|
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
|
