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The First Report > Death Disguised > Chapter 6 - The Medical Evidence Pt II
The Effect of Heat
6.92 Once the circulation has completely ceased, cooling of the body starts. Dr Grenville explained that the rate at which cooling occurs depends on the ambient temperature, and on the presence or absence of insulating material such as clothing. As Dr Grenville observed:
'A naked body in a cold environment cools very much more quickly than a fully clothed body in a warm environment, say, with the gas fire on' .
6.93 Similarly, obese people cool less rapidly than very thin people, because their body fat itself acts as an insulating material. As a rough guide, Dr Grenville said that, in the absence of clear reasons for cooling to be delayed, he would expect the hands, certainly the fingers, to be cool to the touch within an hour or so of death.
6.94 In a significant number of cases where I have found that Shipman killed, the deceased person has been found in a room in which the fire, usually a gas fire, has been turned to an unusually high setting, making the room extremely warm. It is clear that Shipman was responsible for this, but why he did it is less clear. The effect of the increased heat would be to delay the process of cooling of the body after death. Increased heat would also, as Dr Grenville explained in the course of his evidence relating to the death of Mrs Charlotte Bennison, speed up the onset of rigor mortis and bring forward the time when rigor mortis wears off. Low temperature, on the other hand, could be expected to delay the onset of rigor mortis. It is clear that Shipman was aware of the effect of heat on the onset of rigor mortis, as he correctly explained to Mrs Nadya Williamson, the wife of Mrs Bennison's nephew, why rigor mortis had set in earlier than might have been expected.
6.95 It seems likely that the high incidence of bodies found in overheated rooms resulted from efforts by Shipman to make it difficult for others accurately to estimate the time of death. Sometimes, the fact that the body was still warm when found might suggest that death had occurred more recently than was in fact the case, and might, therefore, serve to increase the apparent time interval between an earlier visit by Shipman and the death. On other occasions, the early onset of rigor mortis might lead people to believe that the death had occurred significantly earlier than was in fact the case. In any event, any attempt accurately to estimate the time of death would be made more difficult, if not impossible, by the presence of excessive heat.
6.96 The Inquiry legal team has investigated another possibility, namely, that heat might have the effect of speeding up the metabolism of morphine and that Shipman, knowing this, might have been attempting to minimise the chance of morphine being found in his victims' bodies, should toxicological tests be ordered. Professor Kevin Park, Head of the Department of Pharmacology and Therapeutics at the University of Liverpool, has advised that, after death, hepatic metabolism cannot influence blood levels of morphine; keeping a deceased's body in hot conditions is not, therefore, likely to speed up the metabolism of morphine. It is, of course, possible that Shipman mistakenly believed that it would have this effect, although the Inquiry has no positive evidence of this. On balance, it seems likely that his motive in leaving his victims in overheated rooms was to foil any attempts to assess accurately the time of death.
Estimating the Time of Death
6.97 In many cases, Shipman purported on cremation Form B to estimate the time of death, sometimes claiming to be able to do so from the temperature of the body and, on other occasions, specifying an exact time of death without giving any factual basis for his assertion. Dr Grenville emphasised that the timing of death is an extremely difficult and complex procedure, usually carried out by forensic pathologists. One such forensic pathologist, Professor Helen Whitwell, MBChB FRCPath DMJ(Path), registered medical practitioner, Professor of Forensic Pathology at the University of Sheffield and Consultant Pathologist to the Home Office, gave evidence to the Inquiry about three deaths after which there had been post-mortem examinations. She observed when giving evidence about the death of Mrs Pamela Mottram:
'...essentially the time of death is one of those huge mysteries of forensic pathology' .
Professor Whitwell went on to say:
'…the general rule, even with most deaths, is the best evidence is when they were definitely last positively seen alive and then known when they were found dead ( sic ) . There are lots of complicated equations and things that one can use, but they essentially are not of much use apart from very exceptional circumstances' .
6.98 Dr Grenville said that he does not himself possess the skills necessary to estimate time of death and would not attempt to do so. He is, however, aware that it is mandatory to record the core temperature, usually by obtaining a rectal temperature. The ambient temperature must also be measured, and careful observations noted about the deceased's clothing or covering and those signs which wax and wane after death, such as rigor mortis and post-mortem lividity. There is no evidence that Shipman ever obtained or recorded such information in cases where he estimated the time of death with apparent confidence, nor is there any evidence that he possessed the skills necessary to make such estimates of time.
The Patient who Refuses to Heed Medical Advice
6.99 Dr Grenville was asked how a general practitioner should deal with a patient who has a serious medical condition but refuses admission to hospital, or other necessary treatment. This was a situation in which Shipman claimed frequently to find himself, often with a patient who had suffered signs suggestive of an evolving stroke or transient ischaemic attack, or who had suffered, or may have suffered, a heart attack, or who had a chest infection or bronchopneumonia. Shipman's solution to this problem was, usually at least, to leave the patient at home, without arranging any immediate care, and without seeking the assistance of relatives to change the patient's mind; he would then tell the patient 'tluk' , i.e. 'to let us ( the surgery ) know' if he or she had a change of mind or had deteriorated.
6.100 By contrast, Dr Grenville said that it was 'incredibly rare' for a patient to refuse to take such advice. If the initial reaction is negative, the doctor must explain carefully the reasons for the advice given. In the face of a continued refusal to accept his advice, he said that he would ask the patient whether there was a relative, friend or neighbour to whom he could speak, in the hope that the patient would accept the joint advice of himself and that other person. If he still met with no success, he would make a most detailed note of what had happened, and ask the patient to sign a declaration that he had advised the patient to go to hospital and explained the risks associated with failing to take that advice. The effect of requesting a signature is, he says, to make it clear to the patient that the doctor is serious, and also to protect the doctor in the event of a complaint or litigation in the future.
6.101 Dr Grenville said that he had not had to resort to obtaining a signature from a patient refusing to be admitted to hospital, but he had had to do so where a patient was refusing treatment which he definitely believed was in the patient's best interests. In the event that he was forced, contrary to his own judgement, to leave a patient at home rather than have him or her admitted to hospital, he said that he would want to try to arrange for the patient to be observed on a more or less continuous basis, whether by family, the district nursing service or Social Services. In an extreme case, the National Assistance Act 1948 could be used, although this takes time and is usually resorted to in the case of a person living in chronically poor conditions, rather than someone suffering a serious life-threatening illness.
6.102 In an extreme case, a doctor may have to override a patient's wishes. In the case of Mrs Mary Coutts, Dr Grenville said that, had she been suffering from bronchopneumonia which was plainly life-threatening, a reasonable doctor might have been justified in ignoring any weak protests that she might have raised about not going into hospital and in simply overriding her and getting her into hospital for treatment.
6.103 Most of Shipman's patients had been registered with him for years, had the utmost confidence in his medical abilities and trusted him implicitly. In reality, it is highly unlikely that they would have resisted his attempts to persuade them of the need for hospital admission, particularly if they were as ill as he described. Even those who were genuinely unwilling to be admitted, such as Mrs Elizabeth Battersby, would have been unlikely to maintain their opposition once their relatives were informed and lent their support to Shipman
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Chapter 7 -Drugs
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