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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
|
