Introduction

Mrs Joyce Woodhead died at her home, 1 Sawyer Brow, Newton, Hyde on Sunday, 23^rdFebruary 1997 at the age of 74. She had been a patient of Shipman since his arrival in Hyde in 1977 and had followed him when he moved to the Market Street Surgery. She thought highly of him and had regarded him as a friend. He certified that the cause of her death was coronary thrombosis.

In September 1998, F. Massey and Son, funeral directors gave the police information provided to them by one of their drivers, Mr Joseph Slater, about Mrs Woodhead's death. He said that he had attended at the house after the death. The death seemed to have been sudden and Shipman and his wife were both present after the death. The police investigated the death and took statements from Mr Slater, Mrs Freda Katherine Hibbs (Mrs Woodhead's sister), Miss Carole Coe (a friend and neighbour of Mrs Woodhead), Detective Sergeant John Frederick Ashley (a Greater Manchester Police computer expert) and Mr David Stuart Bambroffe (a funeral director). The police took a statement from Dr John Grenville and obtained the ambulance logs and their own archived incident report in relation to the circumstances of the death. The police also obtained a note made by Mrs Mavis Stott, a friend of Mrs Woodhead.

Shipman was not prosecuted for causing Mrs Woodhead's death but an inquest into the death was held on 25^th January 2001 at which the South Manchester Coroner entered a verdict of unlawful killing.

The Inquiry has taken further statements from Mrs Hibbs, Miss Coe and also from Mrs Primrose May Shipman, Shipman's wife. Mrs Shipman gave oral evidence at a hearing on 16^th November 2001. The Inquiry has had access to Mrs Woodhead's general practitioner records and to appointments sheets, visits books and other practice documents for the relevant period. In addition, the Inquiry has obtained documentation provided by Healthcall Services Limited, the deputising service used by Shipman, and the telephone billing records for Mrs Woodhead, Mrs Hibbs, Miss Coe, Mrs Stott, Shipman's home and two separate lines at the Market Street Surgery. The coroner's papers relating to the inquest, including his notes of evidence, have been received by the Inquiry.

This decision has been written following consideration of the papers. The only oral evidence given was that of Mrs Shipman.

Personal Background

Since the death of her husband in 1995, Mrs Woodhead had lived alone. Until the week of her death, Mrs Woodhead had enjoyed good health. Her sister, Mrs Hibbs, said that she was extremely active. She ran her home and looked after herself.

The Lloyd George folder containing Mrs Woodhead's medical records is remarkably thin for a woman of her age and the computerised records are also brief. There is no record that Mrs Woodhead ever suffered from heart problems. The records show that Mrs Woodhead consulted Shipman in June 1995 on account of pain, presumably in the abdomen, which he attributed to indigestion.

Shortly before her death, Mrs Woodhead became unwell. Miss Coe recalls that Mrs Woodhead first complained of feeling ill over the weekend of 15^th/16^th February. On Tuesday, 18^th February, she felt well enough to promise to take Miss Coe's young daughter out on the Thursday. However, when Thursday came, she told Miss Coe that she was not feeling up to it. She said she had a cold and wanted to rest. On the same day, she told her sister that she thought she had caught a 'bug'. She had had a bad night and had been sick. She did not want her sister to visit in case she was infectious. The next day, Friday, 21^st February, she told her sister she felt a little better, although she was not completely recovered. This recovery seemed to continue on the Saturday, when Mrs Woodhead telephoned Miss Coe to suggest that they should go out for lunch the following day.

The Day of the Death

Despite the apparent improvement the previous day, Mrs Woodhead was not well on the morning of Sunday, 23^rd February. A few minutes after 9am, she telephoned Mrs Hibbs. Mrs Hibbs thought that this telephone call took place at about 10.45am but the records show the time to have been 9.04am. Mrs Woodhead said that she had had a dreadful night. She had had stomach pain and had been sick. She had decided to ask Shipman to visit her, even though it was a Sunday. Mrs Hibbs invited her sister to come to stay with her for a few days. Mrs Woodhead said she would think about it and promised her sister that she would telephone her as soon as the doctor had been.

The telephone billing records show that Mrs Woodhead had telephoned the surgery number at 9.01am, a few minutes before she called Mrs Hibbs. As this was a Sunday, the call was diverted to Healthcall, the deputising service used by Shipman at the time. The Healthcall documentation records that Mrs Woodhead telephoned at 9.03am. Under the heading 'complaint', the following is recorded:

Shipman was apparently informed of the position at 10.34am.

Mrs Hibbs telephoned her sister and they had a brief conversation at 9.57am.

There are some differences between the account which Miss Coe gave to the Inquiry and that she gave to the police. These are mainly differences of timing. When she made both statements, she did not have the benefit of the telephone billing records. The following account of events affecting her is the result of my synthesis of the telephone records with Miss Coe's statements, and represents my findings as to what actually happened.

Mrs Woodhead telephoned Miss Coe at 10.03am and probably told her that she was not well and that the doctor was coming. I think it likely that Mrs Woodhead promised to telephone Miss Coe when the doctor had been.

Mrs Woodhead did not subsequently telephone either Mrs Hibbs or Miss Coe. As time passed, both women became concerned. At 11.52am, Miss Coe telephoned Mrs Woodhead's house and the call was answered by Shipman. He told Miss Coe that Mrs Woodhead had had a heart attack three days previously but that she was now stable and there was no point in her going into hospital. Miss Coe said she would come round straight away but Shipman said that he was leaving immediately to take his son to football and would return in half an hour (or he might have said he would return at 12.30pm), at which time he would meet Miss Coe at the house. Shipman asked Miss Coe if she knew Mrs Hibbs' telephone number, but she did not. When Miss Coe asked to speak to Mrs Woodhead, Shipman said that she was in bed and he had given her something 'to settle her down', as her pulse was still erratic. Miss Coe then telephoned her mother, to ask her to come round to look after her daughter. Within a short time, her mother came and Miss Coe then went to Mrs Woodhead's house. She found that Shipman had gone and there was no reply at the front or back door. Miss Coe asked the neighbours if they had a key but they did not. Shipman did not return to the house as promised at 12.30pm and, after a while, Miss Coe returned home.

At 2.01pm, a call was made from Shipman's surgery to Tameside and Glossop Health Authority. I think it most unlikely that anyone other than Shipman would have access to and would have used the surgery telephones at that hour on a Sunday. At 2.06pm, Shipman made a telephone call from his surgery to Mrs Stott, a friend of Mrs Woodhead. He asked her if she had a key to Mrs Woodhead's house. She did not. Shipman told her that he had visited Mrs Woodhead earlier in the day and had found that she had had a slight coronary thrombosis and advised her to go into hospital. She had not been enthusiastic about that so he had visited another patient so as to give her a short time to think about it. He had just been back to the house but there was no reply. He could not gain entry. Mrs Stott told him that Mrs Hibbs had a key and gave him her telephone number. Another call was made from the surgery telephone system to Mrs Stott's number at 2.11pm. A final call was made at 2.13pm, to what appears to be Shipman's home number. Shipman must still have been at the surgery at that time.

Meanwhile, Mrs Hibbs had waited for a call from Mrs Woodhead. Between 1.45pm and 2pm, she telephoned Mrs Woodhead's home but there was no reply. She drove to her sister's house and arrived about 15 minutes later. She spoke to a neighbour, whom she did not know, who told her that her sister had had a coronary thrombosis. She let herself in with her key and called out. There was no reply. She went through the house and found her sister lying in bed, under the duvet but wearing day clothes. Her left arm was exposed. It appeared to Mrs Hibbs that her sister was dead. She noticed that she looked peaceful.

Mrs Hibbs telephoned 999 and asked for the police to come. Her call was made at about 2.20pm. They had not arrived when Shipman came to the house. He told Mrs Hibbs that he had come back to see if Mrs Woodhead had decided to go to hospital or whether she would go to stay with her sister. Mrs Hibbs said that her sister was dead. Shipman appeared visibly shocked and said something like: 'She can't be. She's only just waved me off'. He went upstairs and when he came down he said that Mrs Hibbs was right. He said that, when he had been there that morning, Mrs Woodhead had been alive and, when he left, she had shown him to the door. He had gone to the surgery to obtain her medical notes and find details of her next of kin but, as she had been healthy, he had no note of her next of kin. He had just obtained Mrs Hibbs' telephone number from Mrs Stott. He had wanted to speak to her to explain that Mrs Woodhead had had a coronary thrombosis and needed time to recuperate.

Shipman called his wife, who was outside in the car, to come into the house and Mrs Hibbs assumed that he did so because she herself was distressed. He then telephoned the police to say that it would not be necessary for them or an ambulance to attend. He said that Mrs Woodhead was dead and that he would provide a Medical Certificate of Cause of Death (MCCD). That call was timed at 2.26pm. He told Mrs Hibbs to make a cup of tea while he went to straighten the body so that Mrs Hibbs could, as he put it, 'say goodbye to her properly'. When he came down, he explained to Mrs Hibbs that her sister had had a heart attack and said that 50 per cent of such cases were fatal, 25 per cent were damaged and 25 per cent recovered. He had advised Mrs Woodhead that she should either have three days in hospital or three days' rest. He said that she had not made an immediate decision so he had called back to see what she had decided to do. He said it would not be necessary to have a post-mortem examination as he had seen Mrs Woodhead earlier that day. He instructed Mrs Hibbs to come to the surgery the following day to collect the MCCD.

At 2.35pm, Mrs Hibbs telephoned Massey's undertakers from Mrs Woodhead's house. Mr Slater attended and Shipman answered the door. Mr Slater remembers seeing Mrs Shipman and that Mrs Woodhead appeared peaceful, as if asleep.

Mrs Shipman said in her statement to the Inquiry that, on the day of Mrs Woodhead's death, she and her husband had taken their youngest son to play rugby. She said in her statement that:

'The only recollection I have, is of my husband being bleeped and responding to this by making a telephone call. I have some idea that I became aware that the ambulance service had contacted my husband with a request for him to attend the home of a patient'.

In her oral evidence, Mrs Shipman said that, if her son had been taking part in a training session or a home game, then they would have gone to Ashton rugby ground. If it was an away game, then of course the game could have been anywhere in the locality. Generally, they would arrive at 10am but the start time varied and their son would not be ready to leave until around 2pm. In her statement, Mrs Shipman said that she could not recall whether her husband remained at the match, although she is sure that she was with her husband at the rugby ground when his pager went off. She remembers that she and her husband left together and went to Mrs Woodhead's house. She thinks that when they arrived there was an ambulance at the house. She confirmed that she went into the house and spoke to someone whom she thinks was Mrs Woodhead's sister.

I do not think that Mrs Shipman's recollection of these events is correct. First, I am sure there was no ambulance at the house when she and her husband arrived. No ambulance ever came. Second, I do not think Shipman returned to Mrs Woodhead's house from the rugby ground at Ashton as the result of being paged. He could not have travelled the five miles from Ashton to Hyde and have been in Hyde by 2.26pm, at which time he telephoned the police to tell them there was no need for them or an ambulance to attend. It is possible that the match was being played not far from Mrs Woodhead's house, in which case the timings might have been possible. But even that is unlikely, as Shipman was at his surgery until at least 2.13pm. He would then have had to go to the rugby ground, receive a paged call and have arrived at Mrs Woodhead's in time to stop the police and ambulance from coming. This is implausible and I am satisfied that it did not happen in this way. In any event, there is no evidence that the police tried to contact Shipman, only that he contacted them. I think he returned to the house from the surgery, where he had been making various telephone calls to the health authority and to Mrs Stott. It may well be that Mrs Shipman was with her husband by this time and it is quite likely that he had spent some time at the rugby ground after leaving Mrs Woodhead's just before noon. In any event, Mrs Shipman's evidence is not relevant to the issue of what Shipman did during the morning when he was with Mrs Woodhead. Mrs Shipman may be correct in her recollection that her husband was paged. However, if that was the case, then it is likely that he was paged earlier than she recalls, on the basis of the Healthcall documentation, shortly before 10.34am, following which he would have left the rugby match alone.

Mrs Woodhead's name appears in the duty doctor diary for 23^rd February 1997. The note records two visits, at 11am and 2.30pm, and that the visits were 'non claimable', which meant that the visits could not form the subject of a financial claim to the health authority. This was because of the times that the visits had taken place.

There are three entries dated 23rd February 1997 in Mrs Woodhead's handwritten medical notes, which record as follows:

'V. 14.00 Sister present C.T.'

On a separate card the following, more extensive note appears:

low sternal pain neck

That entry records a three day history of illness, which, in itself, is consistent with what Mrs Woodhead had told Mrs Hibbs and Miss Coe. Shipman recorded vomiting, which Mrs Woodhead had mentioned to Miss Coe and Mrs Hibbs, and sweating, which she had not mentioned. He also recorded sternal pain radiating into the neck. However, Mrs Woodhead had only mentioned stomach pain. Shipman made a diagnosis of myocardial infarction or heart attack and said that, because she had been unwell and in that condition for a period of three days, Mrs Woodhead should be left at home, presumably as opposed to being admitted to hospital.

There are three entries in the computerised medical records dated 23^rd February 1997. The first, created at 8.41am on 24^th February 1997, records as follows:

'G 30 MI - acute myocardial infarction

probably last tues nausea chest pain into neck sweaty nausea

and vomiting felt weak and tired all the week had little

episodes . to talk to sister ?admit ? to go there'.

The next entry, created at 8.43am on 24^th February 1997, records:

Although the two entries were created at the same sitting on the day after the death, they give the impression of having been created separately. But for the ability to ascertain when the entries were made, the natural inference would be that the first entry was made prior to the discovery of Mrs Woodhead's body and the second, some time later, after the discovery of the body.

The final entry dated 23^rd February is an administrative entry recording that two home visits made on the day of death were 'NOT CLAIMABLE'.

Certification

Shipman completed the MCCD and certified the cause of death as coronary thrombosis. He said that the approximate interval between the onset of the coronary thrombosis and death was four days. Shipman said that he had last seen Mrs Woodhead alive on the day of her death.

Shipman also completed Form B of the cremation certificate. He said that the death had occurred at 2pm, that he had attended Mrs Woodhead for three hours during her last illness and that he had last seen her alive three hours before death. On his timings, that would mean that he visited her at about 11am. He said that he had seen the body about half an hour after death, thus timing his afternoon visit at about 2.30pm. He said that Mrs Woodhead's sister was present at the moment of death. He said that the mode of death was syncope of only seconds' duration. He claimed to know the cause of death and the mode of death partly from his own observations and partly from those of the sister (Mrs Hibbs). It is clear that these entries are not true. Mrs Woodhead's sister had not been present at the death and could not have told Shipman anything about the mode of death or anything from which he could have inferred the mode or duration of death. It seems to me that these lies were designed to create the impression that someone had been with Mrs Woodhead when she had had a coronary thrombosis.

The Expert Evidence

Dr Grenville has seen Mrs Woodhead's medical records, the death certification including the cremation certificate and the statements taken by the police. He noted that Mrs Woodhead appeared to be a fit and healthy lady who attended Shipman infrequently. She had no risk factors for ischaemic heart disease. He noted the computerised and written records relating to 23rd February 1997, as set out above. He noted that Shipman told Miss Coe that he had given Mrs Woodhead 'something to settle her down'. Dr Grenville has said that, if that were true, then Shipman's failure to record that in the notes would be a serious omission.

Dr Grenville has said that, when considering the symptoms recorded by Shipman, a doctor might suspect a heart attack, amongst other conditions. Dr Grenville noted that, of the symptoms recorded by Shipman, chest pain was the only one not mentioned as having been described by Mrs Woodhead to the witnesses. In the absence of a record of chest pain, Dr Grenville has said that a heart attack would be very low on the list of possible diagnoses. Even if one were to accept Shipman's description of the symptoms, including the chest pain, the symptoms are by no means clearly diagnostic of a heart attack. In order to establish such a diagnosis, further investigation such as an electrocardiograph (ECG) and various blood tests would have to be done. In summary, Dr Grenville says there is nothing recorded in the examination that would lead a doctor to conclude that Mrs Woodhead had suffered a heart attack and that the death should have been referred to the coroner.

Professor Richard Baker considered Mrs Woodhead's medical records and then separately the cremation forms. On the basis of the former, he concluded that the death was highly suspicious and, on the basis of the latter, moderately suspicious. He commented:

'There is a relatively full account of the symptoms and signs. The choice of management is not clear. No analgesia or aspirin given. Thus, although there is more detail than usual for HS, suspicions must be aroused'.

Conclusion

I am satisfied that Shipman killed Mrs Woodhead.

Mrs Woodhead was alive when Shipman arrived at some time after 10.30am on the day of her death. No one saw her alive or spoke to her after his visit. There is evidence from which I infer that she was probably dead at the time of Shipman's conversation with Miss Coe at 11.52am. First, I think Mrs Woodhead would have spoken to Miss Coe herself at that time had she been alive. I think Shipman's claim that Mrs Woodhead was resting was just an excuse and the truth was that she could not come to the telephone. Shipman tried to encourage Miss Coe not to come to the house for some time. I am sure he did not want Miss Coe to discover the death too soon. Shipman left soon after that conversation. Had she then been alive, Mrs Woodhead would have telephoned her sister and Miss Coe as soon as Shipman had gone. Shipman gave inconsistent accounts of Mrs Woodhead's condition when he left. To Miss Coe, he said that Mrs Woodhead was resting and that she should not come round. To Mrs Hibbs, he said that Mrs Woodhead had waved him off. Another factor, which makes me think that Mrs Woodhead was already dead when Shipman left, is that, when he spoke to Miss Coe, he asked her for Mrs Hibbs' telephone number. Had Mrs Woodhead been alive, he would have asked her for the number, even if she were having a rest. Finally, Miss Coe went to Mrs Woodhead's house within a few minutes of Shipman's departure. There was no reply at the door. I conclude that Mrs Woodhead was already dead and had died while Shipman was at the house. Shipman lied about this, which points compellingly to his guilt.

There are many other factors which confirm my view that Shipman killed Mrs Woodhead. I am satisfied that Shipman's medical notes are false. He paints a picture of a constellation of symptoms which could indicate that Mrs Woodhead had had a heart attack. However, the symptoms do not closely resemble those which she had mentioned to her sister and Miss Coe. To them she had spoken of having a cold and of having caught a bug. She mentioned stomach ache. Shipman's notes speak of sternal or chest pain radiating into the neck. I suspect that this reference to sternal or chest pain was an attempt to create the impression that Mrs Woodhead had had a heart attack. As Dr Grenville has said, any doctor who was really presented with this constellation of symptoms would wish to admit the patient to hospital for further tests in order to establish a diagnosis. Shipman did not suggest any further tests or offer any treatment at all.

Shipman's explanation to Mrs Hibbs that he had left Mrs Woodhead alone while she decided whether she was prepared to go into hospital, is a variant on the explanation he has given in many other cases. It does not bear examination. First, he wrote in the notes that hospital admission was not necessary. He told Miss Coe that it was not necessary. Had he really suggested hospital admission and had Mrs Woodhead refused, Shipman would have recorded that in the notes. Had Mrs Woodhead refused, and suggested care by her sister as an alternative, either she or Shipman would have telephoned Mrs Hibbs there and then. Instead, Shipman's accounts of why he left Mrs Woodhead, wished to return to see her again and wished to contact Mrs Hibbs, became more elaborate and less plausible as he spoke first to Miss Coe, then to Mrs Stott and then to Mrs Hibbs.

The manner of Mrs Woodhead's death, lying on her bed, looking peaceful, is not at all typical of a death by heart attack or any of the other common causes of sudden death. It is, however, typical of other deaths caused by Shipman, by the administration of diamorphine.

Form B contains a number of demonstrable lies. Mrs Hibbs was not present at the moment of death and could not have contributed any information as to the time or manner of death. The whole document is a fabrication designed to distance Shipman from the death and place another person at the scene. The intention was obviously to allay suspicion.

It is possible that Mrs Woodhead might have had a minor coronary thrombosis during the few days before her death. However, in the light of her previous medical history, no honest medical practitioner could have stated that he had no doubt as to the cause of death. This case should have been reported to the coroner.

All the evidence points to this being a case of an unlawful killing and I am sure that Shipman killed Mrs Woodhead.