Introduction

Mr Kenneth Pickup died whilst taking a walk next to Werneth Low Golf Course on Wednesday, 27^th August 1997 at the age of 77. He had been a patient of Shipman since Shipman's arrival in Hyde in 1977 and had followed him when he moved to the Market Street Surgery. He held Shipman in the highest regard. His death was referred to the South Manchester Coroner who, after post-mortem examination without inquest, certified that the cause of his death was left ventricular failure due to 'dilated heart with old myocardial fibrosis' due to ischaemic heart disease.

In about August 1998, during the police investigation into the death of Mr Pickup's wife, Mrs Mavis Mary Pickup, the police interviewed their son, Mr James Kenneth Pickup. He expressed concern as to the circumstances of his father's death. The police, therefore, investigated the death and took a statement from him.

The Inquiry has taken statements from Mr James Pickup and Mr Leonard Harris, who discovered Mr Pickup's body. The Inquiry has had access to Mr Pickup's general practitioner and hospital records, the surgery appointments sheets, and Shipman's visits books, duty doctor diary and acute prescriptions book. The Inquiry has examined the coroner's file, including a post-mortem examination report, and has obtained the contemporaneous reports made by the police and ambulance personnel. The Inquiry has also obtained reports from Dr John Grenville and Professor Helen Whitwell.

This decision has been written following consideration of the papers and without an oral hearing.

Personal Background

Mr Pickup was a retired solicitor who lived with his wife at 'Westholme', 9 Spring Avenue, Gee Cross, Hyde. He had a history of heart problems and in 1979 underwent aortic valve replacement at Manchester Royal Infirmary. He made an uneventful and relatively quick recovery from the surgery. He continued to suffer from peripheral vascular disease, however, and in November 1996 underwent a left carotid endarterectomy operation.

On 12^th August 1997, about two weeks before his death, Mr Pickup had a cardiac pacemaker fitted. The registrar described the procedure as 'entirely uncomplicated', and Mr Pickup was discharged on 16^th August 1997. The discharge shows that Mr Pickup was taking cimetidine, frusemide, warfarin, lisinopril and flucloxacillin.

Mr James Pickup says that his father was advised to take light exercise following the operation and, within a few days, he had incorporated an afternoon walk into his daily routine. Mrs Pickup would drive him to the top of Werneth Low and he would walk back to their house, which appears from the map to be a distance of about a mile, mainly downhill.

The records reveal that on 19^th August 1997, Mr Pickup was reviewed at the anti-coagulant clinic at Manchester Royal Infirmary. On 20^th August, there is an entry in the general practitioner records, which suggests that Mr Pickup was seen in the surgery, but the reason is not clear. The record is probably an error, as there is no reference to Mr Pickup in the appointments sheet for that day. In any event, it seems that he would not have seen Shipman, who was on holiday. A locum doctor was working in Shipman's place. On 22^nd August, Mr Pickup was seen at the pacemaker clinic at Manchester Royal Infirmary. All was well.

Two separate entries relating to Mr Pickup appear in the acute prescriptions book for 23^rd August 1997. The first says:

I infer from that that Mr Pickup telephoned the surgery to ask for a prescription of cimetidine. The second entry says:

This suggests that Mr Pickup had telephoned the surgery to remind Shipman to see him sometime. Mr James Pickup says that his father held Shipman in very high regard. The two men were on friendly terms. As Shipman was on holiday until 23^rd August, he probably did not see the message until his return to work on Monday, 25^th August.

The Day of the Death

At the time of his father's death, Mr James Pickup was working in London and his account of the events of 27^th August 1997 is based on what he was told by his mother. Mrs Pickup was killed by Shipman less than a month later.

In his Inquiry statement, Mr James Pickup said that Shipman visited Mr Pickup at about 2pm. The purpose of the visit was to check Mr Pickup's pacemaker and Shipman was alone with him during the consultation. Shipman apparently said that Mr Pickup was making good progress and that the pacemaker was working well. After Shipman had left, Mr and Mrs Pickup immediately set off in the car to Werneth Low in order for Mr Pickup to have his daily walk. The journey time would have been about five minutes. Mrs Pickup dropped her husband off and returned home. Mr Pickup had not made any complaint about feeling unwell in the hours preceding his death. Mr James Pickup said that the police called at the house at 3.30pm and told Mrs Pickup that her husband had had a heart attack and died when walking on the footpath alongside Werneth Low Golf Course. Mrs Pickup had already become concerned because she had expected Mr Pickup to return by 3pm.

In December 1998, a police officer spoke with Mr James Pickup about the circumstances of his father's death. The officer took an account of the timing of the events of 27^th August 1997, which differs from the timings given in Mr James Pickup's witness statement. The police report records that Shipman visited Mr Pickup at 'lunchtime to see how he was progressing'. It is recorded that Mrs Pickup drove her husband to the top of Werneth Low at about 3pm and that he was found dead at about 4pm.

The computerised medical records confirm that Shipman saw Mr Pickup on 27^th August for the purposes of a review, and the following comment appears in the records:

Some information concerning timings is available from the practice documents. Shipman's appointments sheets show that the open surgery in the morning was due to begin at 10.15am. However, Shipman had 11 patients to see before then and, as he often overran the scheduled times, it is quite likely that he would not have started open surgery until 10.30am. Six patients attended open surgery, so he had probably finished by about 11.15am to 11.30am. A special appointment had been made for 11.30am but it is not clear how long this was expected to take. When surgery was finished, Shipman usually did administrative work before going out on his visits. It would appear to me that he would probably not have been free to begin his visits until noon at the earliest. On that day, Shipman had four visits listed. Mr Pickup's name was not one of them. However, it would appear from his message of 23^rd August that there was no need to see Mr Pickup on any particular day. Shipman was due back in the surgery at 2pm for a vaccinations clinic, which would have taken about half an hour. He would then have been free to continue his visits and was not required in the surgery again until 4pm. Thus it seems unlikely that Shipman would have visited Mr Pickup at 2pm. It seems that Shipman had two windows of opportunity to visit Mr Pickup. It is quite possible that he could have visited at any time between about 12.15pm and 1.30pm or between about 2.45pm and 3.30pm. If, as Mrs Pickup appears to have said on one occasion, Shipman visited at lunchtime, he must have come during the first of these two periods.

On the afternoon of 27^th August, Mr Leonard Harris was walking from Hyde towards Hattersley. He walked out of Hyde, along Green Lane, and took a footpath, which led towards the monument on Werneth Low. He passed the monument and descended the slope towards the gateway, beyond which the path runs alongside Werneth Low Golf Course. Before he reached the gateway, about 150 yards ahead, he saw what appeared to be a man lying face down alongside the path. He ran to the man, turned him over and realised that he was dead. He called for help from two men who were playing golf nearby. One of them went to call the police and ambulance. Although Mr Harris does not remember what time it was, the police log gives the time at which the emergency call was received and also contains a full account of subsequent events. I have done my best to make an approximate estimate of the distance Mr Pickup must have walked from the car park where his wife left him to the point where he collapsed and died. It appears to me to be about half a mile.

The emergency call was received at 4.38pm. The ambulance arrived at 4.47pm and the police were on the scene at 4.50pm. At 5.01pm, the police log states that a male had been found and the paramedics had tried reviving him but there were no signs of life. The police found identifiable property and, by 5.05pm, Mr Pickup's name and address had been discovered. The ambulance record states that rigor mortis and venous pooling were present in the body. The ambulance left the scene at 5.02pm and the body was taken to the mortuary. An entry in the police log at 5.32pm records that Mrs Pickup had been informed of events and was very upset. The next entry says that Mr Pickup's son had been informed in London and would catch the next train home. He asked the police to wait for his arrival, as he would prefer to identify the body himself rather than put his mother through this trauma. The police enquiries continued and they discovered that Mr Pickup was the retired clerk to the magistrates at Dukinfield and that he had a history of heart problems. Mr James Pickup later identified the body.

The Aftermath

On 28^th August, Mr James Pickup went to the surgery to speak to Shipman. Shipman said that Mr Pickup had been very ill and although there were no problems with the pacemaker, he was sure that it was his illness that had killed him. Although Mr James Pickup found Shipman to be engaging, he recalls that he did not offer his condolences. Shipman appeared concerned about Mrs Pickup and how she would cope following her husband's death. He said that, statistically, two thirds of surviving spouses die within six months of the death of their spouse. Mr James Pickup explained that in his opinion his mother was in good health and considering her strength of personality, she would cope with the bereavement. Shipman said words to the effect, 'Tell her that if she ever needs me, all she has to do is call. She can call me at any time, whether it is a medical problem or any other kind of problem. I will happily call in to see her, even in the evening on my way home. Just tell her to get in touch with me if she needs me'.

The Post-Mortem Examination

A post-mortem examination was carried out on 29^th August 1997. Upon external examination, old surgical scars were noted over the anterior chest wall, the upper part of the left side of the anterior chest wall, the left side of the neck and the inner aspect of the right leg. Small areas of abrasions of the skin on the forehead, bridge of the nose, and right knee were noted. Bruising was noted on the left anterior chest wall and left shoulder.

Upon examination of the heart, the following was recorded:

'The heart was enlarged and dilated. The heart weighed 650g. The left ventricular myocardium was up to 1.6 cm in thickness. A whitish area of old myocardial fibrosis was present in the left ventricle involving the posterior wall and the septum. The anterior mitral valve showed fibrosis and was whitish in colour. There was a pacemaker in situ. The electrode of the pacemaker was securely anchored in the myocardium of the right ventricle. He had had previous aortic valvectomy (replacement of aortic valve). The artificial aortic valve was securely placed in the aortic ring and was quite viable. No thrombus was present around the aortic valve. Coronary vessels showed severe grades of atheromatous changes, their walls were calcified and the lumina nearly occluded in places. The aorta showed severe grades of atheromatous changes'.

The pathologist concluded that Mr Pickup's death was due to natural causes and said that the cause of death was left ventricular failure due to a dilated heart, old myocardial fibrosis and ischaemic heart disease.

The Expert Evidence

Dr Grenville considered the circumstances of Mr Pickup's death in a report dated 8^th October 2001 under the title, 'Report on eight cases where delayed effects of morphine or diamorphine have been considered (to be read in conjunction with Professor McQuay's report)'. He said:

'There is nothing to suggest that Shipman was involved in Mr Pickup's death. I cannot think of any medication which Shipman might have given to Mr Pickup which would have left him well enough to get in the car and to commence his walk but which would have caused his sudden death. It is likely that Mr Pickup suffered a sudden onset of ventricular fibrillation due to his severe ischaemic heart disease. This would have caused sudden death despite the presence of a pacemaker'.

Professor Whitwell noted the history and the account of events of 27^th August 1997, contained within the Inquiry statement of Mr James Pickup. She noted the post-mortem examination findings and commented that as Mr Pickup had collapsed, the death was entirely consistent with death occurring as a result of heart disease. She concluded that the appropriate description of the cause of death would be ischaemic heart disease due to myocardial fibrosis with severe coronary atheroma. Professor Whitwell observed:

'Clearly there is an issue over the visit by Dr Shipman within an hour or so of his death. It is not possible to comment on whether or not any noxious substance had been administered by Dr Shipman although I would be of the opinion that if heroin/morphine was given, it is unlikely he would have been in a position to set off walking'.

Conclusion

In my view, it is highly likely that Mr Pickup died of natural causes, as certified by Shipman.

Mr Pickup had a long history of heart disease and was at high risk of suffering a sudden cardiac death, notwithstanding the successful insertion of a cardiac pacemaker. The post- mortem examination findings confirm that Mr Pickup had severe ischaemic heart disease, although there was no sign of a thrombus which would prove beyond argument that a heart attack had been the cause of death. Dr Grenville says that the post-mortem examination signs were consistent with the theory that Mr Pickup had a fatal episode of ventricular fibrillation. Although Mr Pickup's death was sudden and was unexpected to his family, it was by no means unexpected from a medical viewpoint.

It is, however, entirely understandable that Mr Pickup's family should have great concern about his death, as it occurred so soon after Shipman had seen him. Their concern must be heightened by their suspicions, which I have now held were well founded, that Shipman killed Mrs Pickup a few weeks after her husband's death.

Shipman's preferred method of killing, which by August 1997 he had carried out very many times, was to give an intravenous injection of a lethal dose of diamorphine. He cannot have killed Mr Pickup in that way, as an intravenous injection of a lethal dose would render the patient unconscious within a minute or two and the patient would be dead within about five minutes. I have found that, on occasions, Shipman has probably killed a patient by giving an intramuscular injection. In general, I think he only did this deliberately to a patient who was terminally ill. The effect of an intramuscular lethal injection is, as Professor Henry McQuay and Dr Grenville have said in their joint report, much slower than an intravenous injection. In the immediate post-injection period, an onlooker might not notice anything strange, but probably after 15 minutes and certainly after 30 minutes it would be clear that something strange was happening. The drug would reach maximal effect within between 30 and 60 minutes and death would occur within about an hour. Dr Grenville said that he cannot think of any drug which would have a delayed effect which would allow Mr Pickup to go for a walk and collapse some time later. When he said that, Dr Grenville was not aware of the timing of Mr Pickup's movements on the afternoon on which he died. I am sure he would accept that it would be possible for a patient to walk about and behave normally for a short period, after being given an intramuscular injection of diamorphine. However, I do not think that the period could be more than 15 minutes. After that, I am sure the patient would become very sleepy and would be unable to continue to move.

Mr Pickup saw Shipman at some time on 27^th August. We do not know when, although I have indicated that there were two windows of opportunity. At some time after that visit, Mr Pickup's wife drove him to the top of Werneth Low and left him to walk home. Mr James Pickup says that the journey by car would take about five minutes. Mr Pickup probably collapsed and died about 10 to 15 minutes later, after walking about half a mile. On the face of it, it would seem possible that Mr Pickup might have had an intramuscular injection of a lethal dose of diamorphine, got straight into the car, been driven up to Werneth Lowe and walked for about 10 to 15 minutes before collapsing.

I say this is theoretically possible, but my view is that it is highly unlikely. First, the theory is dependent on the premise that Mr and Mrs Pickup left the house immediately after the injection had been given. Mr James Pickup can only report what his mother told him. He has given two accounts of what she told him. In December 1998, Mr James Pickup told the police that his mother had said that Shipman visited at about lunchtime and that she and her husband went up to Werneth Low at about 3pm. This suggests a time lapse between the visit and trip to Werneth Low. In 2001, Mr James Pickup told the Inquiry that his mother had said that Shipman had arrived at about 2pm and that they had left the house to go to Werneth Low immediately Shipman had gone. A visit at about 2pm is unlikely, as Shipman would have been busy in the surgery. If Shipman visited before 1.30pm and if Mr and Mrs Pickup went straight up to Werneth Low, Mr Pickup must have been left there by about 2pm and Mrs Pickup would surely have been extremely worried and have gone looking for her husband long before the police arrived some time after 5pm. If Shipman visited during the second window of opportunity and the Pickups left immediately for Werneth Low, Mr Pickup could have been dropped off soon after 3pm, at the earliest. He might have been dead within about 15 to 20 minutes. When the body was first examined at about 5pm, there were already signs of rigor mortis and venous pooling. Although venous pooling can appear within about half an hour, rigor mortis is not usually seen for at least two hours after death. If Mr Pickup died at about 3.15pm, the early signs of rigor mortis might have been discernible by 5pm, although the timing is very tight. It is puzzling that Mrs Pickup had not been more concerned about her husband's failure to return. It may be that she assumed he had met someone or called on someone.

In any event, I do not think Mrs Pickup had a very clear recollection of the events of that afternoon. This is not in any way surprising, as she was obviously very distressed. She told her son that the police came to the house at about 3.30pm or about 4pm to say that her husband had been found. She was becoming worried because she had expected him to be back by 3pm. We know that this account must be wrong, as the police did not arrive until after 5pm.

Even assuming that there is some explanation for those discrepancies, I do not take literally the assertion that Mr and Mrs Pickup left the house immediately after Shipman's departure. The Pickups would have had to say goodbye to Shipman, with whom they were on friendly terms. One would expect some sociable chat before he departed. Usually before going out for a walk there are last minute preparations such as changing shoes, going to the lavatory and locking the house. Mr and Mrs Pickup were not young and probably did not move very quickly. I do not believe that they could have left the house within five minutes of the injection. By the time Mr Pickup was ready to get out of the car, I think at least ten minutes would have passed and he would almost certainly have been aware of feeling different, probably a bit woozy and quite possibly feeling sick. I think it is highly unlikely that he would have got out of the car without saying anything to his wife. I also note that there is no suggestion that Mr Pickup told his wife that Shipman gave him an injection. One might have expected him to mention it.

There is another reason why I think it is most unlikely that Shipman would give Mr Pickup an intramuscular lethal injection. It would be highly dangerous for Shipman. The risk would be very great that Mr Pickup would feel ill and that his wife would call an ambulance and Mr Pickup would be brought round and would tell the doctors that Shipman had given him an injection. In short, I think it is most unlikely that Shipman gave Mr Pickup a lethal injection.

Taking the circumstances of this case as a whole, including Mr Pickup's cardiac problems and the post-mortem examination findings, I think it is highly likely that Mr Pickup died of natural causes.