|
The First Report > Death Disguised > Chapter 4 - Shipman's Practice
Shipman's Practice
4.1 The Inquiry has taken witness statements from former members of staff at all three practices at which Shipman worked, as well as from his former partners in Todmorden and his former colleagues at the Donneybrook practice. From their evidence, it has been possible to build up a picture of the structure of Shipman's working week and to gain an understanding of practice procedures and of the purpose and use of those practice documents which are in the Inquiry's possession. This knowledge has provided me with the necessary background against which to view the circumstances of each individual death.
Todmorden
4.2 Shipman joined the Abraham Ormerod Medical Centre in Todmorden in 1974. It would appear that, at that time, there were between 9000 and 12,000 patients registered with the Medical Centre, from a local population of about 17,000 people.
4.3 Shipman was recruited to replace Dr Jim Howat, who had retired by reason of ill health. The other partners were the senior partner, Dr Michael Grieve, and Dr John Dacre, Dr David Bunn and Dr Brenda Lewin. There were two receptionists, Mrs Mollie Dunkley and Mrs Marjorie Walker. All the district nurses who worked in the Todmorden area were also based at the Medical Centre, although they were employed by the local health authority and not by the doctors.
4.4 Each doctor held a morning surgery, before carrying out home visits and then returning for an afternoon surgery. The evidence suggests that morning surgery lasted from about 8.30am or 9am until about 11.30am. In case of emergency, the doctor would visit the patient immediately. The local doctors were frequently called out in an emergency, since the nearest hospital was a 30 minute drive away.
4.5 Although Shipman's partners have different recollections about the matter, it seems unlikely that Shipman inherited an established list of patients when he joined the practice. According to Dr Dacre, Shipman was encouraged to see Dr Howat's patients; Dr Grieve believes that Shipman actually took over Dr Howat's list. However, Dr Bunn is adamant that he inherited Dr Howat's list and that Shipman was at first expected merely to assist the other partners with their patients and to start building up his own list. It seems likely that Dr Bunn's recollection is the most reliable since he would have reason to remember this particular development in his own practice.
4.6 All the doctors did home visits and Shipman did no more than the others. According to Dr Grieve, Shipman was keen to go out and see patients, especially in an emergency.
4.7 Shipman did not have a higher proportion of terminally or severely ill patients than his colleagues, but it was apparently he and Dr Bunn who used to visit the residents of the two local nursing homes, Scaitcliffe Hall (where Mr Edward Walker died) and Mytholm Hall. All but one of the doctors also worked as clinical assistants at the Stansfield View and Fielden hospitals for the mentally handicapped. I have found that neither of the two deaths at Fielden Hospital was in any way suspicious. Dr Lewin, who suffered poor health, did not do emergency visits; she did not attend patients in hospital or nursing homes, nor did she work at the weekend.
4.8 The district nurses had been based at the Medical Centre before the doctors moved in during the early 1970s, and continued to provide nursing services and some domestic assistance to patients of the practice thereafter. They gave instruction and assistance to patients in the self-administration of injections of morphine and pethidine, which were the drugs normally prescribed to patients in severe pain. The usual procedure, according to District Nurse Myra Bairstow, was for patients to collect their own prescriptions from the pharmacy, or to arrange for someone to do so on their behalf.
Donneybrook
4.9 When Shipman joined the Donneybrook practice, he became one of seven doctors practising there, the others being Dr Geoffrey Roberts (who left in November 1980), Dr Geoffrey Bills (who was there until December 1988), Dr William Bennett (who left in 1989 or 1990), Dr Derek Carroll (who retired in 1992), and Dr Ian Napier and Dr John Smith (both of whom remained at the practice throughout Shipman's time there). The practice had been formed by the amalgamation of three smaller practices and each doctor maintained his own patient list. Other doctors who were members of the Donneybrook practice during Shipman's time there were Dr Wojciech Kucharczyk (from 1981 until 1983), Dr Jeffrey Moysey (from May 1983), Dr Alan Rowlands (from January 1989 until 1995), and Dr Anthony Rodgers (from 1990 until 1995). In October 1977, Shipman replaced Dr John Bennett. By October 1991, the number of patients registered with Shipman was 2842.
4.10 Shipman's morning appointments began at about 8.45am and, according to the practice staff, he would arrive at the surgery 15 to 20 minutes before, sometimes earlier. The appointments sheets for the Donneybrook practice were kept for five years (sometimes less); they were then burned, so that no records of appointments from Shipman's time have survived. However, staff at the practice recall that his appointments frequently lasted longer than the allotted time of seven minutes; as a consequence, his morning surgery regularly overran the 'official' finishing time of 11am, ending instead at about 11.30am, or even later. After his surgery, Shipman would prepare and sign any necessary prescriptions and do other paperwork, before going out to visit patients in their homes.
4.11 Unlike the other doctors in the practice, who would often eat their lunch in the reception area or common room, Shipman was rarely in the surgery at lunchtime. Instead, he had already set out on his visits. The exception to this was on Fridays, when representatives of drugs companies would frequently visit and give presentations to the doctors. Shipman was a regular attender at these events.
4.12 The staff noticed that, as well as visiting on request, Shipman would also visit patients without being asked to do so. He often did this only a few days after the patient had attended the surgery. One of Shipman's former partners, Dr Napier, has pointed out that, until the mid-1980s, it was usual for himself and other doctors to pay routine visits about once a month to elderly patients with limited mobility. While such visits would involve some medical examination (for example, the measurement of blood pressure), their purpose was social as much as medical. From the mid-1980s, however, Dr Napier did not offer this service to new patients and he gradually ceased making such visits altogether.
4.13 According to Dr Grenville, this pattern reflects a widespread move by doctors away from visiting their patients at home. The reason for this change was primarily pressure of time; a home visit takes significantly longer than a consultation at the surgery. Some doctors did – and apparently still do – attempt to maintain the habit of making home visits, even when not strictly necessary on health grounds; they recognise that it can be useful to observe a patient in his or her home environment and that a home visit is easier for, and much appreciated by, patients. However, the general trend over recent years has been towards treatment in surgery, rather than at home.
4.14 It is likely that the pattern of routine home visits described by Dr Napier would have been relatively common amongst family doctors when Shipman joined the Donneybrook practice in 1977. Whereas other doctors ceased the habit of making such visits over the years which followed, it is clear that Shipman continued to make regular unannounced visits (which he termed 'cold visits') right up to the end of his professional career; moreover, the type of patient whom he would visit without a prior request went well beyond the elderly patients with limited mobility described by Dr Napier.
4.15 The books in which the Donneybrook practice staff recorded requests for visits and the symptoms of the patients requesting such visits, have not survived. However, throughout his time at the Donneybrook practice, Shipman kept a series of hardback diaries, in which he noted the names and addresses of the patients whom he was to visit. On occasions, he would also record brief details about their condition and any future action (such as referring them to the district nurse or arranging a domiciliary visit) which he proposed to take. Shipman's diaries from 1979 to 1992, which he used as visits books, have survived and are in the Inquiry's possession.
4.16 If a patient's name appears in Shipman's visits book on a particular day, my experience is that this is generally good evidence that a visit was indeed made on that day. A recorded visit on the day of a patient's death may not necessarily have been made before death; the entry might refer to a request for Shipman to visit after a patient had been found dead in order to confirm the fact of death; this is a possibility which I have had to bear in mind when considering the circumstances of each individual death. Sometimes, such entries have a symbol beside them, indicating that the patient had died. In some cases, there is no entry in the visits book, despite the fact that it is clear from other evidence that Shipman visited on that day. The absence of an entry could mean that no request for a visit was made because Shipman was making an unannounced visit; it could also mean that a request was made but was not communicated to Shipman by the practice staff until after he had left the surgery to go out on his rounds. It is not wholly clear whether Shipman carried a pager whilst he was at the Donneybrook practice – he may have done so for part of the time – but, if he was needed urgently, the practice staff would contact him by telephone at the house of a patient whom they knew he was due to visit.
4.17 Afternoon surgery was scheduled to last from 4pm until about 5.30pm except on Thursday, when Shipman had the afternoon off. In addition to the usual morning and afternoon surgeries, Shipman held an antenatal clinic on Tuesdays at noon; this would last about an hour. In the early years of his time at Donneybrook, he had appointments and patient visits every Saturday morning; from the mid-1980s, however, the practice changed its system so that Saturday morning duties were shared and, from then on, Shipman worked on alternate Saturday mornings.
4.18 The doctors at the Donneybrook practice maintained their own lists but covered for each other on their respective afternoons off, during some holidays and, from the mid-1980s, on Saturday mornings. For the first three years or so, Shipman and Dr Roberts provided half day and other cover for each other. After Dr Roberts left the practice, the same reciprocal cover was provided for Shipman's patients by Dr Kucharczyk (for about two years), and then by Dr Moysey.
4.19 In addition, a doctor would be responsible for all the patients registered with the practice when he was on duty in the evenings, at weekends and over bank holidays. The system was that each of the members of the practice provided out of hours cover on a rota. When on evening duty, a doctor was responsible for providing cover from 5.30pm or 6pm until about 11pm, after which telephone calls were diverted to the deputising service used by the practice. The deputising service would then respond to all calls made until 8 or 8.30 the following morning. Dr Bills recalls Shipman telling him that he would sometimes arrange for the deputising service to inform him of calls received during the night; if the call came from one of his own patients, Shipman would on occasions choose to make the visit himself, rather than leave the deputising service to deal with it in the usual way.
4.20 The charges made by the deputising service for dealing with calls received by them from 11pm onwards were shared between all the partners in the practice. Before 11pm, telephone calls made to the surgery were transferred to the home of the doctor on duty. That doctor could choose to have calls diverted to the deputising service earlier than 11pm but, if he chose to do so, he would be financially responsible for the charges of the deputising service for responding to those calls.
4.21 The Inquiry has obtained the Donneybrook duty doctor transfer book, covering the period from May 1982 to November 1995. The book records details of which doctor was on duty each evening, weekend and bank holiday, as well as the time at which each doctor arranged for calls to be diverted to the deputising service. That book has proved extremely useful when considering deaths which occurred out of the normal surgery hours.
Market Street
4.22 Once at the Market Street Surgery, Shipman practised alone. In October 1992, two months after the move, he had a list of 2931 patients. By 1998, the number of patients registered with him had risen to 3046 with a maximum number (in 1994) of 3124.
4.23 The long-standing members of Shipman's staff at Market Street were Sister Gillian Morgan (practice nurse, later nursing practitioner), Mrs Alison Massey (receptionist, then practice manager), Mrs Carol Chapman (receptionist, then building manager/receptionist), Mrs Judith Cocker (receptionist, then senior receptionist) and Mrs Margaret Walker (computer operator). Mrs Primrose Shipman provided cover on Saturdays and for illness and holidays in the later period of Shipman's practice at Market Street. Sister Morgan, Mrs Massey and Mrs Cocker had moved with Shipman from the Donneybrook practice.
4.24 All these members of staff have given statements describing the layout of the surgery, the staffing arrangements and the general working of the practice. Some have given additional statements dealing with specific deaths about which they have some personal knowledge and, in Mrs Chapman's case, about the deaths of relatives which have been investigated by the Inquiry.
4.25 Shipman saw patients with pre-arranged appointments from 8.45am each weekday morning. He arrived at the surgery between 8am and 8.30am. The appointments were recorded on the appointments sheet for the day, the allotted time for two patients being 15 minutes; the Inquiry has in its possession the full set of appointments sheets covering Shipman's time at the Market Street practice. As at Donneybrook, Shipman's appointments frequently overran. They would last until 10.15 to 10.30am, after which Shipman would hold an open surgery, when patients without pre-booked appointments would be seen on a 'first come, first served' basis. The numbers of patients attending open surgery varied from day to day but, on occasions, could be as many as 18. Shipman's willingness to see patients without a prior appointment and to visit his patients at their homes contributed significantly to his popularity as a doctor.
4.26 The time at which Shipman finished his open surgery varied according to the numbers of patients attending and could be at any time from about 11.15am onwards. Sometimes (particularly on Mondays), the numbers of patients attending the open surgery was such that it extended until noon or later. In his evidence at trial, Shipman said that, after the end of surgery, he would first check the visits book to see whether there were any urgent visits to be made. If there were, he would leave the surgery and deal with them immediately. If a very urgent request for a visit came in during surgery, he would attend immediately and the patients in the surgery would have to wait.
4.27 Assuming that there were no visits to be made immediately after the open surgery, Shipman would prepare, check and sign prescriptions, deal with his post, talk to the practice staff and carry out other administrative tasks.
4.28 By contrast with his habit at Donneybrook, Shipman is said to have lunched with staff in the reception area at the surgery several times a week. Since the reception area was situated immediately inside the main entrance to the premises, he would sometimes see patients who had called into the surgery to book an appointment, collect a prescription or for some other purpose. On such occasions, members of staff say that it was not unusual for an informal consultation to take place there and then.
4.29 Shipman paid his home visits to patients between the end of his morning activities in the surgery and the beginning of his afternoon appointments at 4pm. If he had only a few visits to make, he would arrive back in the surgery early and continue with work of an administrative nature. On Tuesdays, he shared an antenatal clinic with the midwife between noon and about 12.45pm. On Wednesday afternoons, he had a vaccinations clinic, starting at 2pm and lasting no more than an hour, sometimes less. He held a minor operations clinic on Fridays at 2pm, which lasted an hour or less. He made home visits to patients before and after his Wednesday and Friday clinics.
4.30 On Thursdays, Shipman often attended postgraduate continuing education sessions at the local hospital; the Inquiry has records of his attendance at many of these sessions and at other professional courses. On Fridays, Shipman would frequently see drugs company representatives from about noon to 12.30pm. Staff meetings at the surgery also took place on Fridays, usually starting at 12.30pm.
4.31 When a patient requested a home visit, that request was entered in the surgery visits book, with the patient's name and address and brief details of his or her symptoms. Where no request for a visit had been received, but Shipman had informed the practice staff of his intention to revisit a patient, the intended revisit would be noted by staff in the visits book. That book stayed in the surgery at all times. The Inquiry has the full set of visits books covering the whole of Shipman's time at the Market Street Surgery.
4.32 After his arrival at Market Street, Shipman initially continued his previous habit of maintaining his own visits book and, for 1993, both his own and the surgery visits books are available. After that time, however, either Shipman ceased to keep his own books or they have been lost or destroyed. At some time – it is not clear precisely when, although it was certainly in operation by December 1996 – a new system was introduced. From then on, a receptionist would fill in a visit request form, containing similar information to that recorded in the surgery visits book; the form would then be handed to Shipman to take with him on his rounds. Some of those forms have been found in patients' medical records; others have been destroyed or lost. In his evidence at trial, Shipman said that he used the forms to record his clinical findings and other information; on his return to the surgery, he would transfer that information onto the computer and then destroy the form.
4.33 There was also an acute prescriptions book, in which telephone requests by patients for a prescription other than a repeat prescription were recorded; the requests would then be communicated to Shipman, who would decide whether or not to issue the prescription which had been requested. Other messages were also recorded in the book. The Inquiry has the acute prescriptions books from the Market Street Surgery for the whole of Shipman's time there.
4.34 Shipman's afternoon surgery began with booked appointments from 4pm or shortly before. This was followed by an open surgery, usually beginning at 5.30pm. The length of the open surgery would again depend upon the number of patients attending. After the surgery had finished, Shipman would sometimes see new patients by appointment. He would leave the surgery premises at 6 to 6.30pm, sometimes as late as 7pm or beyond. Sometimes he would visit patients on his way home from the surgery.
4.35 On Saturday mornings, Shipman saw patients by appointment from 8.45 and then went out on visits before his open surgery, which usually started at 11am. He finished in the surgery at about noon and then carried out any remaining visits.
4.36 Outside surgery hours, Shipman made use of a deputising service, Healthcall Medical Services (Healthcall). Healthcall offered two types of service, namely, a telephone answering facility and a deputising doctor service. Shipman availed himself of both these services at different times. From 6pm, when the surgery closed, the usual arrangement was that all patient calls were transferred to Shipman's home telephone number; Mrs Shipman usually answered these calls and passed messages on to her husband. On occasions, calls were diverted to Healthcall, which would pass the messages on to Shipman for him to deal with. This was the telephone answering facility. Sometimes, when he was going to be unavailable, Shipman used the deputising doctor service during the evening.
4.37 From about 11pm until 7am, the deputising doctor service operated; telephone calls were diverted to Healthcall, whose doctors would deal with them. Between 7am and 8.30am, Shipman again used Healthcall's telephone answering service.
4.38 At weekends, patients' calls were usually transferred direct to Shipman's home and he would deal with any necessary visits himself. Sometimes, calls were diverted to Healthcall. If Shipman was unavailable, he would arrange for Healthcall to provide their deputising doctor service. Otherwise, he would use Healthcall as a 'holding service' so that, when a call was received, Healthcall would contact Shipman by telephone or pager to inform him of the call and he would then decide whether to deal with it himself or instruct Healthcall to do so on his behalf.
4.39 The system of payments for out of hours visits required careful records to be kept, and one member of the Market Street staff was responsible for keeping the 'duty doctor' diary, which recorded out of hours visits by Healthcall and by Shipman and also noted whether or not a claim could be made to the Health Authority in respect of each visit.
4.40 The Inquiry has the duty doctor (previously called the 'night visits') books for the period 1992 to 1997. They confirm that out of hours calls were dealt with sometimes by Shipman and sometimes by Healthcall. On comparing the books for 1995 and 1997, it is noticeable that, in 1995, Shipman was recorded as attending patients at weekends much more frequently than was the case in 1997; in 1997 also, he was more likely to allow Healthcall to visit his patients on weekday evenings and nights. However, Shipman's use of Healthcall as a 'holding service' meant that he retained control of his calls for much of the time when he was officially 'off duty'. He was usually in a position to make the decision as to whether or not he would respond personally to a request by a patient for a home visit out of surgery hours.
4.41 Sister Gillian Morgan worked five mornings a week and a late shift on Friday. She ran regular clinics for the management of chronic conditions such as hypertension, asthma and diabetes. She kept her own diaries, recording the names of patients and appointment times, and those diaries covering the period from 1992 to 1998 have been made available to the Inquiry.
4.42 In 1993, a networked computer system was installed at the practice and used for the storage of patient data. The server for the networked system was on the first floor of the surgery, in the room occupied by Mrs Walker, the computer operator. The four other workstations were at other sites in the surgery; there was one workstation in Shipman's consulting room and another in the practice nurse's room.
4.43 From 1993, Shipman kept a set of computerised medical records for each patient, in addition to the manuscript 'Lloyd George' records. Until January 2001, general practitioners were required to keep paper records for each patient; only in certain circumstances were they allowed to maintain only computerised records. However, Shipman's entries in the manuscript records became increasingly intermittent after the introduction of computerised records and, in the case of some patients, his manuscript entries ceased altogether in the mid-1990s. Notes in the computerised records about patient consultations were entered only by Shipman himself or, following an appointment with her, by Sister Morgan. Other information, such as that contained in letters from consultants, or the results of blood tests, was entered by receptionists and other members of staff; all members of staff, together with Shipman, used a single user name,'HFS', to gain access to the system.
4.44 The computerised medical records of Shipman's patients were stored on the hard drive of the server and they could be accessed from each workstation. Micro-Doc software was installed and was used to maintain and update patient medical records. Prior to 14th October 1996, the version of the Micro-Doc software being used had no facility for identifying the date on which entries in patient records stored on the computer system had been added, deleted or altered. On that date, however, an improved version of Micro-Doc was installed and, from that time, it was possible to carry out an 'audit trail' on any entry, in other words to identify precisely when a particular entry was made.
4.45 During the course of their investigations, the police discovered, by means of the audit trail facility, that Shipman had falsified the computerised records of a number of patients; he had made additions to those records in order to create a medical history which would explain the death. In the case of Mrs Bianka Pomfret, for example, some entries in her computerised records, apparently dated several months before her death, were found to have been added on the day she died so as to provide a plausible explanation for her death, which Shipman certified as having been caused by coronary thrombosis due to ischaemic heart disease.
4.46 The Inquiry has in its possession an image of the computer hard drive from the Market Street Surgery. It has been possible to carry out audit trails on entries made after October 1996 in the computerised medical records of patients whose deaths have been investigated by the Inquiry.
4.47 The practice records at the Market Street Surgery (in particular the appointments sheets and the surgery visits books) were kept meticulously by the practice staff and, except where it is clear that an entry was made at Shipman's specific direction, I have no reason to doubt that the entries in the records are anything other than entirely genuine and accurate. In my decisions on those individual deaths where the fact or timing of a visit is in issue, I have invariably included a description of Shipman's probable movements on the day in question and I have attempted to identify, by reference to the records, any 'windows of opportunity' which would have been available to him to visit the patient concerned. The reliance which I have been able to place on the accuracy of the records maintained by the practice staff at the Market Street Surgery has been of invaluable assistance to me in carrying out this exercise and the records have provided the chronological framework for many of my decisions.
4.48 The patient medical records kept by Shipman were not of the same high standard. The purpose of keeping such records is, as Dr Grenville pointed out, not only to assist the doctor making them, but also to inform other doctors, who might assume responsibility for treating the patient, of the patient's medical history and any treatment which the patient may have received. In the main, Shipman's records were inadequate for this purpose. His manuscript notes were usually sketchy and frequently illegible. Little detail was included of the history given by the patient and of the results of any examination performed. The nature and amounts of medication prescribed frequently went unrecorded. After 1993, the use of the dual system of manual and computerised records led to consultations going unrecorded on one system or the other and, on occasions, both. Where I have found that Shipman killed, his records (both manuscript and computerised) frequently contain false entries which were designed to provide the basis for an innocent explanation of the death. Even where I have found that the death was natural, the patient records are generally of an unsatisfactory standard.
Residential and Nursing Homes
4.49 I have made decisions in 124 individual cases of deaths which occurred in residential or nursing homes. Of these, 109 occurred in residential homes and 15 occurred in Hyde Nursing Home.
4.50 The Inquiry has taken witness statements from members of staff at these homes and has had access to all the relevant documentation from the homes which is still in existence. As I have mentioned elsewhere, daily diaries for Charnley House are available from 1978 through to 1995 and the admissions register from 2nd February 1970 to date is also available. Obviously, wherever contemporaneous documentation has been made available, my task in assessing Shipman's likely involvement in the death has been made much easier.
4.51 The witness statements and the documentation reveal that, Shipman called unannounced on his patients who lived in residential or nursing homes, just as he did upon patients who lived in their own homes, albeit apparently with less frequency. They also show that there were occasions when Shipman saw residents in those homes in the absence of a member of staff. Sometimes this would arise because he had entered the premises without making his presence known. On other occasions, where he was known to be on the premises, a member of staff had to leave him alone with a patient for a short while, in order to attend to other duties. It also appears that there were many occasions when Shipman was summoned to see one resident and then, perhaps of his own volition or perhaps at the request of a member of staff, visited another patient who lived at the same home.
4.52 Comparisons of entries in the diaries from Charnley House and Shipman's visits book shows that the majority – but not all – of the visits recorded in Shipman's visits book were also recorded in the Charnley House diary and vice versa.
© Crown Copyright 2002
Back to Shipman Report Table of Conents
View Chaper 5 - The Existing Procedures for Death Registration and Cremation Certification
|
Posted on: 2007-05-25 10:47:06