Harold Shipman Inquiry Transcript 1

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