Introduction

Mrs Dorothy Mary Andrew died at her home, 156 Sheffield Road, Godley, Hyde on Thursday, 12^th September 1996, at the age of 85. She was a widow and lived alone. 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. He certified that the cause of her death was renal failure due to uraemia and old age.

In October 1998, following the arrest of Shipman in September 1998, Mrs Andrew's son-in-law, Mr Brian Johnson, contacted the police to express concern about the circumstances of Mrs Andrew's death. The police investigated the death and took statements from Mr Johnson, Mrs Kathleen Johnson (Mrs Andrew's daughter), Miss Catherine Johnson (Mrs Andrew's granddaughter), Mrs Patricia Ramsden (Mrs Andrew's neighbour), Mr Brian Ramsden (Mrs Ramsden's former husband), and Mr Ian Campbell (Complaints and Claims Manager of Greater Manchester Ambulance Service, NHS Trust). The police also took a statement from Dr John Grenville.

Shipman was not prosecuted for causing the death of Mrs Andrew but an inquest was held on 5^th April 2001 at which the South Manchester Coroner entered a verdict of unlawful killing.

The Inquiry has had access to Mrs Andrew's general practitioner and hospital records and to appointments sheets, visits books and other practice documents for the relevant period.

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

The Events of the Days Leading up to Death

Although Mrs Andrew was 85, she was quite well and enjoyed life. She spent the August 1996 Bank Holiday weekend (Saturday, 24^th August to Monday, 26^th August) in the Lake District with her daughter and son-in-law. She was well until lunchtime on Tuesday, 27^th August, when she felt sick. She vomited three times that afternoon. At about 8.30pm, she felt better and Mr and Mrs Johnson drove her home. The next day, Mrs Andrew told her daughter that she had improved but was feeling very thirsty.

On Monday, 9^th September 1996, Mrs Andrew told her daughter that she had had a sleepless night, feeling thirsty and wanting to use the lavatory. Mrs Johnson telephoned Shipman's surgery and requested a home visit. Shipman visited Mrs Andrew at home at about 2pm on that day. Mrs Andrew telephoned her daughter later and said that Shipman had taken a blood sample to check for diabetes. He also wanted a sample of urine. Mr Johnson collected this sample from Mrs Andrew and took it to the surgery the next day. Shipman had promised Mrs Andrew that he would return on either the Wednesday or the Thursday with the results of the tests.

On the evening of Wednesday, 11^th September 1996, Mrs Andrew went to her daughter's house for tea. She stayed until about 10.30pm. Apart from looking slightly pale, she seemed her usual self.

The Day of the Death

On the morning of Thursday, 12^th September 1996, Mrs Johnson telephoned her mother who said she had had a very good night and felt a lot better. She said she intended to go into Hyde later on. Mrs Johnson reminded her mother that Shipman would be calling that day. Mrs Andrew's granddaughter also spoke to her that morning and confirms that Mrs Andrew was feeling much better and doing her housework.

At about 2.40pm, Mrs Andrew's neighbour, Mrs Ramsden, was parking her car on her driveway and glanced at Mrs Andrew's house. She would usually see Mrs Andrew by her window or in her porch but, on this occasion, she was not there. Mrs Ramsden walked across and rang Mrs Andrew's front door bell. Shipman answered. Mrs Ramsden asked whether Mrs Andrew would like her to collect a prescription. Shipman said 'No' and asked Mrs Ramsden to come back in a few minutes to see Mrs Andrew. He appeared to be calm.

Mrs Ramsden returned home. Within a few minutes, Shipman came to her house. He was holding what appeared to be a medical record card envelope. He asked Mrs Ramsden if she knew how to get in touch with Mrs Andrew's next of kin. He said that he had already tried one number but an answering machine was on. He said he wanted to get Mrs Andrew into hospital. He mentioned something about an ambulance and wanting to let Mrs Andrew's relatives know. Mrs Ramsden told Shipman that she would contact Mrs Andrew's relatives for him and Shipman walked back to Mrs Andrew's house.

Mrs Ramsden telephoned Mr Johnson and asked him to telephone Mrs Andrew because she was unwell. Mrs Johnson telephoned her mother and Shipman answered. Shipman told Mrs Johnson that her mother was extremely ill. He said he had telephoned for an ambulance and had arranged for a bed at Tameside General Hospital. He asked Mrs Johnson to come round straight away. Just before Mrs Johnson put the receiver down, Shipman said something like: 'I don't think we will be needing an ambulance'.

After he had spoken to Mrs Johnson, Shipman returned to Mrs Ramsden's house. He told Mrs Ramsden that he thought Mrs Andrew had fallen. Mrs Ramsden accompanied Shipman into Mrs Andrew's house and saw Mrs Andrew lying flat on her back on the floor. Her head was by the dining room doorway and her arms were by her side. Her lips were purple and she had an airway in her mouth. Mrs Ramsden thought that Mrs Andrew had died. However, Shipman asked her to press down on Mrs Andrew's chest and whilst she did so, Shipman breathed into Mrs Andrew's mouth.

A short while later, Mr and Mrs Johnson arrived. They went straight into the dining room where they saw Mrs Andrew on the floor. Shipman said that it was too late and that Mrs Andrew had 'gone'. Mr Johnson noticed that Mrs Andrew's lips were blue and that the skin on the left side of her face was discoloured. The left sleeve of her jumper was rolled down whereas the right sleeve was rolled up. Mrs Andrew always had both sleeves rolled up when she was cleaning. One of her slippers was off her foot and was lying at her side. Her arms were by her side. She was lying fairly straight and it did not appear to Mr Johnson that she had fallen.

Shipman said that he would cancel the ambulance. He went into the hallway and could be heard speaking. Shipman later told Mr and Mrs Johnson that Mrs Andrew was very old and that with older people all sorts of things could happen. He said that Mrs Andrew had had kidney failure, which had brought on a stroke. He said that her blood pressure was 'wrong'. He told Mr and Mrs Johnson that they could collect the death certificate from his surgery the following morning. Shipman then left.

The billing records for Mrs Andrew's telephone reveal that a call was made from her home to the main switchboard at Tameside General Hospital at 3.33pm. This call lasted just over five minutes and was followed by a call to the orthopaedic department at Tameside General Hospital, lasting one minute and 42 seconds. At 3.42pm, a call was made to Miss Johnson's home number lasting 21 seconds. It seems likely that the two calls to the hospital were made by Mr Johnson in an attempt to contact his daughter who was a nurse and worked at the hospital. Moreover, police investigations have shown that Shipman did not arrange for a bed at Tameside General Hospital; nor did he order or cancel an ambulance.

Certification

The following day, Shipman gave Mr and Mrs Johnson and their daughter a Medical Certificate of Cause of Death (MCCD) and offered his condolences. The family then tried to register the death but the registrar would not accept the MCCD. Shipman had recorded the cause of death as being due to old age. The registrar said that that was not acceptable. She telephoned Shipman to tell him that he must give more detail. The family returned to the surgery and Shipman apologised and said that, at one time, old age would have been accepted by the registrar. He said that people were like cars and that their body parts wore out. He took back the old certificate and changed it, giving the primary cause of death as renal failure with old age as a secondary cause.

The family then took the certificate back to the registrar's office. After a while the registrar said that she had spoken to the coroner who was not satisfied with the cause of death and might require a post-mortem. This upset Mrs Johnson, who did not want her mother to undergo a post-mortem. The registrar told the family to go back to Shipman's surgery for the certificate to be amended again. They did so. This time Shipman stated that the cause of death was 'Renal Failure' due to 'Uraemia and Old Age'. The family went back to the registrar, who, after speaking to the coroner, said that the certificate was now acceptable.

Shipman also completed Form B of the cremation certificate. He stated that death had occurred at 3.15pm. He said that he had attended Mrs Andrew during her last illness for a period of three days. He said he was present at the moment of death and saw the body immediately after death. He claimed to have made a full external examination of the body. The cause of death was renal failure due to uraemia and old age. The mode of death was collapse of 20 minutes' duration. He said that 'neighbour, daughter, son-in-law' were present at death. In response to the question, 'Has the Coroner been notified?' Shipman wrote: 'Checked certificate acceptable agreed it was'.

The Expert Evidence

Dr Grenville examined Mrs Andrew's medical records. He noted that Mrs Andrew had enjoyed good general health. There is a note in Shipman's writing of a visit on 9th September:

Various blood tests were ordered which Dr Grenville says were appropriate.

The record for the day of the death, 12^th September, reads:

The writing is poor and Dr Grenville interpreted the time of death as 18.15 but the computerised notes make it clear that it was intended to be 15.15 which is the time of death given by Shipman on Form B. Also, it is clear that the death had occurred well before 6.15pm.

Dr Grenville says that in the light of these medical records, the cause of death given by Shipman does not make sense. Uraemia is a condition in which there is a high level of urea in the blood and is caused by renal failure. Shipman suggests that it is the other way round, that the renal failure has been caused by uraemia.

The blood test results for which the hospital records are available are normal but would not in any event be capable of showing renal failure. The urine result in the records is abnormal, showing white and red blood cells in the urine. Dr Grenville says that this is possibly indicative of an infection, although no organism was grown. The laboratory had suggested that this might be an atypical infection. The results of the urea test and the creatinine test are not confirmed by documents from the hospital and investigations by the police show that Shipman never requested that those tests should be done. It is clear that he made those results up. Dr Grenville says that the creatinine result is very high at 500 and would, if it were genuine, indicate renal failure. The urea at 26 is on the high side but is not consistent with a creatinine result of 500. Dr Grenville says that with a creatinine result of 500 he would expect a urea result of about 100 millimoles per litre.

Dr Grenville also says that renal failure is not a cause of sudden death. The patient would deteriorate gradually over a period of time. He also makes the point that old age is appropriate as a cause of death only where there has been a gradual decline over a period of time and death has occurred without any clear agonal event. He observed that a post-mortem examination should have been ordered following this sudden death which could, in theory at least, have been due to heart attack or stroke or pulmonary embolus.

Upon his consideration of the medical records and cremation documentation, Professor Richard Baker assessed the level of suspicion in this case to be high.

Conclusion

Mrs Andrew was quite well on the day of her death, although she had plainly suffered from some sort of infection in the few days before her death. The evidence was that she was feeling much better by 12^th September 1996.

The death took place in Shipman's presence. That in itself arouses suspicion. Dr Grenville has told the Inquiry that it is most unusual for a patient to die during a visit by the general practitioner, unless the patient is known to be terminally ill or the doctor has attended as an emergency in response to the onset of severe symptoms, which might, for example, indicate that the patient was having a heart attack or stroke. Mrs Andrew was not terminally ill and Shipman had not been summoned as an emergency. Mrs Andrew's death during his visit is highly suspicious.

Shipman's note of his visit on the day of the death gives rise to further suspicion. First, there is no clear account of the signs or symptoms on which Shipman based his supposed decision that Mrs Andrew ought to be admitted to hospital. He could not have relied on the urea and creatinine results as they were clearly fabricated. They were probably inserted in the records when the registrar had rejected the certificate which gave the cause of death as old age. Second, Shipman claimed to have called an ambulance and arranged a hospital bed. In fact, he did neither. Third, the note suggests that Mrs Andrew's daughter and a neighbour were present at the death. They were not and it seems clear that Mrs Andrew was dead before Mrs Ramsden was able to go into the house to see her. In short, this note is pure fabrication. It has been created in an attempt to provide a plausible explanation for Mrs Andrew's death. It gives rise to the grave suspicion that Shipman killed Mrs Andrew.

Shipman also made false entries in cremation Form B, which were designed to create the impression that this death had followed a three day illness and that Mrs Andrew's daughter and her neighbour were with her, as they would have been at a death which was not sudden. This death was very sudden and only Shipman was present when it occurred.

These factors leave me in no doubt that Shipman must have killed Mrs Andrew, almost certainly by administering a lethal dose of diamorphine. The possibility that she died suddenly from a natural cause is only theoretical and I can safely rule it out.

In my view, the possibility that Mrs Andrew might have died suddenly from natural causes is only theoretical. The overwhelming likelihood is that she was killed by lethal injection. She was almost certainly dead by the time Mrs Ramsden entered the house. She noticed that Mrs Andrew's lips were purple.

I am sure that this was an unlawful killing.