himself or Sister Morgan. On about a three monthly basis, he would do a lot of blood tests, he would record the signs and symptoms and occasionally he would change the treatment upwards, but he never or rarely seemed to take a step-down approach to see whether they could manage now without their treatment. It is my experience that he probably diagnosed congestive heart failure more frequently than most of my colleagues' .

Cerebrovascular Accident

6.24 Dr. Grenville described three types of cerebrovascular accident – occlusive and haemorrhagic intra-cerebral events and subarachnoid haemorrhages.

6.25 An occlusive cerebrovascular accident, or 'stroke', is analogous to a myocardial infarction. The intra-cerebral arteries become occluded by atheroma and, eventually, there comes a point when the amount of oxygenated blood flowing through these arteries to the brain beyond the occlusion becomes insufficient to sustain the brain cells. The cells die over a period of time, and the long-term effects of this depend upon the volume and part of the brain affected. Brain cell death due to an occlusive stroke usually occurs over a number of hours, and symptoms (for example paralysis of the limbs, failures of speech and/or swallowing, visual field disturbances and unconsciousness leading to death) may appear slowly and serially. It is, in essence, a progressive condition, although there may be minor fluctuations in the rate of progress of the symptoms. When giving evidence in the case of Mrs Charlotte Bennison, Dr Grenville said:

'A stroke is a process rather than an event and…we talk about an evolving stroke. The symptoms start, the process will continue for a period and sometimes it is a short period, sometimes it is a long period.
The degree of damage done to the part of the brain affected will vary over time. We are usually talking a period of a day or two here' .

6.26 According to Dr Grenville, occlusive strokes do not usually cause sudden death, and may not lead to death at all. When death does occur after an occlusive cerebrovascular accident, it is usually due to medium or long-term complications, such as bronchopneumonia, or septicaemia, following the development of pressure sores.

6.27 A haemorrhagic intra-cerebral stroke is caused by a sudden rupture of a blood vessel within the substance of the brain, usually secondary to atheroma. As a result of the rupture, brain cells are killed rapidly. The symptoms produced by this type of stroke depend on the size of the vessel ruptured, and its position. This type of cerebrovascular accident can cause sudden death when it occurs within the brain stem and, in that event, the patient may suddenly lapse into unconsciousness without warning, and respiration and heartbeat may cease within a few minutes . If the stroke occurs within the cortex, death may not follow, or not immediately, and the course of symptoms and signs may resemble those of an occlusive stroke. Older people, who may well have a degree of atheroma, are particularly likely to suffer an occlusive or haemorrhagic intra-cerebral stroke.

6.28 A subarachnoid haemorrhage occurs as a result of a rupture of a blood vessel inside the skull, but outside the substance of the brain. Blood is forced into the narrow space between the skull and the brain, and pressure quickly builds up and causes a sudden, severe headache. The effects of a subarachnoid haemorrhage depend again upon the size of the vessel which has ruptured and the position of the vessel within the skull. A common site of rupture is within a group of vessels known as the Circle of Willis, and a rupture there often leads to sudden death due to a build-up of pressure on the brain stem, similar to that induced by brain stem haemorrhage. A subarachnoid haemorrhage is usually caused by congenital weakness of the blood vessel which ruptures.

6.29 Patients suffering a haemorrhagic intra-cerebral stroke in the brain stem, or a subarachnoid haemorrhage, may lapse suddenly into unconsciousness and die, but such patients represent a very small proportion of all patients suffering a stroke. The majority of stroke patients suffer a cerebrovascular accident of the occlusive type, or an intra-cerebral bleed other than in the brain stem. Such patients complain of neurological symptoms, such as weakness or altered sensation, or clumsiness in one or more limbs, difficulties with speaking or with understanding what is said to them, difficulty in swallowing and/or visual problems. Some patients become confused or partially conscious, and cannot explain their symptoms.

6.30 As to diagnosis, in the absence of clearly localised neurological symptoms, which may make a diagnosis of a cerebrovascular accident straightforward, the doctor should be looking for signs of neurological damage; to this end, he or she should check the relative strength of the muscle groups, test sensation in the limbs and reflexes (including pupillary reflexes of the eye and the plantar reflexes of the feet) and seek patterns which might suggest that there has been a sudden or fairly sudden onset of neurological damage, indicative of a stroke.

6.31 Dr Grenville said that, if a subarachnoid haemorrhage is suspected, a patient should immediately be admitted to hospital, where neurosurgical intervention may be successful in evacuating the blood clots within the brain and the skull, and in securing the blood vessel that has ruptured.

6.32 By contrast, little active treatment is currently available for occlusive and haemorrhagic strokes, and management usually consists of observation and supportive treatment to maintain as much function as possible. More emphasis may be placed on this latter aim in the future, given present trends in medical practice. In the past, however, the strategy has been to assess whether a stroke patient can be provided with adequate support at home and, if not, and if nursing care is required, to decide where he or she would be best cared for. The administration of opiates would not be appropriate where a stroke is suspected, or has been diagnosed, unless there were some other condition present which would warrant it.

6.33 Dr Grenville suggested that, if he had a patient whom he suspected of suffering from an evolving stroke, his approach would be as follows:

'I think I would suggest to the patient that, “There is certainly a possibility that you are having a stroke. It is happening to you; it is a process; it may get better; it may get worse. If it gets worse you could become quite seriously disabled. It may not be safe for you to be on your own. You may not wish to be on your own. We should be thinking about hospital admission. On the other hand, is there someone who can be with you, who can look after you, who can let me know if things deteriorate?”' .

6.34 He went on to point out that each patient has to be dealt with as a person in his or her own circumstances, who needs to be guided by the doctor, but who is ultimately an autonomous person who can make his or her own decision on the information which has been given. However, a patient in this position is at high risk of dying in the near future and should not be left alone without care and supervision.

6.35 If a general practitioner is confronted by a patient who is unconscious but not in cardiac arrest, Dr Grenville said that the doctor should consider the possibility that the patient has suffered a cerebrovascular accident. Other common causes of sudden death (such as myocardial infarction, pulmonary embolism and ruptured aortic aneurysm) tend to produce unconsciousness through the mechanism of cardiac arrest, so can probably be excluded in the absence of such an arrest. There are other mechanisms, which can cause unconsciousness without cardiac arrest, but the doctor should be looking for a previous history of atheromatous disease (which would include a history of angina, transient ischaemic attack or peripheral vascular disease) or of hypertension. Whilst these may be diagnostic pointers, they would not be conclusive in diagnosing a cerebrovascular accident.

6.36 Dr Grenville emphasised that the type of cerebrovascular accident which typically causes sudden death is rare, compared with the other types of stroke which do not usually result in sudden death. By contrast, there are many examples, among the cases which the Inquiry has investigated, where Shipman has purported to observe neurological changes characteristic of the occlusive type of stroke in a conscious patient, who is then said to have died suddenly, sometimes within minutes or seconds. When giving evidence about the death of Mrs Anne Ralphs, Dr Grenville observed:

'If she had suffered a cortical stroke which was affecting one side of her body, then she could have become progressively weaker on that side of the body. She could then have slipped gently into unconsciousness at which point I think admission would be mandatory to arrange at least nursing care of the unconscious patient. This would have been a slow process over a period of, I would have thought, at least 20 to 25 minutes, more likely to be over a period of several hours. The description…of sudden non-responsiveness and pupils dilated, sudden death does not really fit with a cortical stroke. This is more a description of a brain-stem stroke' .

6.37 A patient who suffers from persistent hypertension is at an increased risk of stroke; it appears that hypertension brings about changes to the wall of the arterial side of the blood vessels, and thus causes or encourages the development of atheroma. Furthermore, if a blood vessel is already weakened, then it is more likely to rupture if pressure in the vessel is higher. High blood pressure increases the risk of myocardial infarction also, but treatment, especially of the elderly, is mainly directed at the risk of stroke.

6.38 Blood pressure is generally measured over a period of several months. Dr Grenville's view is that, in order to confirm that high readings are not unrepresentative of the general level of blood pressure in the patient, and in the absence of exceptionally high readings, the doctor should have at least three readings several weeks apart which are sustainably and significantly high before making a firm diagnosis of hypertension. Dr Grenville noted, when giving evidence about the death of Mrs Charlotte Bennison, that Shipman measured his patients' blood pressure fairly frequently and, if it was found to be raised, he would treat it and ensure that the patient was monitored by Sister Morgan, who held regular hypertension clinics. Shipman was less consistent in his prescription of aspirin for those at a high risk of suffering a stroke.
6.39 It is quite common to see, in the medical records of Shipman's patients, the abbreviations 'TIA' , for 'transient ischaemic attack', or 'TCI' , for 'transient cerebral ischaemia'. According to Dr Grenville, a transient ischaemic attack is commonly known as a 'mini-stroke'. A patient will develop symptoms suggestive of a stroke, but will make a full recovery within 24 hours, often much more quickly. The mechanism is thought to be short-lasting occlusion of an intra-cerebral blood vessel, by way of micro-embolism, i.e. a patch of atheroma on a blood vessel which becomes dislodged, reaches a blood vessel of too small a calibre to allow it through, causes an occlusion, then breaks up, whereupon the occlusion disappears.

6.40 So, the brain cells downstream of the transient occlusion lose their oxygen supply temporarily, but are able to recover later, when the occlusion disappears. It is not possible to diagnose a transient ischaemic attack with absolute certainty until after the 24 hour period is up because, until then, an alternative diagnosis would be an evolving stroke. Once the symptoms are present, the patient needs to be observed, and the patients and relatives should be told what to look out for. The advice given to a patient would initially be the same as that given to someone thought to be experiencing an evolving stroke: see paragraph 6.33.

6.41 Dr Grenville told the Inquiry that a transient ischaemic attack is a major risk factor for developing a later completed stroke. There is no particular temporal association; the risk will continue to exist even after the transient incident has resolved.

Respiratory Conditions Causing Death

6.42 Shipman frequently certified bronchopneumonia as a cause of death and, less commonly, lobar pneumonia, respiratory failure, chronic bronchitis and emphysema, chronic obstructive airways or pulmonary disease and other respiratory conditions.

6.43 Dr Grenville explained that pneumonia occurs when the air pockets (alveoli) which form the tissue of the lungs become infected and inflamed. When both the alveoli and the main airways of the lungs (the bronchi) are affected, the condition is known as bronchopneumonia. If just the bronchi are infected, the condition is called bronchitis.

6.44 Pneumonia usually arises in one of the five lobes of the lungs, but can spread from one to another. A patient with pneumonia may become rapidly ill over a period of a few hours – certainly not a few minutes – and usually develops a high temperature, alternate feelings of hot and cold, becomes shivery and shaky, and develops a cough, often productive of sputum which may be bloodstained. Sometimes, there is also pleuritic pain which occurs sharply on one side of the chest when the patient is breathing in deeply or coughing.

6.45 Antibiotics are usually effective in treating pneumonia, provided that it is diagnosed early. However, the condition can be dangerous, particularly in patients who are frail, due to pre-existing illness or extreme old age. Diagnosis is usually made on the basis of a history of an ill patient who has developed noisy, difficult, rattly breathing, and where a doctor can hear abnormal breath sounds throughout the chest on using a stethoscope. Even where the condition is caught early and treated with antibiotics, severe cases may need admission to hospital for intravenous antibiotics and, sometimes, ventilation.

6.46 Dr Grenville explained that, if untreated, the patient's condition usually fluctuates to some extent, but is gradually progressive. There may be sudden resolution of the condition, or the patient may simply become exhausted and lapse into coma, and death may ensue. Dr Grenville said that this latter outcome should be extremely rare in modern medical practice with antibiotics. Pneumonia is, however, a common cause of death amongst patients suffering from terminal diseases and in elderly patients, especially during influenza outbreaks. Patients who are susceptible to death from pneumonia or bronchopneumonia are usually immobile and very weak, and do not have the strength to cough. Once an infection starts in the lungs it can spread rapidly and extensively into the alveoli and the bronchi. The patient's breathing becomes noisy and rattly, and there may be shortness of breath, although the patient may be so immobile that this is not evident.

6.47 In these circumstances, the condition can be treated by antibiotics administered orally or intravenously, and chest physiotherapy can assist in removing the infected secretions but, since such patients are already debilitated, the outlook is often very poor. The condition can also occur in patients who are unconscious, such as those who have had a stroke. Morphine or diamorphine should not be given for the treatment of the pneumonia itself; it would be dangerous to do so, because the patient's respiration will already be depressed. However, the patient may be suffering from a condition causing severe pain, and it may, therefore, be necessary to administer morphine or diamorphine to combat that pain. In such circumstances, it is important to balance the need to relieve pain against the unwanted effect of respiratory depression, which is more significant in a patient suffering from pneumonia than in one who is not. This balancing exercise is part of the problem of 'double effect', which is discussed further in Chapter Seven.

6.48 Dr Grenville told the Inquiry that patients dying of bronchopneumonia are usually weak and bed bound; they are obviously ill and become exhausted, often lapsing into unconsciousness; their respiration becomes increasingly rattly. Eventually, the respiratory effect decreases and their breathing becomes shallower until it ceases altogether. Frequently, the patient manifests Cheyne-Stokes respiration, whereby the breathing becomes shallow and appears to cease altogether and then, after a gap of seconds or minutes, respiration returns, shallowly at first and then deeper and stronger. Breathing may become quite rasping again and stertorous (heavy), before it again begins to tail off and become shallower and shallower and appears to stop again. This cycle of stopping and starting may be repeated many times until, eventually, the breathing does not restart, and the patient dies.

6.49 Dr Grenville observed that the fact that a patient was seriously unwell with pneumonia would be evident to a friend or relative who saw the patient, say, a few hours before his or her death.

6.50 Shipman sometimes certified the cause of death as respiratory failure (which merely means cessation of breathing) due to a variety of conditions, including chronic bronchitis and emphysema. With emphysema, the lung tissue has been damaged and this results in reduced oxygen transfer into the blood. In order to secure sufficient oxygen for transfer into the bloodstream, the patient has to work harder and therefore becomes short of breath, particularly on exertion. Chronic bronchitis is characterised by a productive cough, which persists for long periods. Emphysema and chronic bronchitis are different conditions but, since they share common causes (for example smoking, exposure to certain dusts and fumes), they are often found together in the same person.

6.51 People with chronic bronchitis and emphysema begin to become more breathless on less exertion. In time, this becomes quite noticeable in that they find it difficult or even impossible to walk up slight hills, or even on the flat, without regular stops to catch their breath. As the disease becomes more serious, the patient finds it increasingly difficult to walk even a few metres without stopping. At that point, he or she may need a wheelchair to get out or may even become housebound. In very severe cases, the slightest exertion – such as getting up or even speaking – becomes too much. During this process, the amount of oxygen getting into the bloodstream becomes less and the patient can become chronically cyanosed with blue-tinged extremities and eventually blue lips and nose. Some patients manage to keep themselves oxygenated by breathing harder and they remain pink. The patient's condition can sometimes be improved by oxygen therapy.

6.52 Death which is associated with chronic bronchitis and emphysema usually occurs as a result of an acute infection (such as pneumonia or bronchopneumonia), although a few patients with very severe bronchitis and emphysema develop chronic respiratory failure, whereby their respiratory drive decreases over a period of time. If an acute complication supervenes, deterioration leading to death is likely to occur over a period of several days. The patient will become more short of breath than usual, will start to cough, will probably complain of pleuritic pain, will develop a high temperature and will be obviously ill.

6.53 When giving evidence about the death of Mrs Beatrice Toft, Dr Grenville described the course to be expected in the few patients with very severe chronic bronchitis and emphysema who develop chronic respiratory failure:

'If she had died of respiratory failure, I would have expected her to be…bed-bound or chair-bound, significantly ill and probably needing nursing care by this time because she would not have been able to care for herself. Probably to become increasingly short of breath and then probably to have lapsed into unconsciousness because of hypoxia. Possibly to have exhibited Cheyne-Stokes respiration…It is not something I see frequently or, indeed, at all; it is a theoretical possibility. People who are this ill very often need to be in hospital anyway, to receive the care that needs to be given to them' .

6.54 Dr Grenville went on to emphasise that it is more common with cases of severe bronchitis and emphysema for there to be a long, slow, gradual deterioration, ending with an acute event which may be respiratory or may be cardiac or may even be a stroke

Cancer

6.55 A patient dying of cancer usually declines gradually, stops going out, requires help with shopping and other household chores and finally with personal care. He or she becomes more and more ill, often requiring increasing amounts of analgesia and eventually taking to bed. The usual cause of death is exhaustion or coma. A sudden death is not typical, although it can occur, for example, as a result of a heart attack or stroke or as a result of secondary tumours (metastases) in the brain or subluxation of a cervical vertebra, as appears to have occurred in the case of Mrs Mary Ogden. In general, however, deterioration to the point of death is a slow process. When giving evidence about the death of Mr Harold Eddleston, Dr Grenville said:

'…one has to say, what is the mechanism of death, why would carcinoma of the lung cause him to be found dead, presumably fairly rapidly, sitting upright in a chair? It just does not fit' .

6.56 In the case of Mr Samuel Mills, Dr Grenville said:

'Even in someone who declines extremely rapidly in this sort of situation with a high cancer load, we are talking about a matter of a minimum of several days and possibly a week or two, even if it is rapid' .

6.57 Shipman frequently diagnosed death as having been caused by carcinomatosis, that is widespread cancer throughout the body, which is often associated with cachexia, general wasting and bodily decline caused by the disease. It has not been uncommon to find that, whilst the patient had indeed suffered from cancer in one or more parts of the body, the disease has not been anything like so widespread as to justify Shipman's description of it as 'carcinomatosis'; Mr Mills was an example of such a patient.

The Presence of a General Practitioner at or shortly before a Patient's Death

6.58 Dr Grenville described the circumstances in which a general practitioner may be present at the very time when his or her patient dies. First, this might occur if the doctor has received an emergency call to attend a patient who is, for example, suffering a heart attack. The usual procedure would be that, on arrival, the general practitioner would start treatment, arrange the patient's admission to hospital and call an ambulance. If the patient collapsed, the doctor would undertake cardiopulmonary resuscitation; if that resuscitation were not successful, then the patient might die in the doctor's presence before the arrival of the ambulance. Dr Grenville told the Inquiry that this had happened to him on two occasions in his 20 year career in general practice.

6.59 Another situation in which a general practitioner might be present at the death of a patient could occur when the patient is known to be terminally ill and the doctor is visiting frequently, possibly daily or even more often. Death does sometimes happen during the course of such a visit. According to Dr Grenville, this is not common and only happened to him about once every two and a half years, when he was in full-time practice. Dr Grenville's practice does not operate personal patient lists, but each partner has an official average list size of 1380. That figure is significantly less than the size of Shipman's patient list (2931 in 1992; 3046 by 1998) so that it can be inferred that Shipman may have been expected to experience this type of occurrence more frequently, perhaps as often as once a year.

6.60 Shipman, however, claimed to be present at the deaths of his patients with far greater frequency than this. During the period of six months preceding the police investigation in March 1998, the information recorded by Shipman on cremation forms and in patients' medical records disclosed that he had been present at the deaths of seven patients out of the 31 patients whose deaths he had certified during that time. There were no cases of terminal illness amongst those seven patients; they all died sudden deaths, the cause of which was certified as cerebrovascular accident, coronary thrombosis or left ventricular failure.

6.61 In addition, Shipman frequently claimed to have visited patients in their homes a short time before their deaths. Of the 31 patients mentioned above (excluding those at whose deaths he had been present), he claimed to have visited eight within four hours or less before their deaths. Other years show a similar pattern. Of the 15 patients whose deaths at home he certified in 1989, for example, he admitted having visited eight within a period of two hours or less before their deaths; a ninth patient died in his presence at the Donneybrook Surgery. In 1993, the figures for a visit within the same period were 12 out of 28; in the case of six of those deaths, he admitted being present at the time of death.

6.62 When giving evidence about the death of Mrs Edna Llewellyn, Dr Grenville observed that the coincidence of a doctor being called to attend a patient suffering an angina attack and that patient then suffering a heart attack virtually as the doctor arrived (as Shipman claimed had happened in that case) was such that one might expect it to happen once in a professional career. He made a similar observation in the case of Mrs Marjorie Waller, where Shipman claimed that she had died within a very short time of a visit by him. Yet Shipman would have us believe that this was happening to him – purely by chance – on a regular basis.

6.63 When death does occur in a doctor's presence, there is, Dr Grenville said, a clear need for a most detailed note. Apart from the general obligation to make such a note and the need to remember details which may have to be recorded on the MCCD and cremation Form B, or reported to the coroner, Dr Grenville observed:

'I would also have in mind the fact that anger is a normal part of the bereavement reaction and that it is unusual – so unusual – for a patient to die in my presence that the bereaved relatives may, at one stage or another in their bereavement reaction, seek to blame me and I would want to be able to show that I had acted reasonably and done everything that I could be expected to do' .

6.64 By contrast, Shipman's notes were brief, sometimes non-existent. In the case of Mrs Kathleen Wagstaff, for example, at whose death he admitted having been present, his computerised record reads:

'call 1500 arrive 1515 def ct ( i.e. definite coronary thrombosis ) collapse died 1520' .

In the case of Mrs Irene Chapman, where he claimed that both he and his wife had been present at her death, he made no record at all of his visit (his second of the day), merely recording the fact and cause of her death on the outside of the envelope containing her medical records.

The Deceased's Position in Death

6.65 Dr Grenville told the Inquiry that, in his experience, it is extremely uncommon for a deceased person to be found sitting in a chair, head on one side, appearing peaceful and asleep, as so many of Shipman's patients were found. He went on to say:

'…death being a process rather than an instantaneous event, the patient is usually able to do something just before death, even if it is only to clutch the chest if it is painful, or to try to get up. That of itself, if then death supervenes and the muscle tension disappears, that is likely to cause the patient to slump to one side or to fall from the chair or to slump forwards. In general, I would say that to be found dead, sitting up in a chair, relatively unsupported, would require the patient to have become unconscious in that state, for death to have supervened without anything happening to cause the patient to move.
Once movement has started to occur, the situation becomes physically unstable. The patient is likely to fall or to slump. It is only when the patient is sitting in a balanced, stable state and the tension in the muscle gradually disappears that they are likely to remain in that state, sitting peacefully, looking as if they are asleep' .

6.66 In the course of his evidence, Dr Grenville related the views set out above to some of the causes of death commonly certified by Shipman.
6.67 Dr Grenville told the Inquiry that a patient suffering a fatal myocardial infarction is likely to have an interval of seconds, or one or two minutes, when he or she will be aware of impending disaster. Death is not an instantaneous process, whereby a person is active and alive one instant and is dead the next. The patient may be in severe pain and having difficulty breathing, but is likely to retain a certain amount of consciousness, enough perhaps to make an attempt to get help, to look for or reach for the telephone, to get up and go to the door with a view to shouting for help, or possibly to lie down. Dr Grenville said:

'…I do not think that sitting in a chair looking absolutely peaceful is consistent with death from a heart attack' .

6.68 When giving evidence about the death of Mrs Winifred Arrowsmith, Dr Grenville said:

'The mechanism of sudden death in coronary thrombosis is cardiac arrhythmia, usually ventricular fibrillation. The patient realises that something awful is happening. They either have the very severe pain or, if the disrrhythmia occurs before the pain is established, they still feel that something is going wrong because their circulation ceases. They have this feeling of doom, they may feel dizzy, they may have the pain. They will try to seek help and most patients, in my experience, in this situation are found somewhere between the chair and the telephone or the chair and the bed or the chair and the door or the chair and the alarm cord or whatever. Most of them have attempted to do something about the fact that they feel that something dreadful is going wrong' .

6.69 Dr Grenville went on to say that he is aware of occasions when patients have suffered catastrophic heart attacks while deeply asleep in bed; he has seen such deaths, maybe once every few years, in his own practice. He has never seen a patient who has died of a catastrophic heart attack while asleep in a chair. Dr Grenville did not entirely exclude the possibility that this might occur, but he said that it would require the patient to be very deeply asleep. In order to be able to sleep so deeply, he or she would have to be in an armchair with wings which supported the patient and prevented his or her head from slumping forwards. When talking about the position in which many of Shipman's patients were found, Dr Grenville said:

'…I think the description that we have heard of patients sitting upright in a chair comfortably with their arms on the arm of the chair, head unsupported and perhaps just slightly to one side, it does not seem to ring true to me' .

6.70 When acute left ventricular failure occurs, death can happen within two or three minutes of onset, although, in less severe cases, the fluid build-up in the lungs may occur rather more slowly. The patient is distressed, probably panic-stricken. The bloodstained foam is often evident. There may have been an attempt to loosen clothing, get to a window or relieve discomfort by sitting up or standing. Dr Grenville observed:

'The idea of someone who has died of acute left ventricular failure simply sitting, looking entirely peaceful, is just not credible' .

6.71 Even with death from chronic congestive heart failure, such a death would not be typical. Dr Grenville said, when giving evidence about the death of Mrs Fanny Nichols:

'...if she died of her congestive heart failure, there would have been some sort of agonal event; in other words, the heart might have decompensated and she might have gone into acute left ventricular failure on top of her existing congestive heart failure, or she might have had a heart attack (a myocardial infarction), due to the underlying ischaemic heart disease…neither of these would be consistent with finding her sitting peacefully in her chair' .

However, when talking of the death of Mrs Olive Heginbotham, Dr Grenville said that he could not rule out the possibility that someone in the last stages of heart failure might prefer to sit down and might, therefore, be found in a sitting position.

6.72 Dr Grenville went on to describe the manner of death from a brain stem haemorrhage, which can cause loss of consciousness and death rapidly and without warning. Even then, Dr Grenville said there may be a second or two when the patient realises that all is not well, maybe enough time for a patient who is sitting down to make a convulsive movement or jerk forward. Death from an occlusive stroke, or a haemorrhagic stroke affecting parts of the brain other than the brain stem, is again, in his view, inconsistent with death in the manner and position typical of Shipman's patients. Dr Grenville observed:

…almost having the appearance of being just switched off like a light switch while sitting quietly does not really accord with my understanding of mechanisms of the process of death' .

6.73 Death from occlusive stroke is likely to occur after a period of increasing weakness, followed by a gradual slip into unconsciousness. When giving evidence about the death of Mrs Charlotte Bennison, Dr Grenville observed:

'The sort of stroke that he ( Shipman ) is describing was a weakness in the right arm and the right leg, is a stroke occurring in the cerebro cortex of the left side of the brain, that is the higher part of the brain. That can certainly spread. The effects of it can spread and what tends to happen is that the paralysis tends to get more dense. The arm and leg become increasingly weak to the extent that they may not be able to be used at all.

Very often in this situation, the part of the brain controlling speech is affected and the patient becomes dysphasic, unable to get out the words that they know they want to say; they may well then slip into unconsciousness but it will not be a collapse into unconsciousness, it will be an increasing weakness and they will realise that something is going wrong and they may try to seek help and they may at least try to go to bed or something like that. The sort of stroke where someone might be found looking peaceful…is a brain stem haemorrhage where a catastrophic event happens very suddenly' .

Dr Grenville said that the possibility of a person suffering an occlusive stroke, followed immediately by the type of stroke which would cause a sudden death, is very remote.

6.74 As to death from bronchopneumonia or lobar pneumonia, this is not, in Dr Grenville's view, consistent with finding a deceased person in a chair, looking peaceful and appearing to be asleep. Dr Grenville explained that this was because:

'…we are dealing with patients who are very often ill from other causes, they will be in bed, they will be being cared for, we know their history, they are ill patients. Such patients do not sit up in their chairs, in their ordinary outdoor clothes, and suddenly are found dead. That does not happen' .

6.75 By contrast, the appearance of a deceased person sitting in a chair and appearing peacefully asleep would be entirely consistent with that person having become drowsy, then unconscious, and finally having slipped into death as a result of the administration of a lethal dose of opiates.


The Collapsed Patient

6.76 When a general practitioner is called to a patient who has collapsed, the first priority, according to Dr Grenville, is to check whether the patient is breathing and feel for a pulse. If pulse and respiration are present, the patient should be placed in the recovery position, so as to ensure that the airway is clear, and the doctor should then turn his or her attention to diagnosing and managing the condition which has caused the collapse.

6.77 If, on examination, there is no pulse or respiration, the doctor should assess the situation, in order to decide whether resuscitation is appropriate or not. Resuscitation would not be appropriate, for example, where there is obvious major trauma incompatible with life, or where the doctor can establish that pulse and respiration have been absent for more than a matter of minutes. This latter situation might occur if there were witnesses who gave a history of absence of pulse and respiration for a significant period, or if the doctor found that the patient was cold (other than in death by drowning or hypothermia), or if the doctor observed that rigor mortis had set in, or post-mortem lividity was present. All these would be indicators that respiration and pulse had been absent for so long that irreversible brain damage would have occurred, and the patient must be dead. If, however, it appears that the collapse is very recent, i.e. within the past three or four minutes, then Dr Grenville said that resuscitation should, in general terms, be attempted.

6.78 An exception to that general rule might arise in the case of an elderly person who was expected to die shortly in any event; then, Dr Grenville said that resuscitation may not be appropriate. However, a decision not to resuscitate on the grounds of age alone would not, in his view, be acceptable, and he told the Inquiry that he did not believe that his own policy towards the resuscitation of elderly people had changed over his 20 years in practice, save only that, with the improvement of medical technology, he has, if anything, become more likely to attempt resuscitation because there is a greater chance of ultimate success in saving the patient.

6.79 If a patient collapses in a general practitioner's presence, then the doctor will have the advantage of the knowledge gained by his previous observation of – and, possibly, communication with – the patient, and may well have some idea of the cause of the collapse. In the event that an examination reveals that pulse and respiration are absent, Dr Grenville said that cardiopulmonary resuscitation should always be attempted, unless the doctor is aware that the patient would not wish this to occur, either through knowledge of an advance directive signed by the patient, or from previous conversation with the patient. This statement contrasts with Shipman's practices; although he frequently claimed to be present when a patient collapsed, it was extremely rare for him to attempt resuscitation. There were occasions when he claimed to have attempted to resuscitate in circumstances where he had plainly not done so, but he did not make any such claim in every case, frequently telling the relatives later that resuscitation would have been inappropriate for one reason or another.

6.80 Dr Grenville explained that resuscitation, when attempted, is directed at keeping oxygenated blood flowing to the brain, and thus keeping the patient alive until further definitive treatment can be given. It involves external cardiac massage to keep some blood flowing through the vascular system, together with artificial respiration to ensure that the blood that is being kept flowing is oxygenated. Cardiopulmonary resuscitation itself is not likely to cause spontaneous restoration of the heartbeat and respiration; it is a supportive treatment until definitive treatment is available.

6.81 According to Dr Grenville, it is extremely difficult and tiring for one person (even a trained person such as a doctor) to work on the circulation and the airway at the same time. If there is someone present who, albeit untrained, is physically fit and willing to help, he or she can be shown how to perform external cardiac massage whilst the trained person concentrates on the airway. Such an arrangement has a greater chance of success than if the single person continues to administer resuscitation alone. If three people participate in the resuscitation process, the chances of its succeeding are again increased. In order for external cardiac massage to be effective, the patient needs to be lying on a hard surface. This is because the aim is to compress the heart between the anterior and posterior chest walls, and, if the patient is on a soft surface, pressure just pushes his or her body into the soft surface and the heart is not compressed. An item of clothing with buttons down the front would have to be removed in order for massage to be carried out and clothing would have to be disturbed in order to check that the patient was in cardiac arrest in the first place. These requirements are relevant when considering Shipman's claims that he attempted resuscitation on patients who were found lying on a bed or sitting in a chair with their clothing completely undisturbed.

6.82 If a general practitioner is confronted by a patient who has collapsed in his or her home, the doctor should attempt to get someone else to alert the emergency services, whilst he or she embarks upon resuscitation. If there is someone else in the house, or nearby, then that person can be given the task. Otherwise, the doctor may have to attempt a few cycles of cardiopulmonary resuscitation, make a telephone call, and then return to resuscitation. The latter course would obviously reduce the chances of successful resuscitation but, if there is no help at hand, may be the only course of action available; Dr Grenville has never found himself in that position.

6.83 Nowadays, ambulances are equipped with trained paramedics, defibrillators, endotracheal tubes and oxygen. A defibrillator is a machine that delivers an electric shock to the patient in such a way as to try to reorganise the electrical impulses of the heart which have become disorganised. It only works in a condition called ventricular fibrillation, not in circumstances where there is asystole, i.e. no electrical activity in the heart at all. An endotracheal tube is used to maintain the airway, which can easily become blocked.

6.84 Dr Grenville pointed out that, even before ambulances were equipped with trained paramedics and defibrillators, it was still important to summon an ambulance when a patient collapsed, since ambulance crews were trained in basic resuscitation techniques, and their arrival increased the chance of a successful resuscitation. Indeed, it was possible for two people inside the ambulance to maintain cardiopulmonary resuscitation, whilst the third drove the ambulance to the hospital, where a defibrillator would be available.

6.85 According to Dr Grenville, cardiopulmonary resuscitation should be continued until spontaneous heartbeat and respiration are restored or until it is clear that irreversible brain damage has occurred.

The Diagnosis of Death

6.86 Clearly, it is vitally important for a doctor who is told, or believes, that a patient has died, to make absolutely certain that this is the case. Dr Grenville pointed out that there are conditions – such as severe hypoglycaemia – which can mimic death. He observed:

'You need to be very certain that the heart really has stopped, that it is not beating very, very slowly and very, very slightly, that the respiration really has stopped, that you are not missing very slow, very shallow respirations' .

6.87 Dr Grenville went on to describe the steps which a doctor should take to ascertain whether death really has occurred. He conceded that the requirement to carry out all the steps that he described may vary with the circumstances. If a death has been expected, and there are people on hand who have observed the patient for a time before the doctor arrives, it may not be strictly necessary to follow every step, although Dr Grenville said that he would still make a thorough examination, because of the possibility that other people may be mistaken. If rigor mortis has set in, or lividity, the fact of death may be obvious.

6.88 In the absence of such obvious signs, however, a thorough examination should be carried out. First, the doctor should feel for a pulse at the wrist or, if a pulse cannot be detected there, at the large carotid artery in the neck. Dr Grenville himself would spend about 30 seconds feeling at each location, to ensure that he was not missing a very slow heartbeat. If he did not feel a pulse at the neck, and the patient was wearing a shirt or similar garment, he would unfasten the collar to gain access and ensure that he had correctly located where the pulse should be. The doctor should then observe the chest wall for respiration, again for at least 30 seconds. If no movement is visible, it is necessary to remove or loosen the upper clothing, so as to be able to view the chest itself. The doctor should also listen to the chest, using a stethoscope, again for a period of 30 seconds, possibly longer. The stethoscope should be applied to the skin, usually on the front of the body.

6.89 If the examinations described above have yielded negative results, the doctor will have become fairly certain that death has indeed occurred. The next step is to shine a bright torch into each eye to check the pupillary reaction. Once brain death occurs, the pupils become fixed and dilated, but care must be taken to ensure that there is no other reason (for example pupillary paralysis, caused by previous surgery) for the paralysis. The doctor should then look at the interior of each eye, using an ophthalmoscope to give a clear view of the blood vessels. Dr Grenville explained that, when blood stops flowing through these vessels, the column of blood breaks up and the vessel can be seen to contain short lengths of blood, alternating with short lengths where the blood is absent; this phenomenon is known as 'cattle trucking'. It is difficult to observe and may be obscured, for example by cataracts, but, if seen to be present, it is a very significant pointer to the diagnosis of death. The final step is to apply a painful stimulus, usually by flexing forcibly the end knuckle of the finger, to ascertain whether any response is received; if the patient is deeply unconscious, he or she will probably respond with a withdrawal reflex. The whole of the examination described would take between three and four minutes, and it would be obvious to anyone looking on that it was being conducted.

6.90 If a doctor had seen a patient alive and that patient died unexpectedly a short time later – a situation in which Shipman frequently claimed to find himself – Dr Grenville said that all the tests described should be performed, in order to satisfy the doctor that the patient has indeed died. By contrast, Shipman rarely carried out any such examination. Sometimes, relatives told the Inquiry that he did not even approach nearer than a few feet from the body. If he did, he would usually touch the back of the neck, flick open an eyelid or briefly check the pulse at the wrist. Dr Grenville observed that all these examinations, alone or in combination, would be inadequate in order to diagnose the fact of death, whilst touching the back of the neck as Shipman frequently did (apparently to check for brain stem activity) was, according to Dr Grenville, 'simple charlatanism'.

6.91 It is relevant to mention here that, when paramedics from the Greater Manchester Ambulance Service diagnose a death, they are required to complete a form with tick boxes, confirming:

that the patient has been in a collapsed condition with no signs of life for a period in excess of ten minutes and there has been no bystander cardiopulmonary resuscitation;

that there are no palpable pulses, carotid or femoral;

that there are no signs of spontaneous respiration;

The Shipman Letters

The following letters are the first in a series of letters (the remaining letters will appear on criminalprofiling within the week) written by convicted murderer Dr Harold Shipman from his prison cell. The letters were sent to a couple who were close friends of Dr Shipmans for over 25 years. They remained friends until the end of Shipmans murder trial when the couple became convinced of his guilt and confronted him during a prison visit. The correspondence ended. The letters date between September 1998 and January 2000. All spellings are Shipman's. Annotations are sometimes made in bold parenthesis. Shipman signed his letters with 'Fred' (Harold Fredrick Shipman).

Shipman Report : Chapter 5 - Existing Procedures....

The First Report > Death Disguised > Chapter 5 - The Existing Procedures for Death Registration and Cremation Certification

Shipman Report - Chapter 4 - Shipmans Practice

The First Report > Death Disguised > Chapter 4 - Shipman's Practice

Shipman Report : Chapter 3 - Evidence and Oral Hearing

The First Report > Death Disguised > Chapter 3 - The Evidence and Oral Hearing

Shipman Report : Chapter 2 - The Inquiry

The First Report > Death Disguised > Chapter 2- The Inquiry

Shipman Report: Chapter 1 - Before the Inquiry

The First Report > Death Disguised > Chapter One - Before the Inquiry

Shipman Report Summary

I. The First Report > Death Disguised >

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.

6. Throughout his career as a general practitioner, Shipman 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'.

7. In July 1998, the Greater Manchester Police began an investigation into the death of one of Shipman's patients, Mrs Kathleen Grundy. That investigation was rapidly widened to include the deaths of many other patients of Shipman.

8. On 7th September 1998, Shipman was arrested, interviewed and charged with the murder of Mrs Grundy and with other offences associated with the forgery of her will, under which he was to be the sole beneficiary of her estate. He was subsequently suspended from practice and charged with 14 further murders.

9. On 31st January 2000, following a lengthy trial, Shipman was convicted of 15 counts of murder and one of forging Mrs Grundy's will. He was sentenced to 15 terms of life imprisonment and, for the forgery, a concurrent term of four years' imprisonment. The trial judge said that his recommendation to the Home Secretary would be that Shipman should spend the remainder of his days in prison. Following the criminal trial, the Director of Public Prosecutions announced that no further criminal proceedings would be instituted against Shipman.

10. Subsequently, the Professional Conduct Committee of the General Medical Council erased Shipman's name from the medical register.

11. Before the trial and subsequently, the police investigated a large number of deaths of Shipman's patients where there was evidence that Shipman had been responsible for the death. Those deaths were reported to the South Manchester Coroner, Mr John Pollard. Between August 2000 and April 2001, he conducted inquests into 27 deaths of patients of Shipman, recording verdicts of unlawful killing in 25 cases and open verdicts in the remaining two. On 18th May 2001, the Coroner opened inquests into a further 232 deaths; those inquests were immediately adjourned on the direction of the Lord Chancellor, pending publication of the findings of this Inquiry.

12. On 31st January 2001, following resolutions of both Houses of Parliament, the Secretary of State for Health issued the instrument of appointment establishing The Shipman Inquiry, giving it the powers conferred by the Tribunals of Inquiry (Evidence) Act 1921 and appointing me as Chairman of the Inquiry.

13. The first of the Inquiry's Terms of Reference requires it, 'after receiving the existing evidence and hearing such further evidence as necessary, to consider the extent of… Shipman's unlawful activities'. In this, the Inquiry's First Report, I set out my findings as to how many of his patients Shipman killed, the means employed and the period over which the killings took place.

14. Volumes Two to Six of this Report contain my written decisions in 494 cases – 493 deaths and one incident involving a living person. Those decisions are based on an enormous volume of evidence, which has been gathered by the Inquiry team.

15. I have found that Shipman killed 215 of his patients. The first, Mrs Eva Lyons, was killed in March 1975, when Shipman was practising in Todmorden, and the last, Mrs Kathleen Grundy, died in June 1998.

16. Shipman's usual method of killing was by the administration of a lethal dose of an opiate, most frequently diamorphine. There is some evidence that he may have killed a few patients by the administration of large doses of a sedative. There is no reliable evidence that he killed by any means other than the administration of a drug.

17. Of the 215 killings, one took place in Todmorden, 71 during Shipman's time at the Donneybrook practice and the remaining 143 during his six years at the Market Street Surgery. While at the Market Street Surgery, Shipman killed one patient in 1992, 16 patients in 1993 and 11 in 1994. In each of the years 1995 and 1996, he killed 30 patients, increasing to 37 in 1997. During the first three months of 1998, he killed 15 patients, after which there was an interval of about seven weeks; he went on to kill a further three patients before his arrest in September 1998.

18. Shipman's oldest victim, Miss Ann Cooper, was 93 years old when she was killed. The majority of Shipman's victims were elderly but he did, on occasions, kill younger people. Mr Peter Lewis died at the age of only 41; he was the youngest of Shipman's patients to die at his hands. Mr Lewis was in the advanced stage of a terminal illness and Shipman hastened his death. The youngest of Shipman's victims to suffer an unexpected death was Mr David Harrison, who was 47 years old when he died.

19. Of Shipman's 215 victims, 171 were women and 44 were men. In general, 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. However, he also killed men when the opportunity presented itself.

20. Whilst the majority of the deaths for which Shipman was responsible occurred while he was working as a single-handed practitioner, it is nevertheless clear that, even while working in a multi-handed practice, he was able to kill undetected over a period of many years.

21. I have found that 210 of the deaths investigated by the Inquiry team occurred as the result of natural causes and not by reason of any action on the part of Shipman. I hope that the families concerned with these cases will be reassured by my finding that Shipman was not responsible for their relative's death.

22. There are 45 deaths for which I have found that a real suspicion arises that Shipman may have been responsible, although the evidence is not sufficiently clear for me to reach a positive conclusion that he was. In addition, there are a further 38 deaths in respect of which there was so little evidence, or evidence of such poor quality, that I was unable to form any view at all. These are mainly deaths dating from the early years, where little documentary or witness evidence survives. I regret that the families concerned with these deaths are left in a state of uncertainty, but it was inevitable that there would be some cases where the evidence would not permit me to reach a positive conclusion one way or the other. I can only hope that it will be of some comfort to the relatives at least to know that the circumstances of each death have been investigated as fully as possible.

23. In all, the Inquiry has examined 888 cases; I have given a written decision in 494 (493 deaths and one incident involving a living person) of those cases. In the remaining 394 cases, there was compelling evidence that Shipman was not responsible for the death. The Inquiry legal team therefore closed the files in those cases, without the necessity for a written decision. In all but the most straightforward cases, I examined the file and confirmed the decision to close it.

24. Professor Richard Baker OBE, Professor of Quality in Health Care at the University of Leicester, conducted a review of Shipman's clinical practice, which was published in January 2001. He carried out a number of analyses of the estimated excess of deaths among Shipman's patients during his career as a general practitioner. He estimated that the true number of excess deaths lay between 198 and 277 and concluded that an excess of 236 deaths was 'most likely to reflect the true number of deaths about which there should be concern'.

25. Having considered my findings, Professor Baker has concluded that they support the conclusion that the excess of deaths is in the region of 220 to 240, i.e. very close to his own figure of 236. Here, Professor Baker is taking into account, not only the 215 deaths which I have found that Shipman caused, but also some of the deaths about which I was unable to reach a positive conclusion but where I found that there was a real suspicion that Shipman was responsible. It is inevitable that that group of deaths will, in fact, contain some killings. The striking compatibility between the results of Professor Baker's previous review and my own findings strongly suggests that the conclusions of the Inquiry and of the review are very likely to be correct.

26. All but three of the deaths for which I have found that Shipman was responsible were entered in the register of deaths in reliance upon Medical Certificates of Cause of Death completed by Shipman. The majority of those deaths were followed by cremation. 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. These procedures are intended to provide a safeguard for the public against concealment of the fact that a person has been unlawfully killed. Yet, even with those procedures in place, Shipman was able to kill 215 people without detection. It is clear therefore that, in reality, the procedures provided no safeguard at all. Why that was, and what steps should be taken to devise a system which will afford the public a proper degree of protection in the future, are issues which the Inquiry will consider during Phase Two.

27. Shipman's patients frequently died suddenly at home, without any previous history of terminal or life-threatening illness. Such deaths should be reported to the coroner. Yet Shipman managed to avoid a referral to the coroner in all but a very few cases in which he had killed. He did this by claiming to be able to diagnose – and, therefore, to certify – the cause of death and by persuading relatives that there was no need for a post-mortem examination. In Phase Two, the Inquiry will consider measures which can be taken to ensure that all unexpected or unexplained deaths are reported and their cause properly investigated.

28. After Shipman's convictions for drugs offences in 1976, he declared his intention never to carry controlled drugs again. Accordingly, he was not obliged to have a controlled drugs register. Yet he was able, by a number of different methods, to obtain large quantities of controlled drugs; in 1996, he prescribed and obtained in the name of a dying patient as much as 12,000mg diamorphine on a single occasion. That alone would have been sufficient to kill about 360 people. Despite the fact that the possession and supply of such drugs is said to be 'controlled', those controls did not prevent Shipman from acquiring large amounts of diamorphine without detection. How that could happen, and what measures should be taken to strengthen the system of controlling access to such drugs, are matters which will also be considered by the Inquiry in Phase Two.

29. Professor Baker has observed that one implication of the high number of patients killed by Shipman is that an effective system of monitoring the death rates of patients of general practitioners would have detected the excess number of deaths. No such system was in place during Shipman's time in general practice. In Phase Two, the Inquiry will seek to identify effective systems for monitoring death rates, and will consider other possible improvements to the arrangements for monitoring general practitioners and ways of encouraging those genuinely concerned about possible misconduct on the part of doctors to express their concerns to those in a position properly to investigate and evaluate them.

30. No one reading this Report can fail to be shocked by the enormity of the crimes committed by Shipman and to feel, as I do, the deepest sympathy for his victims and their families. His activities have brought tragedy upon them and also upon the communities in which he practised and which gave him their trust.

31. In its first Phase, the Inquiry has determined the extent of Shipman's criminality. We shall now direct our efforts to attempting to devise improved systems so as to ensure that such a terrible betrayal of trust by a family doctor can never happen again.


First Report : Table of Conents


© Crown Copyright 2002

Shipman - 215 Victims

The public inquiry into further victims of convicted murderer Harold Shipman reported today that in addition to the 15 murders for which he is imprisoned, Shipman killed a further 215 patients. High Court Judge Dame Janet Smith, who headed the inquiry into the deaths, said there was also a suspicion Shipman had killed 45 more people between 1975 and 1998.

Smith said she had "no clear conclusion" about Shipman's motive. In only one case was there evidence that he killed for money, and she said there was "no suggestion of any form of sexual depravity".

Rational Fanatics

What drives a suicide bomber? While most of the world sees them as lone zealots, they are, in fact, pawns of large terrorist networks that wage calculated psychological warfare. According to Ehud Sprinzak, contrary to popular belief, suicide bombers can be stopped-but only if governments pay more attention to their methods and motivations.

Jack the Ripper : Dr. Bond's Post Mortem on Mary Kelly

This post-mortem report was written by Dr. Thomas Bond after he examined the remains of Mary Jane Kelly. The report was lost until 1987, when it was returned anonymously to Scotland Yard.

Jack the Ripper : The Macnaghten Memoranda

The official notes written by Sir Melville Macnaghten in 1894 in response to a published remark in The Sun referring to a man named Thomas Cutbush and his possible connections to the Ripper slayings. It delves more into the Ripper case itself than it does into Cutbush, and is one of the most quoted documents in Ripper investigations. These were sent to Scotland Yard as an official report, and a slightly edited version is available in the Public Record Office.

Case Study : Stopping a Serial Sniper

Suffolk County, New York, located on Long Island, 18-miles east of New York City, has a population of 1.3 million residents, who live in both suburban and rural areas. During the summer of 1994, the Suffolk County Police Department, with 2,663 sworn members, faced a series of sniper attacks that prompted a highly concentrated response from the department.

The Cold Case Concept

Today, murders in our country's major urban areas are more vicious, senseless, and random than ever before. Staggering murder rates in recent decades have overwhelmed law enforcement efforts to investigate these heinous acts, leaving many homicides unsolved for years. In Washington, DC, the Metropolitan Police Department (MPD) and the FBI joined forces to clear the glut of unsolved homicides in the city by establishing a squad to work exclusively on unsolved murders.

Shipman Inquiry Transcript 1

1 Transcript for Hearing Day 1 Wed 20 Jun 2001 2 DAME JANET: Today is the first day of the public 3 hearings of the Shipman Inquiry. In a few minutes, 4 I shall ask Miss Caroline Swift, Queen's Counsel, who 5 is leading counsel to the Inquiry, to open the 6 proceedings but first I want to deal with a few 7 preliminary matters. 8 As you will know, I have decided not to allow 9 broadcasting of the proceedings during Phase 1 and 10 Phase 2 of the Inquiry. I have allowed the cameras in 11 here for a few minutes this morning before the 12 proceedings begin, to allow the broadcasters to set the 13 scene for their future coverage. 14 Let me explain the layout. The witnesses will 15 give evidence from the seat to my left. To my right is 16 Doctor Aneez Esmail, who is my adviser on matters 17 relating to public health and general practice; he will 18 sit with me for much, although not all, of the time. 19 Counsel to the Inquiry are in that rank of seats there 20 and the representatives of the interested parties are 21 arrayed at the benches around the horseshoe. 22 When the evidence begins, as I see now, the face 23 of whoever is speaking will appear on the screen to my 24 right and also, I hope, on the screen up there in the 25 public gallery. Whenever a document is to be examined, 2 1 it will be shown on the screen to my left and the 2 content of any document on that screen can be enlarged 3 so that everyone, including those in the public gallery 4 and the annex at Hyde library, will be able to read the 5 passage under consideration. Today, in anticipation of 6 extensive public interest, the sound and pictures are 7 also being relayed to the Great Hall in this building. 8 Those of you who attended the public meeting on 9 10th May will recall that I then attempted to estimate 10 the number of individual deaths which the Inquiry will 11 look into in Phase 1. I said that we were currently 12 examining 466 deaths but that the number might 13 increase. I stressed that that was not an estimate of 14 the number of people Shipman might have killed. I said 15 that it would be wrong at this stage to speculate about 16 how many deaths he was responsible for. I said that 17 I anticipated that there would be many cases in which 18 I would be able to say that there was no cause for 19 suspicion. Unfortunately, that sentence was widely 20 misreported by the omission of the word "no" which 21 changed its sense significantly. Even this morning on 22 the "Today" programme, that sentence was misquoted. 23 This is most unfortunate and it may have encouraged 24 speculation in the media about the number of deaths 25 caused by Shipman. I am anxious to discourage the kind 3 1 of speculation which at this stage can be no more than 2 guesswork. 3 I am also anxious that the media should be given 4 every assistance to ensure accurate reporting of the 5 proceedings. At the public meeting, I explained that 6 all witness statements and a transcript of the 7 witness's evidence would be posted on the Inquiry's 8 website. However, that cannot be done until about 9 24 hours after the evidence has been given, which is 10 too late for the day's media reports. Accordingly, 11 I have asked Mr Cuerden to provide witness statements 12 to the media as soon as the witness has taken the oath 13 and has acknowledged the statement to be his or hers. 14 I cannot promise that that facility will be available 15 immediately in every case, but it usually will be and 16 I hope it will be of real assistance to the media in 17 their important task. 18 That is all I want to say. Will the cameras now 19 leave and please will all those who are using tape 20 recorders switch them off? Thank you very much. I am 21 now going to close down the microphones until the room 22 has been cleared of cameras. 23 (The media withdrew) 24 DAME JANET: I think we are ready to begin now. I will 25 ask Miss Swift to address the Inquiry. 4 1 Miss Swift, you will recall, I think, on 10th May 2 I outlined the hours that we would keep during the 3 hearings and we will rise for lunch at about 1.00 pm, 4 but I think certainly this morning, and indeed probably 5 on most mornings, we will need a short break in the 6 middle of the morning. Today, as you are effectively in 7 charge, can I leave it to you to decide when would be a 8 convenient moment to break? I suggest around about 9 11.30 am. 10 MISS SWIFT: Certainly, madam. 11 DAME JANET: Thank you very much. 12 Opening remarks by MISS SWIFT 13 MISS SWIFT: Madam Chairman, Doctor Esmail, ladies and 14 gentlemen, Harold Frederick Shipman's medical career 15 began almost 36 years ago when he entered the Leeds 16 University Medical School in September 1965 at the age 17 of 19 years. After five years spent in study and 18 clinical work, he moved on to the post of a junior 19 houseman at the Pontefract General Infirmary. By that 20 time, he was married with one child. During his first 21 year at Pontefract, he completed the six months' 22 medical and six months' surgical work necessary to 23 qualify him as a doctor. Thereafter, he continued to 24 work at the same hospital as a senior houseman, gaining 25 diplomas along the way in child health and gynaecology. 5 1 Shipman's ambitions, however, did not lie in 2 hospital work. He wanted to enter general practice and 3 in March 1974 he achieved that aim by joining a busy 4 group practice at the Abraham Ormerod Medical Centre in 5 Todmorden, a town in the Pennines on the 6 Lancashire/Yorkshire border. There, after a month's 7 trial, he became a junior partner with a view to 8 becoming a full partner in about three years time. 9 Over the ensuing months, he impressed his 10 colleagues with his zeal and with his enthusiasm for 11 and knowledge of modern medical techniques. Amongst the 12 tasks which he undertook on arrival at the surgery was 13 the collection of drugs from the local pharmacy and the 14 organisation of the surgery drugs cabinet. In the light 15 of the events which followed, those facts were to 16 assume a particular significance. 17 Although apparently well regarded by his fellow 18 doctors, his patients and other professionals in 19 Todmorden, Shipman's career there was to be 20 short-lived. In September 1975, only 18 months after 21 joining the practice, he was forced to leave after 22 admitting obtaining large quantities of pethidine for 23 his own use. In the course of its investigations, the 24 Inquiry has obtained the Home Office Drugs Inspectorate 25 file relating to Shipman's dealings with pethidine in 6 1 the 1970s as well as the General Medical Council file 2 for the same period. From these documents, a clearer 3 picture of the events which occurred at that time has 4 emerged. However, there are still further documents 5 being sought and further witnesses to interview. 6 The picture, although clearer, is not yet in full 7 focus. I am, however, able to give a fuller and more 8 accurate account of the events of 1975 and 1976 than 9 has been available hitherto. 10 It is now evident that Shipman's activities 11 had attracted the attention of the Home Office Drugs 12 Inspectorate and the Huddersfield Drug Squad as early 13 as February 1975. Routine checks of local pharmacies 14 had revealed that between April 1974 and the end of 15 January 1975, Shipman had obtained on requisition, 16 ostensibly for practice use or collected on behalf of a 17 patient, over 100 ampoules of pethidine, each 18 containing 100 milligrams of the drug. The Detective 19 Sergeant deputed to investigate this abnormally high 20 use talked to local pharmacists and came away reassured 21 by what he had heard. He subsequently reported that it 22 would appear Doctor Shipman is held in some esteem by 23 them and is described as very efficient and confident. 24 He concluded that there was no evidence of drug abuse. 25 Accordingly, a decision was taken in March 1975 to 7 1 watch and wait to see if anything further came to 2 light. 3 It soon did. In early June 1975, it was noticed 4 that a local pharmaceutical company were supplying 5 abnormally large amounts of pethidine injections to 6 Boots the Chemist in Todmorden. These amounts were 7 accounted for by Shipman's orders for the drug. As a 8 result, he was interviewed in July 1975 by two Home 9 Office Inspectors and a Detective Constable from the 10 West Yorkshire Police. Throughout the interview he was 11 described as "relaxed" with "a confident manner". He 12 gave no impression of being concerned at being 13 questioned and showed no visible sign of being an 14 abuser of drugs. He offered ready explanations for the 15 amount of pethidine he had obtained from the pharmacy. 16 The practice register of purchases of controlled drugs 17 was found to be in order and to contain records of all 18 the drugs which had been acquired, but no register of 19 the supply of the drugs to patients had been kept as 20 was required by law. Shipman was unable satisfactorily 21 to account for all the pethidine ampoules which he had 22 acquired for practice use. 23 Because of the deficiencies in procedures which 24 had been revealed by the practice visit, a Home Office 25 Inspector visited the practice in early August 1975 to 8 1 instruct the partners, including Shipman, in the 2 requirements for the keeping of controlled drugs and, 3 in particular, the maintenance of a drugs supply 4 register and the correct procedures for destroying 5 controlled drugs. 6 Meanwhile, whilst the Home Office officials were 7 not completely satisfied with Shipman's explanations 8 for his use of the drugs obtained, they resolved to 9 take no further action immediately but to keep the case 10 under review. They requested from the police a further 11 report in six months' time giving details of all 12 controlled drugs obtained by Shipman over that period. 13 In the event, the six-month review never took place. 14 In late September 1975, one of Shipman's partners 15 received an invoice from Boots the Chemist detailing 16 quantities of pethidine ampoules which had been 17 obtained by the practice. On consulting the Controlled 18 Drugs Register, he discovered that none of these 19 purchases had been entered in it. He confronted Shipman 20 with this discovery, whereupon Shipman admitted that he 21 was an abuser of pethidine and tendered his resignation 22 from the practice, a resignation which he later 23 attempted -- unsuccessfully -- to withdraw. 24 On the same day, Shipman was admitted to the 25 Halifax Royal Infirmary under the care of a consultant 9 1 physician who rapidly referred him to a consultant 2 psychiatrist. Three days later, he was admitted to 3 The Retreat, a well-known psychiatric centre in York, 4 where he remained until the end of December 1975. 5 Meanwhile, the latest developments had been 6 immediately notified to the Home Office Drugs 7 Inspectorate and to the police and, on 28th November 8 1975, a Home Office Inspector, together with a 9 Detective Sergeant from the West Yorkshire Drugs Squad, 10 interviewed Shipman at The Retreat. Initially, he 11 refused to speak to the police officer but changed his 12 mind and gave what his interviewers at that time took 13 to be a full account of his criminal activities. 14 He told them that he had started taking pethidine 15 about 18 months before (that is in about May 1974) when 16 he became depressed because of difficulties with his 17 partners. He admitted that he had injected himself 18 intravenously and bared his arms showing that the veins 19 had collapsed. He claimed that he had been taking about 20 600 to 700 milligrams of pethidine a day towards the 21 end of the period. He admitted taking for his own use 22 pethidine which he had prescribed in the name of a 23 number of patients who received only a small part, or 24 in one case, none of it. 25 Other methods of obtaining the drug which he 10 1 admitted were: forging the signatures of staff at a 2 local nursing home to make it appear they had 3 authorised the collection of prescriptions, which he 4 then collected himself; and using and obtaining over 5 220 ampoules of pethidine by way of written 6 requisitions for the practice, which he then kept for 7 himself. 8 Having answered questions, Shipman made a 9 detailed written statement setting out his account of 10 what had occurred. In that statement he said these 11 words: 12 "I have no future intention to return to 13 general practice or work in a situation where I could 14 obtain supplies of pethidine." 15 On 13th February 1976, Shipman appeared at 16 the Halifax Magistrates' Court where he pleaded guilty 17 to eight specimen charges and asked for 74 further 18 offences to be taken into consideration. Unfortunately, 19 the list of offences taken into consideration does not 20 survive. It does not appear that the Home Office Drugs 21 Inspectorate or the GMC ever had a copy; certainly 22 there is none on their files and the police and court 23 documents which would have contained such a list have 24 now, we are told, been destroyed. However, it is clear 25 from the contemporaneous press reports that 67 of the 11 1 74 offences concerned the obtaining of pethidine by 2 deception. If each of those offences involved ten 3 ampoules of 100 milligrams each, as did three of the 4 charges, then that would mean that 700 ampoules or 5 70,000 milligrams of pethidine was involved. Shipman 6 was fined a total of œ600 and ordered to pay costs of 7 just less than œ60. 8 By the time of his conviction, Shipman had 9 already been working for a matter of days since 10 2nd February as a Clinical Medical Officer for the 11 Durham Area Health Authority. It was pointed out at the 12 Magistrates' Court hearing that that job did not 13 require him to have access to drugs. However, he was 14 not destined to stay in County Durham for long. 15 Following Shipman's convictions at the 16 Magistrates' Court, his case fell to be considered by 17 both the GMC and the Home Office. The GMC had to decide 18 whether to take disciplinary action against him to 19 remove or restrict his registration as a doctor. The 20 procedure at that time was that when a doctor was 21 convicted of a criminal offence, his case was 22 automatically referred to a body called the Penal Cases 23 Committee which decided on the basis of written 24 evidence and submissions, whether the case should be 25 referred for Inquiry by the GMC Disciplinary Committee; 12 1 in other words, the Penal Cases Committee had the task 2 of filtering out those cases which it considered did 3 not require the attention of the full disciplinary 4 committee. That was the position in 1976. The procedure 5 has since changed and the Penal Cases Committee no 6 longer exists. 7 Shipman's case duly came before the Penal Cases 8 Committee which had before it psychiatric reports from 9 the doctors that had been responsible for treating 10 Shipman, following the revelation of his criminal 11 activities at the end of September 1975. One 12 psychiatrist wrote, expressing the view that: 13 "It would be to his advantage if he were allowed 14 to continue in practice and conversely it would be 15 catastrophic if you were not to be allowed to continue 16 in practice also." 17 Also before the Committee was a supportive letter 18 from the Area Medical Officer of the Durham Area Health 19 Authority, recording that: 20 "Shipman had settled satisfactorily into his 21 new employment, where his previous problems were known, 22 and had been well received by both patients and 23 professional colleagues alike." 24 On 28th April 1976, the Penal Cases Committee 25 of the GMC determined that no inquiry into Shipman's 13 1 case should be held by the Disciplinary Committee and 2 that the case could therefore be concluded. 3 Subsequently, a letter was sent to him, the 4 second paragraph of which reads as follows: 5 "The Committee instructed me to inform you 6 that they take a grave view of offences arising out of 7 an abuse of drugs and of offences involving dishonesty. 8 You would therefore be wise to assume that if 9 information relating to any further conviction of a 10 similar nature should be received by the Council, a 11 charge would then be formulated against you on the 12 basis of both the earlier and the later convictions and 13 referred to the Disciplinary Committee of the Council 14 for Inquiry." 15 The GMC informed the Home Office of its decision 16 by a letter dated 3rd May 1976. 17 Following Shipman's conviction for offences under 18 the Misuse of Drugs Act 1971, the Home Secretary had 19 power under that Act to make a direction under 20 section 12 prohibiting Shipman from having in his 21 possession, prescribing, administering or otherwise 22 dealing with such controlled drugs as was specified in 23 the direction. In the event, the Home Office officials 24 who dealt with the case decided that no further action 25 should be taken. In reaching that decision, they appear 14 1 to have been influenced by the view expressed by the 2 police that there was no evidence that any of Shipman's 3 patients had suffered as a result of his obtaining 4 pethidine and also by the decision of the GMC not to 5 take disciplinary proceedings against Shipman. Shipman 6 was therefore free to practice wherever and in whatever 7 manner he chose and, almost exactly two years after 8 denying that he had any such intention, he chose to 9 return to general practice. 10 On 1st October 1977, Shipman was admitted to the 11 Donneybrook Practice in Hyde. His partners there were 12 told by him that he had had a pethidine addiction and 13 had been convicted in connection with it, but that he 14 had since ceased using the drug. They respected his 15 openness in telling them and accepted his account of 16 the events which had occurred previously. Shipman was 17 to stay at the Donneybrook Practice for over 14 years. 18 Each of the partners there had their own list of 19 patients and Shipman soon built up one of the largest 20 lists. He was hard working and became popular with his 21 patients. He was active in introducing new ideas to the 22 practice and also in other areas. For several years, 23 for example, he was heavily involved with the local 24 St John Ambulance, a member of the then Family 25 Practitioners Committee and, later, Secretary of the 15 1 Tameside Local Medical Committee. 2 In 1991, Shipman's partners discovered that he 3 was intending to leave the Donneybrook Practice. The 4 ostensible reasons for this were his dislike of 5 computers (Donneybrook had introduced a computer to 6 record patient details in 1989) and his distaste for 7 the proposed scheme of fundholding. 8 With hindsight, these official reasons for his 9 departure make little sense, since once in his own 10 practice Shipman embraced enthusiastically the use of 11 computers and, indeed, became Chairman of the local 12 users' group for Microdoc, a software system developed 13 especially for doctors. As to fundholding, in about 14 1995, he joined the Tameside South Consortium for the 15 specific purpose of fundholding. Whatever the reasons 16 behind his move, from 1st January 1992, Shipman ran a 17 single-handed practice, at first from within the same 18 premises of the Donneybrook Practice but, after August 19 1992, out of new premises at Market Street, Hyde. 20 He took with him several members of staff from 21 the Donneybrook Practice and, much to the annoyance and 22 financial detriment of his former partners, his patient 23 list. For the next six years, his practice appeared to 24 flourish. There was not room in his list to accommodate 25 all the patients who wished to join it and by the time 16 1 of his arrest, Shipman was actively attempting to 2 recruit a partner to share his workload and enable the 3 practice to take on more patients. 4 The practice performed regular medical audits 5 which impressed the Health Authority Audit Group and 6 was generally regarded as being advanced in its 7 development. In a letter written in August 1998 to the 8 NHS Appeals Tribunal (in connection with a decision of 9 the local Health Authority about funding of his 10 practice staff), Shipman felt able to make this claim: 11 "We are a proactive practice. We have the 12 highest level of screening for cholesterol, blood 13 pressure, diabetes and asthma in the West Pennine 14 Health Authority. We are a flagship. The Health 15 Authority can always compare the quality of this 16 practice to any other and ask why the other practice is 17 underperforming." 18 In addition, Shipman was active in local 19 medical politics and an enthusiastic member, latterly 20 treasurer, of the local branch of the Single-Handed 21 Practice association. Although there were people who 22 regarded Shipman as arrogant, sometimes overbearing, 23 the majority of his patients, his staff and others with 24 whom he came into contact held him in the highest 25 esteem and firmly believed that the welfare of his 17 1 patients was his first priority. 2 By March 1998, however, certain people in 3 Hyde had begun to feel concern at the number of 4 Shipman's elderly patients who were dying in curiously 5 similar circumstances. After discussion with her 6 colleagues, Doctor Linda Reynolds, a member of the 7 nearby Brook Surgery Practice, alerted the Coroner, Mr 8 John Pollard, to her and others' concerns. He initiated 9 a limited investigation involving the police and the 10 West Pennine Health Authority. That investigation 11 concluded that there was no evidence to suggest foul 12 play. 13 It was not until August 1998 that further 14 concerns surfaced, this time relating to the will of 15 Mrs Kathleen Grundy who had died on 24th June 1998. 16 Police investigations began in early August but Shipman 17 continued to practice from the Market Street Surgery 18 until he was arrested and charged with Mrs Grundy's 19 murder on 7th September. Subsequently he was charged 20 with 14 further murders and remanded in custody. A 21 hearing at the NHS Tribunal was held on 29th September 22 and the decision to suspend Shipman from practice was 23 notified on 15th October. It took effect after the 24 expiration of the appeal period on 29th October. At 25 that time, the Health Authority was able to take 18 1 control of his practice. 2 On 31st January 2000, after a lengthy trial 3 at Preston Crown Court, Shipman was convicted of 15 4 offences of murder and one of forging Mrs Grundy's 5 will. Thereafter, he was suspended from practice by the 6 GMC Preliminary Proceedings Committee and, on 11th 7 February 2000, his name was erased from the register by 8 the Professional Conduct Committee of the GMC. Thus, 9 Shipman's medical career came to an end. 10 On 31st January 2001, exactly a year after 11 Shipman's conviction, and following debates in both 12 Houses of Parliament, the Secretary of State for Health 13 issued the instrument of appointment establishing this 14 Inquiry. The terms of reference first require that 15 after receiving the existing evidence and hearing such 16 further evidence as necessary, the Inquiry should 17 consider the extent of Harold Shipman's unlawful 18 activities. This is the subject of Phase 1 of the 19 Inquiry. During Phase 1, the Inquiry will consider how 20 many patients Shipman killed, the means employed, and 21 the period over which the killings took place. 22 Today, I shall confine my remarks to matters 23 relating to Phase 1 alone. Issues relating to such 24 matters as the current procedures for death and 25 cremation certification, the outcome of the abortive 19 1 police investigation of March 1998, the adequacy of the 2 procedures governing possession and use of controlled 3 drugs, and other possible systemic inadequacies and 4 failures belong to Phase 2 of the Inquiry and will be 5 thoroughly explored and debated at the appropriate 6 time. They are not for consideration at present. 7 Madam Chairman, from the moment when the 8 Inquiry team was first assembled, you were determined 9 that, wherever possible, worried relatives and friends 10 should receive an answer to the distressing question 11 uppermost in their minds: did Shipman kill my parent, 12 grandparent, aunt, uncle or friend? Your concerns 13 sprang first and foremost from a recognition that the 14 people affected needed to know the truth and, secondly, 15 from a realisation that, without knowing how many 16 people Shipman killed and over what period, it would be 17 impossible to judge whether existing systems should 18 have led to his earlier detection. Of course, you have 19 said previously, and I reiterate now, that it will not 20 be possible for you to reach a firm decision as to the 21 cause of death in every case which is put before you. 22 In some instances, particularly deaths in the 1970s and 23 early 1980s, the evidence may be too limited to permit 24 a decision to be made. However, it has been and remains 25 the aim of the Inquiry team to obtain sufficient 20 1 evidence to enable you to reach a decision in as many 2 cases as possible. 3 How, then, has the Inquiry team gone about the 4 task of identifying the deaths which the Chairman is to 5 consider? Information about the deaths of Shipman's 6 patients or others with whom Shipman may have had some 7 connection has come from a number of separate sources. 8 The first of these has been the police, the Greater 9 Manchester Police and, in connection with Shipman's 10 activities in Todmorden, the West Yorkshire Police. The 11 Greater Manchester Police gave us immediate access to 12 their database, the Home Office Large Major Enquiry 13 System (known by the acronym "HOLMES"), and all deaths 14 reported to the police by concerned relatives or 15 otherwise appearing on HOLMES are included on the 16 Inquiry's database. 17 The second major source was Professor Baker. In 18 the course of his research, which I shall refer to 19 later, he identified every death or virtually every 20 death from Todmorden and Hyde where Shipman signed the 21 death certificate. Obviously there is an overlap 22 between these deaths and those already known to the 23 police, but any additional deaths on Professor Baker's 24 list have been placed on the Inquiry database. 25 The third category comprises those deaths in 21 1 respect of which relatives or friends have expressed 2 concern directly to the Inquiry or to the helpline 3 operated by West Pennine Health Authority following 4 Shipman's arrest. 5 Fourthly, we put up a database for the names of 6 deceased patients whose medical records were found in 7 Shipman's house or garage. There were 158 of these. 8 The final category which the Inquiry has decided 9 to include in its investigations comprise all deaths 10 reported to the South Manchester Coroner between 11 October 1977 and the end of Shipman's practice in Hyde 12 in 1998, a period of 21 years, where Shipman was 13 involved as the deceased's GP, as the referring doctor 14 or in any other capacity. Identification of those 15 deaths is not easy, involving, as it does, 16 handsearching of approximately 2,500 coroner's files 17 for each of the 21 years in question. But we have 18 decided that, in order to gain a complete picture, the 19 task must be undertaken. 20 Examination of a random five years of referrals 21 completed so far has revealed that the majority of 22 deaths plainly occurred as a result of natural causes 23 and not by reason of any criminal activity on the part 24 of Shipman, but enquiries have been initiated into a 25 small number of deaths identified by this route. It is 22 1 too early to say what those enquiries will uncover. 2 The compilation of the database has been, and continues 3 to be, an evolving process and it may be that there are 4 yet more names to be added from sources at present 5 unknown to us. 6 Not every death identified by the means which 7 I have described has been investigated. In 152 cases, 8 the only information which the Inquiry had was a death 9 certificate or a copy entry in the deaths register 10 signed by Shipman which was insufficient to enable any 11 view to be formed as to the circumstances of death. We 12 are currently writing to relatives of each of these 13 deceased persons with a view to obtaining further 14 information about the circumstances of their death. Of 15 those deaths which have been examined, there are 125 16 cases in which the Inquiry has been able to conclude 17 that there is no cause for suspecting that the death 18 was unlawful. Relatives in those cases are being 19 notified and asked to communicate any concerns or 20 comments to the Inquiry. In due course, a full list of 21 closed cases will be published. The total number of 22 files open as at today's date and requiring the 23 Chairman's decision is 459. 24 Madam Chairman, you and the Inquiry team are all 25 too familiar with the types of evidential material 23 1 which will be available to you in files relating to 2 individual deaths. For the benefit of those without 3 that familiarity, however, it is important that I take 4 a little time to describe the evidence upon which your 5 decisions will be based. This also affords me, 6 conveniently enough, the opportunity to demonstrate the 7 working of the Trial-Pro Document Display System which 8 we shall be using throughout the hearing. 9 For the purposes of example, I shall be using the 10 file relating to Miss Ada Warburton, a lady who died in 11 March 1998 and whose death has been the subject of an 12 inquest resulting in a finding of unlawful killing. The 13 file relating to a particular deceased person is 14 preceded by the letter "D", followed by the initial of 15 the deceased person. To take the example of 16 Miss Warburton, she is the first deceased in the system 17 with a surname beginning with the letter "W" so that 18 her file has the code _DW01^. The first documents in 19 the deceased person's files are the witness statements 20 taken on behalf of the Inquiry. These have been taken 21 either by the Inquiry's solicitor agents Eversheds, or 22 by the solicitors acting for some of the families. The 23 bulk of these statements have been taken from relatives 24 and friends of persons whose deaths are being 25 investigated, but other individuals have also been 24 1 interviewed and this process will continue right 2 through Phases 1 and 2 of the Inquiry. To date, more 3 than 325 statements have been taken on behalf of the 4 Inquiry and many more are still to come. 5 Witness statements have a prefix "01" in the 6 final group of numbers. To take the example of Miss 7 Warburton's file again, the first witness statement I 8 which is that of William Catlow appears at _D101^ for 9 witness statement, 01 for the first person beginning 10 with W, 01 for the witness statement, 001. Could we 11 have that document please? 12 When first displayed as you see, the document 13 is difficult, if not impossible, to read on screen. 14 However, it is easily enlarged and what we shall do is 15 to select the section upon which we wish to concentrate 16 -- let us say here paragraph 2 -- and can we enlarge 17 that, please, and can we highlight it also. Can we 18 then take the first sentence of that paragraph and 19 enlarge and highlight that alone. 20 At this point, I want to say something about 21 the way in which witness statements will be treated. 22 Not all those who give witness statements will be 23 called to give oral evidence. Indeed, those who are 24 called will be very much in the minority. The number of 25 deaths in respect of which evidence will be heard in 25 1 the Inquiry chamber will be limited, not least because 2 the Inquiry team is only too aware of the strains which 3 attendance to give evidence will impose upon family 4 members and friends of the deceased. We are anxious to 5 keep their ordeal to a minimum. 6 Those who are not asked to attend to give 7 oral evidence must not feel that their evidence will in 8 any sense be treated as second class. Their statements 9 will go before the Chairman and be accorded the same 10 weight as if their authors had given their evidence 11 from the witness box. Nor must it be thought that the 12 fact that the Inquiry does not hear evidence in 13 relation to a particular death means that that death is 14 considered any less important than others in respect of 15 which live evidence is given. The Inquiry regards every 16 death which it is investigating as equally important 17 and entitled to the same careful consideration. This 18 will be given whether or not the Inquiry hears oral 19 evidence. 20 The choice of cases in which oral evidence is to 21 be called is governed by a number of different factors 22 but chief of these is the need to clarify some part of 23 that evidence. All those relatives and friends of the 24 deceased from whom witness statements have been taken 25 have been given the opportunity to comment on what they 26 1 perceive to be the systemic failures which allowed 2 Shipman to kill without detection and they have been 3 invited to volunteer their own suggestions for change. 4 Some of those who responded to that invitation will be 5 called to give evidence at various stages of Phase 2 of 6 the Inquiry. Thus, whilst the Inquiry will not, in the 7 light of the jury's verdicts, be considering the cause 8 of death in the conviction cases, some of the relatives 9 of Shipman's known murder victims will be invited to 10 contribute to the Inquiry's deliberations during Phase 11 2. 12 In many cases, the police had already taken 13 statements, all of which have been made available to 14 the Inquiry through the HOLMES database. As at 6th June 15 of this year, the last occasion when the HOLMES 16 database was updated, we have been supplied with 2,311 17 police statements by this means. Police statements have 18 the prefix, for our purposes, "02". By way of example, 19 the first police statement for Miss Warburton can be 20 seen at _DW0102001^. There you see the document; there 21 is no need for us to examine it now. 22 Not every person who provided a statement to 23 the police has been invited to give a witness statement 24 to the Inquiry. Often the police statement contained 25 sufficient information for our purposes and, in that 27 1 event, it will stand alone and be received in evidence 2 in precisely the same way as a statement which has been 3 taken specifically for the Inquiry. 4 The third category of evidence are coroners' 5 documents. In some cases which the Inquiry is 6 considering, as I have already mentioned, there was a 7 referral to the Coroner at the time of death and, on 8 occasions, a post-mortem or even an inquest. There are 9 also 27 cases where inquests have taken place since 10 Shipman's convictions for murder. In all cases where a 11 referral to a Coroner has been made, the documents 12 arising from a referral are included on the file with 13 the prefix 03. There was an inquest in Miss Warburton's 14 case following the criminal trial and the inquest 15 documents begin at _DW0103001^. That is the first 16 document. Again, there is no need for us to examine it 17 in detail at this stage. 18 The fourth category of evidence relates to 19 death certification. Here I must say something about 20 the current system of death certification. This is a 21 topic which will be fully explored in stage 1 of Phase 22 2 of the Inquiry but, in order to make sense of the 23 events surrounding the individual deaths, it is 24 necessary to understand how the system works. The 25 Births and Deaths Registration Act 1953 requires that 28 1 in the case of the death of a person who has been 2 attended during his last illness by a registered 3 medical practitioner, that practitioner shall sign a 4 medical certificate in the prescribed form (which is 5 known as the Medical Certificate of Cause of Death or 6 MCCD) stating to the best of his knowledge or belief 7 the cause of death and shall forthwith deliver that 8 certificate to the Registrar for the sub district in 9 which the death took place. The words "in attendance on 10 the deceased during his last illness" are not defined. 11 The intention clearly is that the cause of death should 12 be certified by the doctor with the best knowledge of 13 his patient's medical history, who is likely to be able 14 to provide an accurate cause of death. 15 In addition to cause of death, the 16 certificate also contains certain other details and 17 that can be seen on the MCCD relating to Miss Warburton 18 at _DW0104001^. Can we enlarge that, please, the top 19 section above the box with "Cause of Death". We have 20 the medical cause of death, a title which should be 21 readily seen underneath that. For those who cannot make 22 out the very small lettering: 23 "For use only by a registered medical 24 practitioner who has been in attendance during the 25 deceased's last illness and to be delivered by him 29 1 forthwith to the Registrar of Births and Deaths." 2 Then we have certain information: the name 3 of the deceased; the date of death as stated by the 4 medical practitioner who is completing the certificate; 5 the age which appears on the right-hand side; below 6 that, "Place of Death" and, underneath that -- and 7 important often for our purposes -- the date when the 8 deceased was last seen alive by the medical 9 practitioner who is completing the form. 10 Is it possible to enlarge the section which 11 appears below so as to get the lettering a little 12 larger than it is at present? Thank you. 13 Taking the left-hand column first of all, 14 there are four options, one of which should be ringed 15 by the medical practitioner completing the form. 16 The first is: 17 "The certified cause of death takes account 18 of information obtained from post-mortem." 19 So in other words, the post-mortem has taken 20 place and has informed the information on the 21 certificate. 22 The second option is: 23 "Information from a post-mortem may be 24 available later." 25 The third: 30 1 "Post-mortem not being held", and the 2 fourth: 3 "I have reported this death to the Coroner 4 for further action." 5 On the right-hand side, there are again three 6 options on this occasion: 7 "A. Seen after death by me" [that is the 8 certified medical practitioner]; 9 "B. Seen after death by another medical 10 practitioner but not by me", and: 11 "C. Not seen after death by a medical 12 practitioner." 13 Here you can see that Shipman has ringed "3" 14 on the left-hand side and "A" on the right and that is 15 the most common combination to be seen on the MCCDs, 16 which will be examined in the course of Phase 1 of the 17 Inquiry. 18 Can we go now, please, to the box headed 19 "Cause of Death" and enlarge that. This is, as is 20 evident, cause of death in 1(a): 21 "Being the disease or condition directly 22 leading to death; 23 "(b) other disease or condition, if any, 24 leading to 1(a); 25 "(c) other disease or condition, if any, 31 1 leading to 1(b)." 2 We shall be considering the construction of 3 the certificate, as I have said, further in Phase 2 of 4 the Inquiry. 5 Then number 2 is: 6 "Other significant conditions contributing to 7 the death but not related to the disease or causing 8 it." 9 You see here that Shipman has entered the 10 words "cerebrovascular accident" in Miss Warburton's 11 case and on the right-hand side we are asked for the 12 approximate interval between onset and death; he has 13 given a time of six to eight hours. 14 Then going to the bottom of the form below 15 the next box, we there have the declaration made by the 16 medical practitioner who declares: 17 "I hereby certify that I was in medical 18 attendance during the above named deceased's last 19 illness and that the particulars and cause of death 20 above written are true to the best of my knowledge and 21 belief ..." 22 and the signature of the doctor (in this case, 23 Shipman); the residence (which in fact is more usually 24 the practice address); qualifications and relevant 25 date. 32 1 MCCDs are only available for deaths 2 registered after September 1994. Very recently, 3 however, the Inquiry has obtained books of MCCD 4 counterfoils completed by Shipman during most of the 5 Donneybrook years and these are now available for many 6 of the pre-1994 cases. The counterfoils contain almost 7 as much information as the certificates themselves and 8 should, therefore, prove helpful in those cases where 9 the available evidence is sparse. 10 Although the duty to deliver the certificate 11 to the Registrar is imposed on the medical 12 practitioner, in practice what usually happens is that 13 the doctor hands over the certificate to a member of 14 the deceased's family and a family member takes it to 15 the Registrar at the same time as fulfilling his or her 16 own duty to inform the Registrar of the death. Books of 17 blank MCCDs are supplied by the Registrar to local 18 medical practitioners. When a certificate is issued, a 19 counterfoil is completed and retained in the book and 20 it is these counterfoils which have recently been 21 discovered at the Donneybrook Surgery. 22 The informant of the death must give certain 23 information about the deceased to the Registrar: the 24 date and place of death; full name; date and place of 25 birth; occupation; usual address, and one or two other 33 1 details. The information given by the medical 2 practitioner and the informant is then entered in the 3 register and signed by the informant. If the Registrar 4 is satisfied that the death does not need to be 5 reported to the Coroner, a Certificate of Registration 6 of Death (usually called the Death Certificate) will be 7 issued, giving authority for burial or to apply for 8 cremation. That certificate also has a counterfoil 9 which has to be returned to the Registrar to inform him 10 whether a burial or a cremation has taken place and of 11 the details thereof. 12 The history which I have given so far assumes 13 the cause of death can be identified and a death 14 certificate issued. Sometimes, of course, this is not 15 possible and a death has to be referred to the Coroner. 16 It is the duty of the Registrar of Deaths to report 17 deaths to the Coroner in the following circumstances: 18 where the deceased was not attended during his last 19 illness by any doctor (and again the words "attended 20 during his last illness" are not defined); or where the 21 Registrar has not been able to obtain a completed MCCD; 22 or where it appears that the doctor who has certified 23 the cause of death did not see the deceased after 24 death, nor within 14 days before death; or where the 25 cause of death appears to be unknown; or where the 34 1 Registrar has reason to believe that the death was 2 unnatural or caused by violence or privation of neglect 3 or to have been attended by suspicious circumstances or 4 abortion; or where the death appears to have occurred 5 during an operation or before recovery from the affects 6 of an anaesthetic; or, finally, where the death appears 7 to have been due to industrial disease or industrial 8 poisoning. 9 There are certain circumstances where persons 10 other than the Registrar have a duty to report a death 11 to the Coroner, but it is unnecessary to go into them 12 here. 13 When a Coroner is informed of a death, he must 14 make preliminary enquiries which may lead to a 15 post-mortem. If that shows conclusively that the death 16 was due to natural causes, he need not hold an inquest 17 and will instruct the Registrar to register the death. 18 If there remains some doubt and an inquest is required, 19 that must, of course, take place before death can be 20 certified, although it may be possible for the deceased 21 to be buried or cremated in the intervening period. 22 What, then, are the duties of a doctor when 23 confronted by a patient who has died suddenly? Where 24 the doctor can state a cause with confidence (a patient 25 with terminal cancer dying of the disease, a person 35 1 with a long history of heart problems succumbing after 2 exhibiting the classic signs of a coronary thrombosis), 3 the doctor may properly complete the MCCD and state 4 what he believes to be the cause of death. If the cause 5 of death is uncertain, then he should not give the 6 certificate and the death should be referred to the 7 coroner. In practice, the doctor himself will probably 8 inform the Coroner in those circumstances, although he 9 is not obliged to do so; the obligation lies on the 10 Registrar who has failed to obtain a completed MCCD. 11 In some cases, a doctor will telephone the 12 coroner's office and seek advice as to whether he can 13 sign an MCCD. The Inquiry will be examining this 14 practice and, indeed, the general issue of referral to 15 the Coroner during stage 1 of Phase 2 of the Inquiry. 16 Present in each file is a death certificate 17 or copy of the entry in the Register of Deaths. In 18 Miss Warburton's file, there are both. At _DW0104002^, 19 there is a copy of the entry in the death register. 20 There is also a death certificate amongst the inquest 21 documents at _303O^. There is no need for us to look 22 closely at those documents at this stage. 23 The next category of evidence comes from the 24 cremation certificate. Where the deceased was cremated 25 and the death occurred after 1984, the file usually 36 1 contains a cremation certificate. Crematoria are 2 required to preserve cremation certificates for a 3 period of 15 years after which they are usually 4 destroyed by shredding. If the deceased is to be 5 cremated, an additional and rather more elaborate 6 procedure for certification applies. 7 Application for a cremation is usually made 8 by the executor or nearest relative of the deceased who 9 should complete Form A of the certificate. In 10 Miss Warburton's case, Form A can be seen at _05006^. 11 The form was completed by Miss Warburton's great-niece 12 whose details, together with those of Miss Warburton 13 herself, appear at the top of the form. Can we just 14 enlarge the details at the top of the form, please. 15 It gives the name of the applicant for 16 cremation, the address, occupation, and then similar 17 details for the deceased together with age, and marital 18 status. Can we now enlarge the first five questions. 19 Question 1 asks whether the applicant is an executor or 20 the nearest surviving relative of the deceased and here 21 we see Miss Creasey is the nearest surviving relative. 22 Then the next box is only applicable if neither an 23 executor nor the nearest surviving relative. The third 24 question is: 25 "Have the nearest relatives of the deceased 37 1 been informed of the proposed cremation?" 2 The fourth question asks about any objection 3 which may have been raised, and the fifth relates to 4 the date and time of the death of the deceased. 5 Can we now look at questions number 6 to 10. 6 Question 6 asks about the place where the deceased died 7 and the category of residence, whether it was own home, 8 lodgings, hotel, hospital, nursing home; here it is 9 clearly at a home address. 10 Question 7 asks whether the applicant knows or 11 has any reason to suspect that the death of the 12 deceased was due, directly or indirectly, to violence, 13 , poisoning, privation or neglect, and the answer there 14 is obviously all "no". 15 Question 8: "Do you know any reason whatever for 16 supposing that an examination of the remains of the 17 deceased may be desirable?" 18 Again here, as in most, if not all, of the 19 others, we shall see the answer "no". Then the name and 20 address of the ordinary medical attendant (which is 21 given as Doctor Shipman), and the names and addresses 22 of the medical practitioners who attended during the 23 deceased's last illness and, again, the answer here 24 being Doctor Shipman. 25 Can we now look at the declaration signature at 38 1 the bottom of the form. The applicant declares that to 2 the best of his or her knowledge and belief the 3 information given in the application is correct and no 4 material particular has been omitted, and signs that 5 and then has to have the form countersigned by a second 6 person who knows the applicant and has no reason to 7 doubt the truth of any of the information furnished. 8 In practice, the details on Form A of the 9 certificate are often filled in by the funeral director 10 who coordinates the arrangements for the cremation. In 11 order to validate the application for cremation, two 12 medical certificates are usually required. The first is 13 Form B which is completed by the deceased's medical 14 attendant and the second is Form C, which is completed 15 by a second medical practitioner. Form B contains far 16 more information than does the MCCD and the information 17 entered by Shipman on this form is of fundamental 18 importance when assessing the likely cause of death in 19 many cases being considered by the Inquiry. It is 20 important, therefore, to look at it in some detail. 21 Miss Warburton's example of Form B appears at 22 _5001^. Can we enlarge the section above the questions 23 please. First of all, we see the preamble that the 24 forms are statutory, all the questions must be answered 25 to make the certificate effective for the purpose of 39 1 cremation, and this medical certificate is regarded as 2 strictly confidential with the right to inspect them 3 being limited. 4 We then have the certificate of the medical 5 attendant: 6 "I am informed that application is about to 7 be made for cremation of the remains of" and then the 8 name, address, occupation and age of the deceased and 9 then the declaration: 10 "Having attended the deceased before death 11 and seen and identified the body after death, I give 12 the following answers to the questions set out below." 13 Can we now look, please, at the first five 14 questions. The first question is: 15 "On what date and at what hour did the 16 deceased die on this occasion?" 17 Shipman has entered "about 17.30 hours on 18 20th March 1998." 19 The attendant is then asked the place where 20 the deceased died and, again, the categories of 21 accommodation and home address is entered there. The 22 doctor is asked whether he or she is a relative of the 23 deceased and then the fourth question is whether he or 24 she has any pecuniary interest in the death of the 25 deceased. On this occasion, the answer to both of 40 1 those is "no". 2 Question 5: 3 "Were you the ordinary medical attendant of 4 the deceased? [were you the deceased's GP]", and on 5 this occasion Shipman correctly indicated that he was. 6 Then he is asked how long he has been the ordinary 7 medical attendant to which he replies: 8 "21 years". 9 Can we go on to questions 6 to 8(a) now, 10 please. Question 6, first of all: 11 "Did you attend the deceased during his or 12 her last illness?" 13 Again, that is not defined but is answered 14 here: 15 "Yes". 16 "And if so, for how long?", the answer here 17 being five hours. 18 "When did you last see the deceased alive?", 19 indicating how many days or hours before death and it 20 will be seen here that Shipman has entered: 21 "About 17.30 hours on 20th March 1998". You 22 may recall that is precisely the time and date which he 23 gave for the time of death so if that were to be read 24 literally in conjunction with his answer to question 1, 25 it would put him present at the time of death. 41 1 But at question 8(a): 2 "How soon after death did you see the body?", 3 "about 45 minutes." "What examination did you make?" 4 and Shipman has answered here, as I think invariably 5 was his answer, and indeed no doubt the answer of many 6 other doctors completing this form: 7 "A complete external examination". 8 Then there is a question relating to whether 9 the deceased died in hospital which is not applicable 10 in this case. 11 Can we now look at question 9, please, and if 12 we take the whole bottom section. Question 9 relates to 13 the cause of death and one would expect to see, as 14 indeed we do see, the same information here as on the 15 MCCD and, indeed, the death certificate for the same 16 deceased. Can we go to the next page, now, and 17 questions 10 to 13(a). 18 10(a) "What was the mode of death" and 19 examples are given possible answers to questions: 20 syncope, coma, exhaustion, convulsions, et cetera. In 21 this case, Shipman has given "coma" last and that is 22 the answer to the next question, "half an hour, an hour 23 or so." 24 Then the doctor is asked how far the answer 25 to the last two questions (that is cause of death and 42 1 mode of death) are: 2 "... the result of your own observations or 3 are based on statements made by others." 4 Here the answer was given as: 5 "Neighbours at 79 Grange Road." 6 I mention in passing that those neighbours 7 have not been traced. 8 12(a): "Did the deceased undergo an operation 9 during the fatal illness or within a year before 10 death?" 11 Answer: "No." 12 Then again there are questions to be asked in 13 the event that there has been an operation which is not 14 relevant here. 15 Can we look at 13: 16 "By whom was the deceased nursed during his 17 or her last illness?" 18 The doctor is supposed to specify whether it 19 was a professional nurse or a relative and if it is a 20 long illness that is to be answered with reference to 21 the period of four weeks before the death. On this 22 occasion, it being a sudden death, the answer is 23 no-one. 24 Can we now look at questions 14 to 19. 25 Question 14: 43 1 "Who were the persons, if any, present at the 2 moment of death?" 3 "Neighbour at 79 Grange Road North." 4 Question 15: 5 "In view of the knowledge of the deceased's 6 habits and constitution, do you feel any doubt 7 whatsoever as the character of the disease or cause of 8 death?" -- invariably answered "no". 9 Question 16, again similar to form A: 10 "Have you any reason to suspect that the 11 death of the deceased was due directly or indirectly to 12 violence, poison, privation or neglect?" 13 The answer is "no" to all of those, as is 14 invariably the case. 15 Question 17: 16 "Have you any reason whatsoever to suppose a 17 further examination of the body to be desirable?" 18 This was answered: "No." 19 Question 18: 20 "Have you given the certificate required for 21 registration of death?" 22 The answer here is usually "yes", it usually 23 being the same person who completes this form as signs 24 the death certificate. 25 "Has the Coroner been notified?" 44 1 The answer to that is "no." 2 Can we go now to the section at the bottom of 3 the page, please. We again see the declaration here, 4 the doctor filling in this form certifies that: 5 "The answers given above are true and 6 accurate to the best of my knowledge and belief and 7 that I know of no reasonable cause to suspect that the 8 deceased died either a violent or unnatural death or a 9 sudden death of which the cause is unknown or died in 10 such a place or in circumstances as to require an 11 inquest in pursuance of any act", signed by the doctor 12 completing the form, giving his address, 13 qualifications, date and his telephone number. 14 Form B is not seen by the deceased's 15 relatives at the time of completion or, indeed, 16 subsequently. During the Inquiry's investigations, 17 where family witnesses giving statements have been 18 shown the cremation certificate, marked discrepancies 19 have frequently been noted between the details given by 20 Shipman on Form B and the witness's memory of events, 21 discrepancies most frequently as to time of and the 22 persons present at the deceased's death. Sometimes the 23 contents of Form B have been found to be internally 24 inconsistent and the form we have just looked at is a 25 prime example. 45 1 Form C of the cremation certificate is signed 2 by a second medical practitioner. The system is that 3 the medical practitioner signing Form B contacts a 4 colleague and tells him or her the circumstances of the 5 death and the deceased's medical history, after which 6 the latter attends at the premises of the funeral 7 director where the deceased is lying, examines the 8 deceased and signs Form C. The doctor signing Form C 9 does not usually meet or speak to the family and, 10 indeed, the relatives are usually unaware of his or her 11 identity, possibly even the fact that a second doctor 12 plays any role in the certification process. 13 The Form C in Miss Warburton's case is at 14 _05003^ and, again, it is worthwhile looking at it 15 carefully at this stage. 16 Can we just enlarge the section above the 17 questions, please, the very top of the form. This 18 certificate has to be completed by a medical 19 practitioner registered in this country for not less 20 than five years and who is not a relative of the 21 deceased or a relative or a partner of the doctor who 22 has given the certificate in B. The doctor completing 23 the certificate declares that: 24 "Being neither a relative of the deceased nor 25 a relative or partner of the medical practitioner who 46 1 is giving the forgoing medical examination (...read to 2 the word...) as stated in my answers to the questions 3 below." 4 Can we look at those questions 1 to 5 please? 5 The doctor filling in this form must answer three 6 questions in the affirmative for it to validate the 7 form and the first of these is question number 1: 8 "Have you seen the body of the deceased?", 9 of which the answer must be yes. 10 Secondly: 11 "Have you carefully examined the body 12 externally?" 13 That also must be answered "yes" in order for 14 this form to be effective. 15 The third one does not have to be answered in 16 the affirmative and was not here: 17 "Have you made a post-mortem examination?" 18 There was no post-mortem at that stage in this case. 19 Question 4 again has to be answered in the 20 affirmative: 21 "Have you seen and questioned the medical 22 practitioner who gave the above certificate?"-. 23 That is Form B and the answer there, yes. 24 Question 5, and the questions which we will 25 look at in a moment which are below it, are optional in 47 1 the sense that an answer "no" does not invalidate the 2 certificate and, indeed, in many of the certificates 3 Form C which we look at the answer to, all the 4 questions which follow will be no. 5 Question 5: 6 "Have you seen and questioned any other 7 medical practitioner who attended the deceased?" 8 Then: 9 "Give details if you have and state whether 10 you saw them alone." 11 The answer to that is "no" in this case. 12 Can we look at question 6 to 8, please. 13 Question 6(a): 14 "Have you seen and questioned any person who 15 nursed the deceased during his or her last illness or 16 who was present at the death?" 17 Again, an optional again in the sense that it 18 can be answered "no" and was in this case. 19 Question 7: 20 "Have you seen and questioned any of the 21 relatives of the deceased?" 22 Again, the answer is "no". 23 Question 8: 24 "Have you seen and questioned any other 25 person?" 48 1 Again, the answer is "no" in the negative. 2 Can we then look at the bottom section of the 3 form. Here, the doctor completing this form states: 4 "I am satisfied that the cause of death was ..." 5 and here inserts the cause of death as given on the 6 previous form as "cerebrovascular accident" and: 7 "I certify I know of no reasonable cause to 8 suspect that the deceased died either a violent or an 9 unnatural death or a sudden death of which the cause is 10 unknown, or died in such a place or circumstances as to 11 require an inquest in pursuance of any Act." 12 That is then signed by the doctor completing the 13 Form C, their practice address and relevant details. 14 The other part of the cremation certificate which 15 I should mention is Form F and an example of this can 16 be seen at _05004^. This is signed by the Medical 17 Referee of the Cremation Authority, who must be a 18 registered medical practitioner and is frequently a 19 retired doctor. He or she must certify his or her 20 satisfaction that all requirements have been met, that 21 the cause of death has been definitely ascertained and 22 that there is no reason for any further Inquiry or 23 examination. Again, the relatives of a deceased person 24 will have no part in that process. 25 That then is the background to the obtaining of 49 1 the cremation certificates which are contained in the 2 files of those deceased persons who were cremated 3 rather than buried. For all but a few cremations 4 occurring after 1984, the certificate is available. 5 For those taking place before that time, few have been 6 preserved. 7 Where a cremation certificate survived and was 8 made available to him, Professor Baker carried out an 9 assessment in order to categorise the death as highly 10 suspicious, moderately suspicious or not suspicious on 11 the basis of the information contained in the cremation 12 certificate alone. An example of such an assessment can 13 be seen at _08002^. Can you please highlight the bottom 14 half of that and enlarge it; thank you. 15 As you can see, the assessment is in summary form 16 and is not easy for the uninitiated to interpret. 17 I shall not embark

Green River Victims

1. Agisheff, Amina; disappeared 7-7-82; found 4-18-84, at Highway 18 & Kerriston Road (near North Bend, south of I-90 interchange) 2. Coffield, Wendy; disappeared 7-8-82; found 7-15-82 at Peck Bridge, in Green River, in Kent 3. Lovvorn, Gisele; disappeared 7-17-82; found 9-25-82 at South 200 St. and 19th Ave. S., south of airport, west of Highway 99 4. Bonner, Debra; disappeared 7-25-82; found 8-12-82 at S. 252nd in Green River (just outside Kent) 5. Chapman, Marcia; disappeared 8-1-82; found 8-15-82 at S. 255 in Green River (outside Kent) 6. Hinds, Cynthia; disappeared 8-11-82; found 8-15-82 at S. 255 in Green River (outside Kent) 7. Mills, Opal; disappeared 8-12-82; found 8-15-82 at S. 255 in Green River (outside Kent) 8. Lee, Kase; disappeared 8-28-82; not found 9. Milligan, Terry; disappeared 8-29-82; found 4-1-84 in Star Lake area (just south of Kent, east of I-5) 10. Neehan, Mary; disappeared 9-15-82; found 11-13-83 at S. 192nd Tyee Golf Course, SeaTac 11. Estes, Debra; disappeared 9-20-82; found 5-30-88 in Federal Way 12. Bush, Denise; disappeared 10-8-82; found 6-12-85 at Bull Mountain Oregon (and partial skeleton also in Tukwila) 13. Summers, Shawnda; disappeared 10-9-82; found 8-11-83 at 2222 S. 146th St., north of airport 14. Sherrill, Shirley; disappeared 10-20/11-7-82; found at Bull Mountain, Ore. 15. Marrero, Becky; disappeared 12-3-82; still missing 16. Brockman, Colleen; disappeared 12-24-82; found 2500 Jovita Blvd, Pierce Co. (just east of Milton) 17. Smith, Alma Ann; disappeared 3-3-83; found 4-24-84 at Star Lake 18. Williams, Delores; disappeared 3-8/3-17/83; found 3-31-84 at Star Lake 19. Mathews, Gail; disappeared 4-10-83; found 9-18-83 at Star Lake 20. Childers, Andrea; disappeared 4-14-83; found Tyee Golf Course, SeaTac 21. Gabbert, Sandra; disappeared 4-17-83; found 4-1-84 at Star Lake 22. Pistor, Kimi-Kai; disappeared 4-17-83; found 12-15-83 at Mountview Cemetery, Auburn 23. Malvar, Marie; disappeared 4-1-65; still missing 24. Christensen, Carol; disappeared 5-3-83; found 5-8-83 in Maple Valley 25. Authorlee, Martina; disappeared 5-22/5-23-83; found 11-14-84 Hwy 410 about 10 miles east of Enumclaw 26. Wims, Cheryl; disappeared 5-23-83; found 3-22-84 at South 146th St. and 16th South, north of airport, west of Highway 99, east of Highway 509 27. Antosh, Yvonne; disappeared 5-31-83; found 10-15-83 at Soos Creek/S.E. 316, just east of Seattle International Raceway 28. Rois, Carrie; disappeared 5-31/6-13-83; found 3-10-85 in Star Lake area 29. Naon, Constance; disappeared 6-8-83; found 10-27-83 at Tyee Golf Course, SeaTac 30. Liles, Tammie; disappeared 6-9-83; found 4-23-85 Tualatin Golf Course, Ore. 31. McGinness, Kelli; disappeared 6-28-83; still missing 32. Ware, Kelly; disappeared 7-19-83; found 10-29-83 at Tyee Golf Course, SeaTac 33. Thompson, Tina; disappeared 7-25-83; found 4-20-84 on eastside Hwy 18, just south of I-90 interchange 34. Buttran, April; disappeared 8-18/9-1-83; still missing 35. Debbie Abernathy; disappeared 9-5-83; found 3-31-84 on Highway 410 east of Enumclaw 36. Winston, Tracy; disappeared 9-12-83; still missing 37. Feeney, Maureen; disappeared 9-28-83; found 5-2-86 at Hwy 18 (west side), just south of I-90 interchange, near North Bend 38. Bello, Mary; disappeared 10-11-83; found on Hwy 410 39. Osborn, Patricia; disappeared 10-20-83; still missing 40. Avent, Pammy; disappeared 10-26-83; still missing 41. Plager, Delise; disappeared 10-30-83; found 2-14-84 on s. side I-90 at exit 38 - 8 miles east of North Bend 42. Nelson, Kim; disappeared S. 141 & PHS; found 6-13-86 at I-90 at Garcia Road, east of North Bend 43. Yates, Lisa; disappeared 12-23-83; found 3-13-84 at I-90 & Exit 38 44. West, Mary; disappeared 2-6-84; found 9-8-85 in Seward Park 45. Smith, Cindy; disappeared 3-21-84; found S.E. 312 Way, Auburn 46. Bones; found 3-31-84 at S. 146 & 16th , north of airport 47. Bones; found 4-22-85 at Tualatin Golf Course, Ore. 48. Bones; found 12-30-85 at Mountain View Cemetery, Auburn 49. Bones; found 1-2-86 at Mountain View Cemetery, Auburn

Interview with Usamah Bin-Ladin