Introduction

Mrs Elsie Barker died at her home, 9 Green Street, Hyde on Monday, 29^th July 1996 at the age of 84. She had been a patient of Shipman since about 1992 and thought highly of him. Shipman certified that the cause of her death was cerebrovascular accident due to hypertension.

In February 2000, members of Mrs Barker's family expressed concern to the police about the circumstances of her death. The police investigated the death and took statements from Mrs Lynn Lythe (Mrs Barker's daughter), and from Mrs Wendy May Barker (Mrs Barker's daughter-in-law) and Mr Carl Lythe (her son).

Shipman was not prosecuted for causing the death of Mrs Barker. An inquest into her death was opened and adjourned by the South Manchester Coroner on 18^th May 2001.

The Inquiry has taken statements from Mrs Lythe and a paramedic from Greater Manchester Ambulance Service, Mr David Gill. The Inquiry has also had access to Mrs Barker's general practitioner and hospital records, appointments sheets, visits books and other practice documents for the relevant period.

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

Personal Background

Mrs Barker had been a widow for many years. She lived alone although her daughter, Mrs Lynn Lythe, visited her every day. She led an active social life despite some medical problems. She suffered from hypertension, an irregular heartbeat and failing eyesight. She enjoyed going out although she could not go far alone on account of her poor eyesight. The handwritten medical records confirm these medical problems. However, they throw little light on Mrs Barker's state of health in the period immediately preceding her death. The final entry is a note written by a locum doctor, dated 20^th July 1996 (a Saturday), which refers to treatment for the eyes and a blood pressure reading of 190/100. There is then the comment, 'see Monday'. This might have meant Monday 22^nd, or possibly 29^th July 1996.

The computer records are more extensive and potentially more helpful in elucidating Mrs Barker's condition in the last few weeks of her life. Unfortunately, it has not been possible to check when each entry was made, as the computer audit trail facility was not installed until October 1996.

The computer records contain an entry, dated 8^th July 1996, showing that Mrs Barker had made a telephone call and requested a repeat prescription for zopiclone, a sedative. The note suggests that Shipman decided to issue the prescription but to make a point of seeing Mrs Barker the next time she requested a prescription for this drug. That a request for zopiclone was made on 8^th July is confirmed by an entry in the acute prescriptions book. A further entry in the computerised records shows that Mrs Barker saw Shipman for 'a chat' about her eyesight and visual aids on Tuesday, 23^rd July. The record for 24^th July suggests that Sister Gillian Morgan, the practice nurse, took Mrs Barker's blood pressure, which was 220/120. If this is a true record, the blood pressure was very high and, as Dr John Grenville explained, would indicate that Mrs Barker was at increased risk of cerebrovascular accident. Curiously, it appears from Sister Morgan's diary for that day that Mrs Barker's appointment was cancelled.

The Day of the Death

On Monday, 29^th July 1996, Mrs Barker spoke to her daughter at about 9am. Mrs Lythe arranged to call round in the evening. Mrs Lythe was going to play darts and her mother was to go with her. At about 2pm, Mrs Barker telephoned Mrs Lythe's home and spoke to her granddaughter, Rebecca. Mrs Lythe was not at home and Rebecca asked if her grandmother needed any help. Mrs Barker said that she did not and would speak to her daughter later on. She did not say that she was unwell or mention that she was expecting a call from the doctor.

At about 5pm, on her return from work, Mrs Lythe telephoned her mother but there was no reply. She tried again at about 6pm and, when there was still no answer, she became worried. When her son, Mr Carl Lythe, returned home from work, he took her to her mother's house, where they arrived at about 6.30pm. They found Mrs Barker in the living room, dressed in day clothes, sitting in her usual chair with her arms resting on the arms of the chair. She was dead. Mr Lythe told the police that Mrs Barker's head was tilted back and her mouth wide open but his mother told the Inquiry that her head was to one side. Mrs Barker looked as if she had fallen asleep. Her spectacles, on which she was very dependent, were neatly folded on her lap. Her face was a bluish white colour. There was no sign that she had attempted to use the telephone. Neither the television nor radio was switched on, as Mrs Lythe would have expected if her mother had sat down for a rest.

Mrs Lythe contacted her brother, Mr Graham Barker, and he and his wife came to the house. Mr Graham Barker called an ambulance. The ambulance log confirms that the call was made at 6.45pm. Two paramedics attended and pronounced Mrs Barker dead. They asked who Mrs Barker's doctor was and, on being told, summoned Shipman.

Shipman arrived at about 7.30pm. He did not examine the body but pulled it into an upright position in the chair. He told the family that the cause of death was a stroke and that a post-mortem examination would not be necessary. He said that, if the family had any concerns, a post-mortem could be arranged but Mrs Lythe said she did not want one. Shipman said he would issue a death certificate the next day. He told the family that Mrs Barker had been very poorly for many years, which came as a shock to them. He also said that there was no need for them to contact the police, as he had seen Mrs Barker within 48 hours of her death. He did not say when he had last seen her and he did not mention an earlier visit that day.

Mrs Barker's computerised medical records contain several entries dated 29^th July which suggest that Shipman saw Mrs Barker on that day. Shipman records that he 'Had a chat' with Mrs Barker about her zopiclone prescriptions. Shipman also claims to have taken Mrs Barker's blood pressure but the reading is not recorded. The record says simply:

It is not clear from the record where this consultation is supposed to have taken place. It seems very unlikely that it could have taken place at the surgery. Mrs Lythe always accompanied her mother when she went to the surgery and she did not take her that day. Mrs Barker's name does not appear on the appointments sheet for that day, which virtually rules out the possibility that, despite her poor eyesight and unbeknown to her daughter, she had visited the surgery. Nor does her name appear in the visits book for that day. Moreover, it is worth noting that the acute prescriptions register does not record a request for zopiclone on that day. There is a further entry in the computer records for 29^th July, which says:

That must relate to Shipman's visit to the house after Mrs Barker had been found dead. The other two records must relate to when she was alive.

These computer entries are the only evidence available to suggest that Shipman saw Mrs Barker alive on the day of her death. There is a subsequent entry suggesting that Mrs Barker was seen in her own home on the day after her death; this is likely to be the result of the computer defaulting to the date when the entry was made, no doubt early on 30^th July.

Neither Mrs Lythe nor Mrs Wendy Barker was aware that Shipman was to visit Mrs Barker on 29^th July. They would usually have expected her to tell them of an anticipated visit. The absence of Mrs Barker's name from the visits book suggests that, if Shipman did see her on that day, it was not by pre-arranged appointment. The duty doctor diary does record a visit but this would almost certainly relate to the visit made after the death, as this diary was only used to record out of hours visits. It appears to me that Shipman must have visited Mrs Barker at home on the day of her death.

Certification

On the Medical Certificate of Cause of Death (MCCD), Shipman stated that the cause of death was cerebrovascular accident due to hypertension, from which he said Mrs Barker had been suffering for 27 years. He said he had last seen her alive on 24^th July, five days before her death.

Shipman also completed cremation Form B. He stated that the hour of death was 'About 16.00hrs' although he had altered this from 'About 14.00hrs'. He said he had last seen Mrs Barker on 24^th July 1996. The cause of death was as stated on the MCCD. He said the mode of death was syncope of minutes' duration. How he could have known that, is hard to understand as he reported that no one was present at the moment of death. When asked to state how far his answers in respect of the cause and mode of death were based on his own observations or on statements made by others, he did not answer directly but wrote:

The reference to a nephew might well be a mistaken reference to Mr Lythe, Mrs Barker's grandson, but the suggestion that Mr Lythe had spoken to Mrs Barker by telephone at 4pm seems to be pure invention. So is the suggestion that Mrs Barker had collapsed on furniture. The evidence is that she was sitting in her chair.

Conclusion

There are a number of suspicious features surrounding this death. Although there is no eyewitness evidence of Shipman's presence at Mrs Barker's house on the day of her death, I consider that the only inference which can be drawn from the computerised medical records is that he did in fact visit her. I say that, despite the fact that Shipman has not admitted or asserted that he was at the house, as he often did in other cases. It is hard to imagine why Shipman would have made entries in the medical records clearly stating that he had seen Mrs Barker on the day of her death if he had not done so. As with all medical records made by Shipman, these must be approached with caution, especially in this case as it has not been possible to check when they were made or whether they have been altered. The records could be a genuine account of a visit, at the end of which Mrs Barker was alive and well. However, they could be false and be part of Shipman's design to cover up his involvement in Mrs Barker's death. If Shipman had decided to visit Mrs Barker and kill her, one must ask why he would make entries in her records which showed he had visited her if his primary contention, as evidenced on the MCCD and Form B, was that he had not seen her since 24^th July.

In my view, it is entirely reasonable to suppose that, when Shipman visited and had killed Mrs Barker, he believed that he had not been observed at the house and therefore took the risk of asserting on the official forms that he had not seen her that day. That would be the best way of deflecting any possible suspicion that he had been involved in her death. However, he would wish to have some ready explanation if it transpired that he had been seen at her house. The medical records, as entered by him, would enable him to give a plausible explanation for him having visited her, even though she had not requested it. He could say that he had called in, as he was passing (as he said in other cases), in order to speak to Mrs Barker about her use of zopiclone and to take her blood pressure again as he was worried about it, having seen the result of the reading on the 24^th. The entry made on the day of death relating to blood pressure, which carries with it the (no doubt intended) implication that the reading was high but had to be 'accepted', would also provide support for the feasibility of a sudden death due to a stroke.

How likely is it that Mrs Barker had a sudden catastrophic cerebrovascular accident during the afternoon of 29^th July? Undoubtedly, her blood pressure was high. Whether it was as high as the record for the 24^th shows, we do not know. However, it is reasonable to assume that Mrs Barker was at some increased risk of a stroke. If she did die of a cerebrovascular accident that day, this must have been of sudden onset as she was well when she spoke to her granddaughter at about 2pm. But, as Dr Grenville has said, patients whose illness is due to sudden haemorrhage represent a very small proportion of all patients suffering a cerebrovascular accident. Much more common is the occlusive type of stroke, which evolves gradually and results in neurological signs, such as weakness and/or slurring of speech. In those circumstances, the victim can summon help. Also, a victim of sudden haemorrhagic stroke would not be expected to be found sitting upright in a chair looking peaceful and as if asleep. So, it appears to me that, although it is possible that Mrs Barker had a sudden fatal stroke, this is unlikely.

Form B contains a number of inconsistencies and untruths. First, Shipman claimed that he last saw Mrs Barker alive on 24^th July, when the medical records tend to show that he saw her on the day of her death. The statement that the 'nephew' had found the body at 6.45pm and had spoken to Mrs Barker at 4pm is a lie and in my view an important one. Shipman is here creating the impression that Mrs Barker was still alive after the time when he might have been seen at her house. Also, the statement that Mrs Barker had collapsed on furniture is, in my view, a lie, designed to add verisimilitude to Shipman's claim that this was a death from a sudden fatal stroke.

The appearance of Mrs Barker, sitting peacefully in her armchair, is entirely typical of a death from diamorphine poisoning.

Taking all these matters into account, I am quite satisfied that Shipman did visit Mrs Barker on the afternoon of her death, without prior arrangement. She trusted him and would have let him in without hesitation. I am sure that he then killed her, almost certainly by diamorphine injection, and left, believing, correctly as it transpired, that no one had seen him.