Introduction

Mr Charles Henry Barlow died on Monday, 22^nd November 1995 at the age of 88. He died at his home, 138 Dowson Road, Hyde where he had lived alone for many years after separating from his second wife. Mr Barlow had been a patient of Shipman since Shipman's arrival in Hyde in 1977 and had followed him when he moved to the Market Street Surgery. He thought very highly of Shipman.

Mr Barlow's death was reported to the coroner because he had recently undergone an operation. The death was certified by the South Manchester Coroner following a post-mortem examination as having been caused by bronchopneumonia resulting from tracheal compression, due in turn to nodular thyroidal goitre.

In the early part of 2000, Mr Barlow's family contacted the police to express concern about his death. The death had not previously come to the attention of the police, as it was not certified by Shipman. The police investigated the death and took statements from Mr John Barry Barlow (Mr Barlow's son) and Mr Norman Newton (a friend and neighbour of Mr Charles Henry Barlow).

There was no prosecution arising from the death and no inquest has been held.

The Inquiry has obtained statements from Mr Barry Barlow, Mrs Janet Barlow (Mr Barry Barlow's daughter-in-law), Mr Newton and the police officer who attended after the death, Mr William Trattles. Mr Barry Barlow, Mrs Barlow and Mr Newton gave oral evidence at the hearing on 8^th October 2001. The Inquiry has had access to general practitioner, hospital and district nursing records and to appointments sheets, visits books and other practice documents for the relevant period. The Inquiry has obtained a report from Professor Helen Whitwell, consultant forensic pathologist, who also gave oral evidence on 7^th December 2001.

Personal Background

Mr Barlow was a former police officer who had retired from the force in his fifties but worked part-time in other capacities until his late sixties or early seventies.

He had had a goitre on his neck since he was a young man and, as a result, his trachea was narrowed and he was sometimes wheezy. He had a history of cardiac failure for which he was treated with drugs such as frusemide and lisinopril. He had been found to have a grossly enlarged heart. This history is confirmed by hospital correspondence.

Despite his heart problems and the fact that he could not walk very far, Mr Barlow is described by the witnesses as an independent man. He was reasonably active for his age and particularly enjoyed his garden. Mr Newton helped him with his housework and his family shopped for him. He was a good cook and prepared himself a hot lunch every day.

The Events of the Weeks Leading up to Death

On 5^th November 1995, Mr Barlow underwent an operation to repair a hernia. Whilst in hospital he had shown signs of mild cardiac failure and was in atrial fibrillation. His jugular venous pressure was raised. He was also noted to be breathless due to his large goitre. He was discharged from hospital on 13^th November, nine days before his death. He had wanted to spend some time in a convalescent home following his discharge but this was not possible and he went home. The hospital requested district nursing assistance in order to check his wound and assess his needs.

According to Mr Barry Barlow, his father was somewhat 'down' following his operation. However, Mr Barlow was not confined to his chair and was able to care for himself and could do some gardening. Mr Newton saw Mr Barlow on a daily basis and recalls that he was rather 'wheezy' but he did not appear seriously ill.

The district nurses visited on 14^th November, the day after Mr Barlow's discharge from hospital. They noted that his wound had healed but he was unable to get upstairs or dress and undress himself. He was refusing any assistance from Social Services. He was provided with a urinal and was to be given a chemical commode for which the district nurse was to arrange an emptying service. She recorded:

That comment may explain an entry in the surgery acute prescriptions book which reads:

This may well have been written as a result of a telephone call from the district nurse. Certainly members of the family do not remember making any such call. In any event, Mr Barlow's name was added to Shipman's visits book for 14^th November. A computerised note of the subsequent visit by Shipman reads:

That is the last entry in the computer records prior to the date of Mr Barlow's death. The Lloyd George cards had not been used since August 1995. The district nurse visited again on 15^th November.

Mr Barry Barlow last saw his father on 20^th November, two days before his death. Mr Barlow did not complain of any particular symptoms on that occasion. The district nurse also visited on that day. Her note records:

'Not eating well. Occasional inco (incontinent)of faeces. ? overflow inco.
buttocks excoriated - GP contacted - sudocrem ? for enema'.

Mr Barry Barlow's daughter-in-law, Mrs Janet Barlow, visited on 21^st November and cut his hair in the late morning or early afternoon. She describes him as looking 'fine'. He showed her some family photographs and gave her chocolates for her children.

District Nurse Marion Gilchrist seems to have visited twice on 21^st November. On one of those occasions, she recorded similar observations to those of the previous day. She queried whether Mr Barlow had a pressure sore and noted that he was 'Unable to maintain personal hygiene'. She then recorded the action to be taken:

Once again, it may have been as a result of contact by the district nurse that the following visits book entry of 22^nd November came to be made:

It is clear from the documentation that both Shipman and the district nurses were to visit Mr Barlow on the 22^nd November. It is noteworthy, however, that there is nothing in the district nursing notes to suggest that Mr Barlow was suffering from symptoms typical of bronchopneumonia. Nor would Mrs Barlow's account of his condition when she saw him on 21^st November suggest that that was the case.

The Day of the Death

On the morning of 22^nd November, Mr Newton called to see whether his friend wanted any shopping. Mr Barlow was sitting in his usual high-backed chair and seemed well, although more wheezy than usual. He asked Mr Newton to buy him some mints but first asked him to find the remote control for his television and to make him a cup of coffee. Mr Newton said that this last was an unusual request, as he cannot remember ever before having been asked to make a cup of coffee by Mr Barlow. That Mr Barlow made the request might indicate that he was in discomfort or possibly that he was feeling generally unwell.

When Mr Newton returned from shopping between 12.30pm and 1pm, Mr Barlow was sitting in the same chair with the television on. Mr Newton asked him if he wanted anything but he said he did not. There was no sign of him cooking any lunch. Mr Newton washed up the coffee beaker. That was the first time he had ever performed such a service for Mr Barlow. I think this must be an indication that Mr Barlow was not his usual self. He said he was expecting two nurses to call later and asked Mr Newton to leave the side door unlocked when he left. Mr Newton did so.

At about 3pm, Mr Newton's doorbell rang. Mr Newton did not recognise his visitor, who informed him that he was Dr Shipman and had come to see Mr Barlow. In his statement, Mr Newton said that Shipman asked whether he had a key to Mr Barlow's house, the clear implication being that he had not previously been in the house. Mr Newton told Shipman that he did not have a key but offered to accompany Shipman to Mr Barlow's house. In his oral evidence, Mr Newton said that Shipman came to his house and told him that he had been to Mr Barlow's house and that Mr Newton 'had better come across straight away'. In any event, they set off and entered the house by the unlocked side door, with Shipman in the lead. By the time Mr Newton entered the house, he says that Shipman was kneeling in front of Mr Barlow who was sitting in the same chair as he had previously occupied. However, the chair had been moved slightly so that it was no longer facing the television. Its back was towards the door so that Mr Newton could only see the top of Mr Barlow's head. The fire was full on, which had not been the case earlier in the day. Beside Shipman was a doctor's black case, which he had not had with him when he called on Mr Newton. It was obvious that Shipman had been into the house before coming across to Mr Newton. As Mr Newton entered the room, Shipman told him to keep back, saying that Mr Barlow needed all the air he could get. Mr Newton stood in the doorway. He remembers that he then heard Mr Barlow tell the doctor that he didn't feel very well. His voice was slurred and weak. Shipman replied, 'I know but you are going to die anyway'. Mr Newton then saw Mr Barlow's head drop to one side whereupon Shipman felt Mr Barlow's pulse and told Mr Newton that he had 'gone'. He asked Mr Newton the time, which by Mr Newton's watch was 3.15pm. Shipman said that 'these people have got very particular about such things as that'.

Mr Newton said he was certain that Mr Barlow was alive when he entered the house. He describes himself as having been in a 'terrible state'. He thought that another seven to ten minutes passed before Mr Barlow died.

Shipman asked Mr Newton to help him to find the telephone numbers of Mr Barlow's next of kin. He showed Shipman Mr Barlow's address book. Shipman telephoned someone and started chatting. After a while he told the person that Mr Barlow had died. Mr Newton said to Shipman that he had not thought that Mr Barlow was so ill that he would die. Shipman replied that Mr Barlow had had a bad heart for years. He gave the impression that Mr Barlow had died of a heart attack. His manner was abrupt. He asked Mr Newton to stay in the house until Mr Barlow's son arrived. When Mr Newton remarked that the electric fire was on very high and went to turn it down, Shipman restrained him saying, 'We want to keep him warm.' Shipman then left saying that he had to see other patients.

Shipman's telephone call had been to Mrs Susan Barlow, wife of Mr Barry Barlow. She told her husband the news and he drove immediately to his father's house. Mrs Barlow followed later. Shipman returned shortly after Mr Barlow's arrival. He told Mr Barry Barlow he had given his father an injection but this had not helped his breathing. Shipman then left.

At some stage, Shipman telephoned the coroner's office to inform them of the death. The reason for his call apparently being that Mr Barlow had undergone an operation only 17 days previously. The coroner's office informed the police at 4.03pm. The message reads:

'SUDDEN DEATH CHARLES BARLOW (88 YRS)...RELATIVES (SON) AT THE HOUSE. LIFE PRONOUNCED EXTINCT BY DR SHIPMAN (367-9777) AT 15.15 HRS BUT HE CANNOT ISSUE DEATH CERTIFICATE...REPORT NECESSARY AS THE DECEASED HAS RECENTLY UNDERGONE SURGERY FOR HERNIA REPAIR'.

PC Trattles attended at 4.24pm and completed forms 751 and 751A from information provided by Mr Barry Barlow. Mr Barry Barlow told the police that Shipman had found Mr Barlow dead when he came back to the house, having left to fetch a neighbour.

The computerised note of Shipman's attendance reads:

'Congestive heart failure

chat for admission

O/E - dead

chf repored (sic) coroner'.

I interpret this to suggest that Shipman formed the view that Mr Barlow was suffering from congestive heart failure of such severity that he discussed admission to hospital. Mr Barlow's supposed reaction to this was not recorded. There is no reference to the interlude in which Shipman fetched Mr Newton. Nor is there any explanation of the transition from life to death. The note merely records that Mr Barlow was dead on examination and that the cause was congestive heart failure.

The Aftermath

The coroner directed a post-mortem examination. The pathologist, Dr Hale, recorded that Mr Barlow had died whilst sitting in his chair and that the general practitioner had found Mr Barlow dead when he returned from fetching a neighbour. The pathologist had been told that Mr Barlow suffered from 'heart problems'. Dr Hale recorded no marks of violence and noted that there was no oedema of the limbs. On internal examination he noted a large goitre which was causing compression and narrowing of the trachea.

He recorded that the trachea and both main bronchi contained a moderate amount of muco-purulent material. Both lungs showed bilateral basal bronchopneumonic consolidation. There was no evidence of neoplasm or infarction. There was marked pulmonary oedema.

The heart was unremarkable. There were signs of probable left ventricular hypertrophy. There was no sign of an infarct. There was mild atheroma of the coronary arteries without significant narrowing and no thrombi were seen. The remainder of the examination was unremarkable.

Dr Hale concluded that death was due to bronchopneumonia due to tracheal compression caused by the goitre. There was no inquest as the coroner was satisfied that this was not necessary. I note as a matter of interest that the cause of death suggested by Shipman in the medical note, namely congestive heart failure, was certainly wrong. This was plainly not a cardiac death.

Mr Barlow was buried so there is no cremation certificate.

The Expert Evidence

Professor Whitwell has examined all the papers available to the Inquiry. She observed that it is quite usual for a pathologist to undertake a post-mortem examination without first seeing the deceased's medical records or talking to anyone who had seen the deceased in the days before the death. It appears that this was the case here, as Dr Hale appears to have been told only that Mr Barlow had 'heart problems'. Professor Whitwell also said that it is not usual for the coroner to discuss a case with the pathologist unless there is particular reason for concern. In this case there was no reason to suspect foul play. It appears therefore that Dr Hale will have known very little about Mr Barlow before conducting the post-mortem examination. He will not have known for example that Mr Barlow had been sitting up, drinking coffee and watching television about two hours before his death.

As to the facts of this case, Professor Whitwell said that it would be most unusual for a patient to die of airway obstruction associated with a large goitre in the absence of a history of breathing difficulties. She would not expect a death from that cause to be at all sudden. Mr Barlow's goitre had been present for very many years and there was no history of real breathing difficulty at any stage. She also observed that bronchopneumonia is not usually asymptomatic. Dr John Grenville has also said this in his generic evidence. Both doctors agree that before dying of bronchopneumonia, one would expect that the patient would be very ill, usually for two or three days, but at least for several hours. Mr Barlow was not very ill two hours before his death. Professor Whitwell also said that macroscopic diagnosis of bronchopneumonia is unreliable as it may easily be confused with other conditions such as pulmonary oedema or congestion. The only reliable way to diagnose bronchopneumonia is by histological examination, which was not undertaken in this case and is not routinely carried out in many hospitals.

Taking all the evidence into account, Professor Whitwell concluded that the cause of death was highly unlikely to have been the cause certified. It was possible although unlikely that the death could have been due to a sudden expansion of the goitre due to bleeding, which had caused complete tracheal compression. That did not appear to have been found. There were some signs of heart failure but these appeared to have been present for some time and there were no specific changes to indicate that this had led to the death. There was no sign of a myocardial infarction and nothing from which it could clearly be inferred that Mr Barlow had died a cardiac death. In short, the post-mortem examination was quite inconclusive and the death might well have been due to a lethal injection of diamorphine. The fact that the pathologist had not noted an injection mark was not a factor of significance. Sometimes, they would not be visible even though recently made. Sometimes, the pathologist might notice a mark but not record it, as he or she might not regard it as important. Professor Whitwell said that it would be most unusual for a coroner to order toxicological tests in a case such as this. If the pathologist were able to provide a feasible explanation for the death, nothing more would be done.

Conclusion

Mr Barlow was not well at the time of his death but he did not appear to be close to death. He was not seen to be in severe respiratory distress. He was not as weak or obviously ill as would be expected if he were about to die of bronchopneumonia. There is no evidence that he died of a heart attack or stroke. Although the post-mortem findings were suggestive of bronchopneumonia, the diagnosis was not proved by histology. When the surrounding factors are taken into account, I am driven to the conclusion that the death was probably not due to bronchopneumonia. There is no other obvious natural cause and on the medical evidence there is a real possibility that this death was due to diamorphine overdose.

Mr Barlow died during a visit by Shipman. That factor always gives rise to very grave suspicion that Shipman has killed the patient. Other doctors find that patients very rarely die during their visits. With Shipman this happened frequently.

There are some features of this case that are typical of cases in which Shipman killed. After the death, Shipman made a note in which he did not record any complaints or signs observed on examination. The note contained no description of the transition from life to death and no explanation for the death. In this case, it contains a diagnosis unsupported by evidence and later proven to be wrong. The note did not contain any reference to the administration of a drug although Mr Barry Barlow says that Shipman told him that he had given his father an injection, ostensibly to help his breathing. In short, the note is not what one would expect if a patient had died suddenly from natural causes during a consultation.

Another feature typical of cases in which Shipman killed is that he involved a neighbour. One wonders why Shipman went over to fetch Mr Newton if the consultation with Mr Barlow had been only a chat about admission to hospital. If an ambulance were to be called it is possible Shipman might have wanted Mr Newton to collect Mr Barlow's personal requirements for a hospital stay. It is possible that Mr Barlow had refused admission and Shipman wanted someone to persuade him. It is also possible that Shipman wanted Mr Newton to be present in the house so that he could say that someone else was present at the death. Shipman would also be free to leave the house before the arrival of relatives.

Another typical feature of a Shipman killing is that the electric fire was turned up high and Shipman restrained Mr Newton from turning it down. Shipman's motive in keeping bodies warm is not entirely clear. In some cases I have thought that he may have wished to make it difficult for a pathologist to establish the time of death. In this case, there was no doubt about the time of death or Shipman's presence at it. It is possible that Shipman thought that morphine might metabolise more rapidly if the body were kept warm. Whatever his belief or his motive, this is a suspicious factor as the electric or gas fire has been found left on high in a significant number of cases in which Shipman killed.

If this is a Shipman killing, there is an unusual feature in that Mr Newton believes that Mr Barlow was still alive when he and Shipman returned to Mr Barlow's house. It is possible that Mr Newton is mistaken about this and did not actually hear Mr Barlow's voice. He could not see Mr Barlow properly and it is possible that Shipman pretended that Mr Barlow was still alive and kept Mr Newton back so that he could not see that he was already dead. If Shipman had spoken to Mr Barlow, Mr Newton might have had the impression that Mr Barlow responded when in fact he did not. It is also possible that Mr Barlow was on the verge of unconsciousness as Mr Newton and Shipman arrived and that he died a few minutes later. However, if Shipman had given an intravenous injection of a lethal dose of opiate, which was his usual method of killing, he must have gone to fetch Mr Newton immediately and Mr Newton must have returned with him within a very short space of time. A further possibility is that Shipman gave Mr Barlow a lethal injection but that part of the dose failed to enter the vein directly and entered the body subcutaneously. It can be difficult to inject a very old thin person intravenously. If that had happened, Mr Barlow's death would have been somewhat delayed. This might account for Mr Barlow saying that he did not feel well and Shipman replying that he was going to die anyway.

If this was a case in which Shipman killed, there was another unusual feature. Shipman must have known that Mr Barlow had undergone an operation recently and that if he died, his death would have to be referred to the coroner. One might think that Shipman would be taking a big risk if he killed him. But it appears that this was not so. Mr Barlow was obviously not in good health. It would be highly likely that a feasible explanation for the death would be found, as it was. It is not usual for specimens of tissue to be sent for toxicological examination and the risk of detection would be very slight. Even if a test had been ordered and had produced a positive result for morphine, it would not have been too difficult to explain its presence in a patient who had recently undergone operative treatment.

Although at first sight there are features of this case which suggest that Shipman might not have killed Mr Barlow, on further examination they do not appear significant. The fact remains that Mr Barlow was not thought to be on the verge of death when Mr Newton saw him at lunchtime. He died about two hours later in Shipman's presence. I am quite satisfied that Shipman had been with Mr Barlow for some time before Mr Newton was brought in. It seems to me that Shipman killed Mr Barlow, almost certainly by his preferred method of giving him a lethal dose of diamorphine. After giving the injection, I think he went over to fetch Mr Newton so that if he could say that someone else had been present at the death. He would also be able to leave the body in Mr Newton's care while he went about his duties.

I am sure that Shipman unlawfully killed Mr Barlow.