Introduction

Mr Peter Lewis died at his home, 17 Briardene, Denton late in the evening of Tuesday, 1^st January or very early in the morning of Wednesday, 2^nd January 1985. He was only 41. He had been a patient of Shipman since 1982. Shipman certified that the cause of his death was congestive heart failure and that he died on 2^nd January.

In September 2001, Mr Lewis' mother-in-law, Mrs Elsie Gee, contacted the Inquiry to express concern about the circumstances of her son-in-law's death.

The Inquiry has taken statements from Mrs Gee and from Mr Lewis' widow, Mrs Muriel Hamilton, who has remarried since Mr Lewis' death. Mrs Hamilton and Mrs Gee gave oral evidence at a hearing on 12^th April 2002. The Inquiry has had access to the copy entry in the register of deaths ('death certificate') and to Shipman's visits books for the relevant period. The medical and district nursing records have not survived, nor has the Medical Certificate of Cause of Death (MCCD), its counterfoil or the cremation documents.

Personal Background

Mr Lewis and his wife had known each other for nine years when they married in 1983. He was a fit and very active man. His only medical problem had been the development of a lump in his abdomen. This was removed at the Christie Hospital and Mr Lewis was told that it was benign.

The couple moved to Denton when they married and both became patients of Shipman. Not long afterwards, Mr Lewis developed a lump between his shoulder blades. Shipman referred him to Tameside General Hospital where it was removed. Mrs Hamilton says that they heard nothing from the hospital afterwards and assumed that the lump had been benign. This happened again with another lump on Mr Lewis' back.

Mr Lewis' Terminal Illness

Not very long after the marriage, Mr Lewis developed stomach pains. His symptoms were not relieved by proprietary brands of medication and he consulted Shipman, who diagnosed an ulcer and prescribed Zantac with little effect. Mr Lewis continued to consult Shipman and his wife sometimes went with him, as they both became concerned that the illness was serious. Mr Lewis was losing weight and was often sick. Mrs Hamilton's perception was that Shipman thought Mr Lewis was making a fuss about nothing and on occasions made rather sarcastic remarks about the frequency of his visits. Eventually, after what Mrs Hamilton describes as 'badgering', Shipman referred Mr Hamilton to the Manchester Royal Infirmary. They said he must go in for investigation. Before this happened, Mr Lewis collapsed one evening while playing darts in his local public house. He would not let his friends request an ambulance and they brought him home. That evening, he was very sick and his wife realised that there was blood in the vomit. It is plain that Mr Lewis was very ill. This must have been either at the end of November or early December 1984.

Very shortly afterwards, Mr Lewis was admitted to Manchester Royal Infirmary where it was found that he had advanced cancer. The cancer had begun in the stomach but it had already spread and was inoperable. He was told of the diagnosis and of the poor prognosis. He expressed a wish to die at home. He came home a few days before Christmas 1984.

On his return, Mr Lewis was very weak and could not walk unaided. He spent much of his time in bed or lying on a sofa. Shipman visited virtually every day, including Christmas Day. The district nurses also visited regularly. Mrs Hamilton recalls that her husband was receiving three different types of drug, administered by the district nurses. These were a morphine-based drug to relieve pain, something to stop him being sick and a drug to make him 'euphoric'. The drugs, syringes and other equipment were kept on the dining table in the living room. The bedroom was across the hallway from the lounge.

Mrs Hamilton's mother came to stay with her to give help and support at this very distressing time. Mr Lewis' pain increased and Mrs Hamilton says that the district nurses' visits became more frequent as the period between the injections became shorter. She recalls that eventually, just before the death, the nurses were coming about every two hours round the clock. At that time, the use of syringe drivers was not common in community medicine and Mr Lewis was not given one. Shipman's visits book shows that he visited Mr Lewis virtually every day in the week leading up to his death. Mrs Gee formed the impression that Shipman was trying to make up for his earlier failures by giving a high level of care once the correct diagnosis had been made.

By 31^st December, his 41^st birthday, Mr Lewis was very ill indeed. He lay in bed, drifting in and out of consciousness; he was experiencing hallucinations. Shipman visited and gave Mrs Hamilton his home telephone number and told her to telephone him at home, rather than on the emergency number, if there was any change in her husband's breathing.

The Death

The following day, 1^st January 1985, Mr Lewis was in the same condition and the district nurses came as usual to give injections. As the day went on, Mrs Hamilton noticed a change in her husband's breathing; it became 'rattly'. She wondered whether to telephone Shipman but was reluctant to bother him, as it was New Year's Day and she knew he would be spending the day with his family. Eventually she telephoned him. Her husband's pain was worse. She thinks that this was at about 7pm. She told Shipman of the change in her husband's breathing. Shipman arrived soon afterwards, carrying his doctor's bag. His wife, Mrs Primrose Shipman, was with him. She sat on the sofa throughout the visit.

Mrs Hamilton's account of the events of that evening is now somewhat hazy. This is not surprising. Not only did these events occur many years ago, they were deeply distressing. I found Mrs Hamilton to be a very impressive witness. She is a teacher and is obviously an intelligent and sensible woman. She gave me the impression that she has been able to put these tragic events behind her. She found recounting them to the Inquiry, and to some extent reliving them, profoundly distressing. The details of the last evening are now blurred in her memory.

Shipman went into the bedroom, accompanied by Mrs Hamilton. Mr Lewis was conscious but obviously very ill. Shipman said that he was going to give Mr Lewis an injection and asked Mrs Hamilton to hold the needle in her husband's arm. As the needle entered the vein, Mrs Hamilton saw blood flow back into the barrel of the syringe. She had never before helped with an injection and had not usually been present when they were given. The sight of the blood flowing up the needle greatly distressed Mrs Hamilton and she could not continue. She left the room. In fact, the appearance of blood when the plunger of the syringe was drawn back would confirm to Shipman that the tip of the needle was correctly located within the lumen of the vein.

Mrs Hamilton's next recollection is that she returned to the bedroom to see Shipman with one hand around her husband's throat. She now says that he seemed to be squeezing her husband's windpipe. When she asked Shipman what he was doing, he said that he was preventing Mr Lewis from swallowing his tongue. When Mrs Hamilton first gave an account of these events to the Inquiry she said that she saw Shipman with his fingers in her husband's throat. He said he was stopping him 'choking on his tongue'. She also recalled that he said something like, 'Give up lad, we've all had enough. We can't take any more'. She had the impression that he was willing her husband to die. I am unsure of what Mrs Hamilton saw Shipman doing when she went back in. I think it more likely that she saw him with his finger in Mr Lewis's throat rather than round his neck.

In any event, Mrs Hamilton was very upset. She had realised that her husband was going to die. She went into the living room and sat down, sobbing. I accept that something which Shipman said conveyed to Mrs Hamilton that her husband's death was imminent. Whether or not she recalls the words with precision, I accept her impression as accurate.

Until then, Mrs Gee had been sitting with Mrs Shipman. She recalls that while her daughter was in the bedroom, Shipman came into the living room and told his wife what he was going to do; it appeared to Mrs Gee that he was explaining what treatment he was going to give. When Mrs Hamilton came into the room saying that there had been blood in the syringe, Mrs Gee went into the bedroom. She told the Inquiry that when she went in she saw Shipman with a pillow in front of and apparently touching Mr Lewis' face. She asked Shipman what he was doing; she says he looked startled and put the pillow behind Mr Lewis' head. Mr Lewis was propped against several pillows. She says that she heard Shipman say something like, 'Come on lad, breathe'. Mr Lewis' breathing was, she says, very rattly at this time.

At this stage in the evidence there is a marked difference between the evidence of Mrs Hamilton and Mrs Gee.

Mrs Hamilton recalls that a further period of about an hour and a half passed before her husband died. She estimates that Shipman was at the house for about two hours altogether. She says that she sat on the sofa and that it all seemed to take quite a long time. Eventually, her mother came into the living room and told her that her husband had died. Shipman followed and advised Mrs Hamilton to go into the bedroom and to spend a few minutes with her husband to say goodbye. He said that in this way she would acknowledge that he really had died. She sat with her husband for a few minutes. She cannot remember much more of that night, although she recalls that Shipman took the remaining drugs with him. Her parents made the funeral arrangements.

Mrs Gee recalls that the death took place quite soon after the giving of the injection. After her daughter came out of the bedroom and she had gone in and saw Shipman with the pillow, she says that she could hear the rattly breathing and knew that the end was near. She says that she went to fetch her daughter and told her to go into the bedroom to be with her husband. She says that Mrs Hamilton went into the bedroom and that it was not long before she came out crying and Mr Lewis was dead. She is adamant that her daughter was present at the death and that she herself was not. She says that Shipman wrote out a note, which she thinks gave the cause of death; he told them to take it to the register office. He and his wife then left. She says that Shipman was at the flat for only about 20 minutes in all.

Certification

The death certificate records that the cause of death was congestive heart failure contributed to by carcinomatosis and a carcinoma of the stomach. The date of death was said to be 2^nd January 1985. This is strange as both Mrs Hamilton and Mrs Gee recall that the death occurred before midnight on New Year's Day.

Conclusion

It is clear that Mr Lewis was severely and terminally ill when he died. It is also clear that he was in severe pain despite the medication that was being given, which included an opiate, probably diamorphine. If Shipman hastened his death, he can only have done so by a very short period.

It seems clear that Shipman gave Mr Lewis an intravenous injection not long before he died. It is highly likely that this was diamorphine. Mr Lewis had probably been taking diamorphine regularly for some time for pain relief and would be accustomed to its effects. It is not known how large a dose he had been receiving at each injection. Nor is it known how much Shipman gave that night. A further injection would have been appropriate treatment, provided that the dose was estimated in good faith as being that which was necessary to relieve Mr Lewis' pain. Doctors in this position may face a difficult decision. They may realise that the dose they think will be necessary to relieve pain will also have the effect of shortening that patient's life. If the dose is given with the primary intention of relieving pain, the act is not only lawful, it is entirely proper. If, on the other hand, the doctor deliberately gives a dose which is larger than that necessary for the relief of pain, with the primary objective of bringing life to an end, that would be unlawful.

It would have been entirely proper for Shipman to give an injection on the evening of New Year's Day to relieve Mr Lewis' pain. We do not know how much he gave or how much would have been appropriate as pain relief. It follows that the only evidence from which I can infer Shipman's intention is evidence of his words and actions that evening and the period of time which elapsed between the injection and the death.

Professor Henry McQuay and Dr John Grenville agree that if an intravenous injection of diamorphine contains a lethal dose, the death will occur within a few minutes of the injection. There is a conflict of evidence between the two witnesses as to how much time elapsed between the injection and the death. On Mrs Gee's account, death occurred very soon after the injection. On Mrs Hamilton's account, it did not occur for an appreciable time. If the death occurred within a few minutes of the injection, this would suggest that Shipman might have intended to hasten death. However, I could not safely conclude, on this evidence alone, that it had been so intended, as the dose might have been intended only to relieve pain but had had the unintended effect of hastening the death.

I am puzzled by the evidence of timing. The only documentary evidence still available is the death certificate. It records that the death took place on 2^nd January. Unless Shipman made a mistake and wrote 2^nd when he meant 1^st January (which seems an unlikely error on New Year's Day) he seems to have been saying that the death took place just after midnight. Shipman was often both careless and dishonest in his completion of the official documents connected with death certification but I doubt if he would have deliberately entered a false date of death when the death had taken place in his own presence and that of the deceased's family. So I incline to the view that Mr Lewis did indeed die after midnight on 2^nd January. If that is so, I think both Mrs Hamilton and Mrs Gee must be mistaken about the time at which Shipman was summoned and the time of his arrival. I think it must have been later than they recall. If he came much later, say at some time around 11pm, it would more readily explain why Mrs Shipman was with him. Possibly they had been out together to a social occasion or possibly Shipman had had a drink at home and did not want to drive.

Even if this theory explains the time given on the death certificate, it does not help me to decide whether the death occurred a few minutes after the injection was given or considerably longer. I am inclined to doubt the accuracy of Mrs Hamilton's recollection about the passage of time on this evening. I think that these events were so traumatic that events which took only a few minutes seemed to her to have taken a long time. Although I have reservations about some aspects of Mrs Gee's evidence, I do think it likely that her estimate of the time between the start of the injection, Mrs Hamilton's hurried exit from the bedroom, Mrs Gee's entry into the bedroom, her return to the living room, Mrs Hamilton's return to the bedroom and the moment of death is more likely to be accurate than Mrs Hamilton's. I think the likely course of events is that Mrs Hamilton went in with Shipman and stayed until Shipman was giving the injection. She then ran out in distress, having seen blood in the needle. Mrs Gee went into the bedroom and saw Shipman doing something with a pillow. She heard Mr Lewis' 'rattly' breathing and realised that he was close to death. She returned to the living room and told her daughter to go into the bedroom; she probably assured her that the injection was over. When Mrs Hamilton went back into the bedroom, she saw Shipman with his hand at her husband's mouth or throat. Something was said which made her realise that her husband was about to die. She felt unable to remain and returned to the living room. When Shipman came out of the bedroom, he advised her to sit with her husband's body for a while, so that, in her own mind, she would accept that he had died. I think all of those events probably took place almost continuously. I also think it highly unlikely that, if Shipman had not known how long it would take for Mr Lewis to die, he would have waited at the house with his wife. Accordingly, I conclude, not without some hesitation, that the death probably occurred quite quickly after the giving of the injection.

The other evidence which helps me to judge Shipman's intention is that relating to his behaviour and comments. If Mrs Hamilton were right in her impression that Shipman was trying to strangle her husband, that would be an indication of his intention. However, as I have indicated, I think her first recollection on that issue is probably correct and that she saw him with his fingers in Mr Lewis' throat. That was something that Shipman has been seen doing on other occasions when he had killed a patient. If asked, he would say he was keeping the airway open. I think he did that (in cases where he had killed) in order to stop the patient gagging on his or her tongue, an event which might well cause the patient to struggle, which might interfere with the otherwise smooth progress towards death following an overdose of opiate. So, I infer that what Mrs Hamilton saw was probably not an attempt at strangulation but might well have been designed to ensure that the diamorphine had its expected and intended effect. I bear in mind Mrs Hamilton's evidence that she had the impression from what Shipman said that he was willing her husband to give up and die.

If Mrs Gee is correct in her impression that Shipman attempted to smother Mr Lewis, this would suggest an attempt to hasten the death. However, Mrs Gee's description did not sound like a very determined attempt to smother and it is quite possible that Shipman was rearranging the pillows. Mrs Gee did not mention the episode with the pillow until very recently. I regard Mrs Gee as an honest witness, although her recollection of some events is not clear.

There is another factor which I must take into account. By 1985, Shipman had killed a number of patients. I am quite sure that he had no moral or ethical scruples about hastening the death of a terminally ill patient. Indeed, I think it likely that he thought that when he did so he was doing the best thing for everyone concerned. I think that this visit took place very late at night. I think Shipman believed that Mr Lewis would not survive until morning. I think there is a real possibility that he wished to hasten Mr Lewis' end, as he would not wish to be called out again during the night.

The evidence is not entirely clear. If these circumstances had arisen with any doctor other than Shipman, I would say that it was probable that nature had taken its course. However, knowing what I do of Shipman, I have come to the conclusion Shipman probably intended to ensure that Mr Lewis died that night, whether or not he might otherwise have survived for a little longer. My conclusion is that Shipman probably hastened Mr Lewis' death by the administration of a dose of opiate, which was deliberately assessed as larger than was appropriate for the relief of pain.