Introduction

Mrs Jean Lilley died on 25^th April 1997 at the age of 58. She was a married woman. At the time of her death, she was not in good health. She suffered from heart disease, hypertension and respiratory problems. She used a wheelchair when out of the house. These illnesses might well have accounted for her sudden death. However, following exhumation of her body, morphine was found in the tissues and at the trial it was accepted that she had died as the result of morphine toxicity. The jury must have found that Shipman had injected her with morphine or diamorphine.

The Circumstances of the Death

Mr Albert Lilley, Mrs Lilley's husband, worked as a long-distance driver. He carried a mobile telephone with him, which was always switched on. For about two days before her death, Mrs Lilley had had a cold and cough. At about 11am on the day of his wife's death, Mr Lilley telephoned his wife from his vehicle to see how she was. She told him she had telephoned to ask the doctor to visit on account of her cold. She was awaiting his visit.

Mrs Elizabeth Hunter, a neighbour, visited Mrs Lilley for a chat and a cup of tea in the middle of the morning. Mrs Lilley said she was not feeling well and was waiting for the doctor to visit. From her own home, Mrs Hunter saw Shipman arrive at about noon. She was about to go round 45 minutes later, when she saw Shipman leave. Shortly afterwards, she went into Mrs Lilley's flat and found her on the sofa, apparently asleep. She felt her hand and found it cold. She ran out to try to stop Shipman but he had just gone. She went back inside and tried to resuscitate Mrs Lilley but there was no response and she noticed that her lips were blue. Mrs Hunter telephoned the surgery and was advised to call an ambulance, which she did. This was at 1.19pm. The paramedics arrived at 1.29pm and pronounced Mrs Lilley dead. They removed her body into the bedroom. Then Shipman arrived. He was quite brusque with Mrs Hunter, who was crying. He told her that Mrs Lilley had had a bad heart and her death had been expected. He said that, when he had visited earlier, he had tried to persuade her to go to hospital but she had refused. He did not examine the body or even go into the bedroom. He told the paramedics that he would sign a Medical Certificate of Cause of Death (MCCD). He told them that Mrs Lilley had had a long medical history and her death was not unexpected.

Early in the afternoon, Shipman spoke to Mr Lilley and told him that he had tried to persuade Mrs Lilley to go to hospital but she would not agree to do so. Mr Lilley found that hard to believe, as his wife respected Shipman and had previously accepted his advice on such matters without question. Shipman said that he had been waiting until Mr Lilley came home and could persuade her to go to hospital but it was now 'too late'. Her heart had failed. Mr Lilley wondered why his wife had not telephoned him if she had wanted to discuss admission to hospital.

The Defence Case

Shipman's account, which the jury must have rejected, was that he had called upon Mrs Lilley at about 1pm at her request. He found her dressed. She said she was not breathing well and had pains in the chest and was producing phlegm. He checked her pulse, took her blood pressure and listened to her chest where he heard fine crackles, which convinced him that Mrs Lilley should be admitted to hospital. When told of this opinion, Mrs Lilley was reluctant to agree and asked him to give her an antibiotic. He tried to persuade her to go to hospital and suggested that she should telephone her husband or a member of her family. He then left, saying that if, when she had spoken to her husband, she would agree to be admitted, he would come back and arrange it. Otherwise he would come back that evening. He was with her for about 20 to 25 minutes. About 20 minutes after leaving, he was paged by the surgery and was told that Mrs Lilley had collapsed. He returned to the flat and found the paramedics in attendance. Mrs Lilley was on the bed. He did not examine her as the paramedics had done so. He made appropriate arrangements to tell members of the family of the death. The following day, he asked Mr Lilley if he wanted a post-mortem examination but Mr Lilley did not think it necessary.

Certification

Shipman completed the MCCD, saying that Mrs Lilley had died of heart failure due to ischaemic heart disease and hypertension. He stated she had also suffered from fibrosing alveolitis and hypercholesterolaemia.

The Expert Evidence

Dr John Grenville examined the medical records and accepted that past entries showed that Mrs Lilley had chronic ill health with angina due to narrowing of the arteries and apparent alveolitis. The cholesterol levels were raised. Hypertension had been treated. The entry for the day of the death, made by Shipman after the death, created an impression of a very poor state of health, entirely consistent with heart failure. There were references to basal crepitations and a rapid irregular heartbeat. The liver was said to be enlarged, a sign of heart failure. The Crown's case was that this entry had been fabricated to give credibility to Shipman's account of the death.

Dr Grenville made two points. First, if Shipman's account were true, he had found Mrs Lilley in urgent need of medical treatment. She should have been admitted to hospital as an emergency. Had she refused, Shipman should have contacted relatives who could have tried to persuade her. On no account should he have left her. Second, if Mrs Hunter's evidence was right, Shipman left Mrs Lilley when she was either in extremis or just dead. The cyanosis observed by Mrs Hunter would have taken two to three minutes to develop after the heart had stopped. Mrs Lilley must at least have been in cardiac arrest when Shipman left.

After exhumation, a post-mortem examination was performed and samples taken for scientific examination. Morphine was found in the tissues at a level consistent with the administration of a fatal dose. Shipman could offer no explanation for its presence.

Dr John Rutherford, the pathologist, said that Mrs Lilley had only mild to moderate atherosclerosis. There was no sign of alveolitis. There were no blood clots. In short, there was no clear cause for her sudden death, other than the finding of morphine. He pointed out that to give morphine to someone suffering from a chest infection, with impaired respiratory function, would be disastrous. Even a therapeutic dose might kill.

Comment

The following significant points arise from this case:

• Because Mrs Lilley was in poor health, her sudden death would readily have been passed off as due to heart failure, had it not been for the finding of morphine in the body tissues. When Shipman had killed a patient, he usually attributed the death to a cause for which some foundation could be found in the medical records.
  
  
• This was a sudden death which occurred in the patient's home, either while Shipman was present or very shortly indeed after he had been with her. If, as Mrs Hunter said, the body was cold by the time she found it, then Shipman had been present at the death. For a patient to die in the presence of his or her general practitioner during a home visit is a very rare event in the experience of most doctors.
  
  
• Mrs Lilley was found sitting in a chair as though asleep. This appearance is typical of many of Shipman's victims who have been killed by diamorphine injection. This appearance would not be typical of a death from heart failure.
  
  
• Shipman's explanation of events was not credible. It would have been most unlikely that Mrs Lilley would have rejected his advice to go into hospital. She would have contacted her husband on his mobile telephone to discuss the situation.
  
  
• Shipman's account of his actions fell well below acceptable standards of medical practice. He claimed that Mrs Lilley rejected his advice to be admitted to hospital. If she were so ill as to require admission as an emergency, he should not have left her without making some efforts to find a relative who might persuade her to be sensible or without making some arrangements for her care.