Harold Shipman Report Summary

I. The First Report > Death Disguised >

SUMMARY

1. Shipman entered general practice in early 1974, when he joined the Abraham Ormerod Medical Practice in Todmorden. He remained there until September 1975, when his partners discovered that he had been dishonestly obtaining controlled drugs for his own use.

2. In February 1976, Shipman pleaded guilty at the Halifax Magistrates’ Court to three offences of obtaining pethidine by deception, three offences of unlawful possession of pethidine and two further offences of forging a prescription. He asked for 74 similar offences to be taken into consideration. He was ordered to pay a fine and compensation.

3. The fact of his convictions was reported to the General Medical Council, which decided to take no disciplinary action against him. The Home Office imposed no prohibition on his future dealings with controlled drugs. He was, therefore, free to continue practising as a doctor without limitation or supervision.

4. In October 1977, Shipman joined the seven doctor Donneybrook practice in Hyde. He remained there until January 1992, when he began to practice single-handed from within the same building.

5. In August 1992, he moved to new surgery premises at 21 Market Street, Hyde, where he continued to work as a single-handed practitioner until his arrest in September 1998.

6. Throughout his career as a general practitioner, Shipman enjoyed a high level of respect within the communities in which he worked. In Hyde, he was extremely popular with his patients, particularly his elderly patients, and was regarded by many as ‘the best doctor in Hyde’.

7. In July 1998, the Greater Manchester Police began an investigation into the death of one of Shipman’s patients, Mrs Kathleen Grundy. That investigation was rapidly widened to include the deaths of many other patients of Shipman.

8. On 7th September 1998, Shipman was arrested, interviewed and charged with the murder of Mrs Grundy and with other offences associated with the forgery of her will, under which he was to be the sole beneficiary of her estate. He was subsequently suspended from practice and charged with 14 further murders.

9. On 31st January 2000, following a lengthy trial, Shipman was convicted of 15 counts of murder and one of forging Mrs Grundy’s will. He was sentenced to 15 terms of life imprisonment and, for the forgery, a concurrent term of four years’ imprisonment. The trial judge said that his recommendation to the Home Secretary would be that Shipman should spend the remainder of his days in prison. Following the criminal trial, the Director of Public Prosecutions announced that no further criminal proceedings would be instituted against Shipman.

10. Subsequently, the Professional Conduct Committee of the General Medical Council erased Shipman’s name from the medical register.

11. Before the trial and subsequently, the police investigated a large number of deaths of Shipman’s patients where there was evidence that Shipman had been responsible for the death. Those deaths were reported to the South Manchester Coroner, Mr John Pollard. Between August 2000 and April 2001, he conducted inquests into 27 deaths of patients of Shipman, recording verdicts of unlawful killing in 25 cases and open verdicts in the remaining two. On 18th May 2001, the Coroner opened inquests into a further 232 deaths; those inquests were immediately adjourned on the direction of the Lord Chancellor, pending publication of the findings of this Inquiry.

12. On 31st January 2001, following resolutions of both Houses of Parliament, the Secretary of State for Health issued the instrument of appointment establishing The Shipman Inquiry, giving it the powers conferred by the Tribunals of Inquiry (Evidence) Act 1921 and appointing me as Chairman of the Inquiry.

13. The first of the Inquiry’s Terms of Reference requires it, ‘after receiving the existing evidence and hearing such further evidence as necessary, to consider the extent of… Shipman’s unlawful activities’. In this, the Inquiry’s First Report, I set out my findings as to how many of his patients Shipman killed, the means employed and the period over which the killings took place.

14. Volumes Two to Six of this Report contain my written decisions in 494 cases – 493 deaths and one incident involving a living person. Those decisions are based on an enormous volume of evidence, which has been gathered by the Inquiry team.

15. I have found that Shipman killed 215 of his patients. The first, Mrs Eva Lyons, was killed in March 1975, when Shipman was practising in Todmorden, and the last, Mrs Kathleen Grundy, died in June 1998.

16. Shipman’s usual method of killing was by the administration of a lethal dose of an opiate, most frequently diamorphine. There is some evidence that he may have killed a few patients by the administration of large doses of a sedative. There is no reliable evidence that he killed by any means other than the administration of a drug.

17. Of the 215 killings, one took place in Todmorden, 71 during Shipman’s time at the Donneybrook practice and the remaining 143 during his six years at the Market Street Surgery. While at the Market Street Surgery, Shipman killed one patient in 1992, 16 patients in 1993 and 11 in 1994. In each of the years 1995 and 1996, he killed 30 patients, increasing to 37 in 1997. During the first three months of 1998, he killed 15 patients, after which there was an interval of about seven weeks; he went on to kill a further three patients before his arrest in September 1998.

18. Shipman’s oldest victim, Miss Ann Cooper, was 93 years old when she was killed. The majority of Shipman’s victims were elderly but he did, on occasions, kill younger people. Mr Peter Lewis died at the age of only 41; he was the youngest of Shipman’s patients to die at his hands. Mr Lewis was in the advanced stage of a terminal illness and Shipman hastened his death. The youngest of Shipman’s victims to suffer an unexpected death was Mr David Harrison, who was 47 years old when he died.

19. Of Shipman’s 215 victims, 171 were women and 44 were men. In general, women live longer than men, so that there are more elderly women than elderly men living alone. Since Shipman’s typical victim was an elderly person living alone, he found most of his potential victims among his female patients. However, he also killed men when the opportunity presented itself.

20. Whilst the majority of the deaths for which Shipman was responsible occurred while he was working as a single-handed practitioner, it is nevertheless clear that, even while working in a multi-handed practice, he was able to kill undetected over a period of many years.

21. I have found that 210 of the deaths investigated by the Inquiry team occurred as the result of natural causes and not by reason of any action on the part of Shipman. I hope that the families concerned with these cases will be reassured by my finding that Shipman was not responsible for their relative’s death.

22. There are 45 deaths for which I have found that a real suspicion arises that Shipman may have been responsible, although the evidence is not sufficiently clear for me to reach a positive conclusion that he was. In addition, there are a further 38 deaths in respect of which there was so little evidence, or evidence of such poor quality, that I was unable to form any view at all. These are mainly deaths dating from the early years, where little documentary or witness evidence survives. I regret that the families concerned with these deaths are left in a state of uncertainty, but it was inevitable that there would be some cases where the evidence would not permit me to reach a positive conclusion one way or the other. I can only hope that it will be of some comfort to the relatives at least to know that the circumstances of each death have been investigated as fully as possible.

23. In all, the Inquiry has examined 888 cases; I have given a written decision in 494 (493 deaths and one incident involving a living person) of those cases. In the remaining 394 cases, there was compelling evidence that Shipman was not responsible for the death. The Inquiry legal team therefore closed the files in those cases, without the necessity for a written decision. In all but the most straightforward cases, I examined the file and confirmed the decision to close it.

24. Professor Richard Baker OBE, Professor of Quality in Health Care at the University of Leicester, conducted a review of Shipman’s clinical practice, which was published in January 2001. He carried out a number of analyses of the estimated excess of deaths among Shipman’s patients during his career as a general practitioner. He estimated that the true number of excess deaths lay between 198 and 277 and concluded that an excess of 236 deaths was ‘most likely to reflect the true number of deaths about which there should be concern’.

25. Having considered my findings, Professor Baker has concluded that they support the conclusion that the excess of deaths is in the region of 220 to 240, i.e. very close to his own figure of 236. Here, Professor Baker is taking into account, not only the 215 deaths which I have found that Shipman caused, but also some of the deaths about which I was unable to reach a positive conclusion but where I found that there was a real suspicion that Shipman was responsible. It is inevitable that that group of deaths will, in fact, contain some killings. The striking compatibility between the results of Professor Baker’s previous review and my own findings strongly suggests that the conclusions of the Inquiry and of the review are very likely to be correct.

26. All but three of the deaths for which I have found that Shipman was responsible were entered in the register of deaths in reliance upon Medical Certificates of Cause of Death completed by Shipman. The majority of those deaths were followed by cremation. Before a cremation can be authorised, a second doctor must confirm the cause of death and the cremation documentation must be checked by a third doctor employed at the crematorium. These procedures are intended to provide a safeguard for the public against concealment of the fact that a person has been unlawfully killed. Yet, even with those procedures in place, Shipman was able to kill 215 people without detection. It is clear therefore that, in reality, the procedures provided no safeguard at all. Why that was, and what steps should be taken to devise a system which will afford the public a proper degree of protection in the future, are issues which the Inquiry will consider during Phase Two.

27. Shipman’s patients frequently died suddenly at home, without any previous history of terminal or life-threatening illness. Such deaths should be reported to the coroner. Yet Shipman managed to avoid a referral to the coroner in all but a very few cases in which he had killed. He did this by claiming to be able to diagnose – and, therefore, to certify – the cause of death and by persuading relatives that there was no need for a post-mortem examination. In Phase Two, the Inquiry will consider measures which can be taken to ensure that all unexpected or unexplained deaths are reported and their cause properly investigated.

28. After Shipman’s convictions for drugs offences in 1976, he declared his intention never to carry controlled drugs again. Accordingly, he was not obliged to have a controlled drugs register. Yet he was able, by a number of different methods, to obtain large quantities of controlled drugs; in 1996, he prescribed and obtained in the name of a dying patient as much as 12,000mg diamorphine on a single occasion. That alone would have been sufficient to kill about 360 people. Despite the fact that the possession and supply of such drugs is said to be ‘controlled’, those controls did not prevent Shipman from acquiring large amounts of diamorphine without detection. How that could happen, and what measures should be taken to strengthen the system of controlling access to such drugs, are matters which will also be considered by the Inquiry in Phase Two.

29. Professor Baker has observed that one implication of the high number of patients killed by Shipman is that an effective system of monitoring the death rates of patients of general practitioners would have detected the excess number of deaths. No such system was in place during Shipman’s time in general practice. In Phase Two, the Inquiry will seek to identify effective systems for monitoring death rates, and will consider other possible improvements to the arrangements for monitoring general practitioners and ways of encouraging those genuinely concerned about possible misconduct on the part of doctors to express their concerns to those in a position properly to investigate and evaluate them.

30. No one reading this Report can fail to be shocked by the enormity of the crimes committed by Shipman and to feel, as I do, the deepest sympathy for his victims and their families. His activities have brought tragedy upon them and also upon the communities in which he practised and which gave him their trust.

31. In its first Phase, the Inquiry has determined the extent of Shipman’s criminality. We shall now direct our efforts to attempting to devise improved systems so as to ensure that such a terrible betrayal of trust by a family doctor can never happen again.