Introduction

Mr Kenneth Wharmby Woodhead died at his home, 1 Sawyer Brow, Hyde on Thursday, 14^th December 1995 at the age of 75. He had been a patient of Shipman for several years and had followed Shipman when he moved to the Market Street Surgery. Shipman certified that the cause of his death was carcinomatosis due to adenocarcinoma of the lung.

In November 1998, Mr Woodhead's death came to the attention of the police when his name was seen in the Norwest Co-op Pharmacy Drugs Register, which showed he had been prescribed large amounts of diamorphine. The police investigated and took a statement from Mrs Freda Katherine Hibbs (Mr Woodhead's sister-in-law), Mrs Marion Gilchrist and Mrs Ethel Dooley (district nursing sisters with Tameside and Glossop Community and Priority NHS Trust), Mrs Jennifer Chilenge (formerly Doherty, a trainee district nurse with Tameside and Glossop Community and Priority NHS Trust) and Ms Ghislaine Brant (a pharmacist at the Norwest Co-op Pharmacy).

Shipman was not prosecuted for causing the death of Mr Woodhead and no inquest into the death has been opened.

The Inquiry has taken a further statement from Mrs Hibbs and also from Mr Fred Lowe, a close friend and former business partner of Mr Woodhead. The Inquiry has had access to Mr Woodhead's general practitioner, hospital and district nursing records, as well as to appointments sheets, visits books and other practice documents for the relevant period.

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

Personal Background

Mr Woodhead lived with his wife, Joyce, who has since died and whose death has also been investigated by the Inquiry. An inquest into her death resulted in a finding of unlawful killing and I have reached the same conclusion in respect of her death. According to Mrs Hibbs, Mr Woodhead enjoyed good health until about two years before his death, when she thinks he suffered a heart attack. Mr and Mrs Woodhead were a close and affectionate couple.

The medical records reveal that Mr Woodhead was referred to Tameside General Hospital in May 1994 with a suspected coronary thrombosis. In June of that year, he was found to have lung cancer. In August 1994, Dr C R Payne, consultant physician, wrote to Shipman explaining that Mr Woodhead's tumour had progressed rapidly. Dr Payne explained that there was little the hospital could do to relieve Mr Woodhead's symptoms. Mr Woodhead received palliative radiotherapy between August and November 1995. A letter written by the consultant radiotherapist on 6^th November 1995 explained that Mr Woodhead's disease was progressing rapidly and that the prognosis was poor. The visits book reveals that Shipman regularly attended Mr Woodhead at home from the beginning of November 1995 until his death. From 10^th November 1995, the district nurses were involved in Mr Woodhead's care.

Initially, Mr Woodhead's pain was controlled by Durogesic patches. By 14^th November, his pain had increased and he was prescribed Oramorph, a morphine preparation taken orally.

The Day of the Death

Mrs Hibbs recalls that her sister telephoned her at about 6.45am on Thursday, 14^th December 1995. Mrs Woodhead said that she had been up all night with her husband, who had been in a lot of pain. She said that she had called out the doctor and that a deputising doctor had visited. The form completed by the deputising doctor records that Mr Woodhead was suffering constant abdominal pain. He was treated with 10-15mg of Oramorph, which was to be taken every four hours, until his symptoms were under control. The deputising doctor's form records that Mr Woodhead was warned about the prognosis.

After breakfast, Mrs Hibbs went to visit her sister and brother-in-law. She recalls that Mr Woodhead was sitting up in bed. The bed was disarranged and it appeared that he had had a disturbed night. Not long after she arrived, Shipman came to the house. He was told what the deputising doctor had said and approved the advice given. Mrs Woodhead asked if Shipman would arrange for a nurse to attend that night so that she herself could have some sleep and be better able to look after her husband the next day. Shipman said that Mrs Woodhead need not worry and that he would get her 'one of his nurses'. Shipman made a telephone call and arranged for a nurse to attend that night. Shipman brought in a syringe driver and stand and told Mrs Woodhead that he would arrange for the district nurses to attend and make Mr Woodhead comfortable.

There is no record in the Lloyd George cards or computerised records relating to this visit or any later visit to the house that day whilst Mr Woodhead was still alive. Shipman did, however, make entries on the District Nurses' Patient Drug Record Card to the effect that Mr Woodhead was to be given diamorphine by a syringe driver in a 200mg daily dose.

Later that morning, at about 11.15am, Sister Dooley attended and set up the syringe driver. Two ampoules of 100mg of diamorphine were used from a box of five ampoules with the serial number E5273A, leaving a 'stock balance' of eight ampoules, three from that box and five comprising a second box with the serial number E5276E. Both boxes were there when Sister Dooley arrived. On that day, Shipman obtained ten x 100mg ampoules of diamorphine from the Norwest Co-op Pharmacy. The most recent recorded occasions on which Shipman had previously obtained diamorphine were on 18^th, 22^nd and 23^rd September 1995, when he obtained large quantities of diamorphine in 100mg ampoules in the name of Mr Peter Neal, who died on 23^rd September 1995.

Mrs Hibbs recalls that Mr Woodhead seemed more at ease once the drip had been set up. She was able to talk with him and she moistened his lips to make him more comfortable. The district nurses left late in the morning and Mrs Hibbs left the house in the mid-afternoon, when her sister was again fit to look after Mr Woodhead. This was the first time that Mr Woodhead had spent the whole day in bed.

The narrative in the district nurses' record says:

'14 12 95	Seen this am by Dr Shipman
	pt in increasing pain - comm on Diamorphine 200mg Nozinan 25mg via Syringe Driver (see yellow card)
	unable to perform personal hygiene
	Mrs Woodhead very tired due to staying up during the night'.

At about 7pm that evening, Mrs Hibbs received a telephone call from her sister, who told her that Shipman had called again. He had just left and before leaving he had said that he only expected Mr Woodhead to live for another 48 hours. Mrs Hibbs was distraught. The two sisters spoke for about five or ten minutes, during which time Mrs Woodhead did not say anything about Shipman having given her husband an injection. At 7.25pm, Mrs Hibbs received another telephone call from her sister to say that Mr Woodhead had died. Mrs Hibbs was very shocked because she had thought they would have had about another two days with him.

A few days later, Mrs Woodhead gave Mr Lowe a similar account of Shipman's last visit shortly before the death. She told him that, when Shipman came out from seeing her husband, he said, 'He'll be alright now'. The next time Mrs Woodhead looked in on her husband, he was dead. He understood that Mrs Woodhead was very shocked at the suddenness of the death following Shipman's last visit. Mr Lowe does not think that Mrs Woodhead would have waited long before going in to see her husband. The essence of this account is the same as Mrs Hibbs'. Mr Woodhead was found dead very soon (30 minutes at most) after a visit by Shipman.

On receiving the news, Mrs Hibbs went to her sister's house. She saw her brother-in-law dead in bed. At about 7.50pm-8pm Shipman arrived. Mrs Hibbs recalls Shipman said that he would take Mr Woodhead's drugs. He dismantled the syringe driver and took all the medication with him. Shipman wrote on the Drug Record Card that he took all drugs away for disposal at 8.30pm. Whether that time was accurate is doubtful. After he had gone, which Mrs Hibbs thinks was at about 8pm, a night nurse attended but was told of the death and sent away. The following day, trainee district nurse Doherty (now Chilenge) wrote on the card that she had destroyed 3 x 100mg of diamorphine as well as the remaining patches. This was witnessed by Sister Gilchrist. Both women assumed that Shipman had taken the unopened batch of five ampoules for disposal, as suggested by his entry on the Drug Record Card.

There are three computerised entries relating to the date of death which say:

This suggests that Shipman had made only one visit that day, at 7.45pm, by which time Mr Woodhead was dead. This tends to confirm the accuracy of Mrs Hibbs' recollection of the time of his post-death visit. The copy entry in the register of deaths ('death certificate') would certify that the cause of death was carcinomatosis due to adenocarcinoma of the lung.

Certification

Shipman completed the Medical Certificate of Cause of Death (MCCD) and confirmed that he had last seen Mr Woodhead alive on the day of his death. The cause of death was carcinomatosis due to adenocarcinoma of the lung.

Shipman also completed cremation Form B. He recorded that death had occurred at 5.45pm on 14^th December 1995. This is clearly inconsistent with the evidence given by Mrs Hibbs and cremation form A, which records the time of death as 7.20pm. Shipman stated that he had attended Mr Woodhead during his last illness for a period of 12 months. He said that he last saw Mr Woodhead alive six hours before his death, which Mrs Hibbs says is a lie. The mode of death was said to be coma lasting hours, which may well be untrue, as Mr Woodhead had been able to converse that afternoon. Shipman recorded that he saw the body about 15 minutes after death, and made a complete external examination of it. It was recorded that Mr Woodhead's wife was present at the moment of death.

The Expert Evidence

Professor Richard Baker found the death not to be suspicious on the basis of the cremation documentation.

Conclusion

Mr Woodhead was terminally ill with lung cancer. By 14^th December, he was not expected to live long. The deputising doctor who attended during the night seems to have formed the impression that the death was imminent. It is very likely that, even without any intervention from Shipman, Mr Woodhead would have died over the course of the next few days. However, it appears that neither Mrs Woodhead nor Mrs Hibbs expected him to die on 14^th December. Mrs Woodhead asked for the help of a night nurse so that she would not be too tired to cope on 15^th December. Shipman arranged this. During the afternoon, Mr Woodhead was able to converse. When Shipman came in the early evening and told Mrs Woodhead that her husband would die in the next 48 hours, she was very shocked that he would die so soon. Even Shipman did not appear to think that he would die within the next half hour. To that extent, the death was sudden and unexpected. I accept, of course, that accurate predictions of the time of death are not possible.

The death was discovered within half an hour of Shipman's departure. It appears that Shipman left the house just before 7pm and that the death was discovered at about 7.20pm. It is possible that Mr Woodhead died very soon after Shipman's departure, solely as the result of the natural progression of his disease. However, this would be something of a coincidence, particularly bearing in mind that his death had not appeared to be imminent. There is a real possibility that Shipman gave Mr Woodhead a large dose of diamorphine to supplement the dose being given by the syringe driver.

The suspicion arising from these factors is increased by the lies that Shipman told on the cremation form. Specifically, he seems to have attempted to distance himself from the death in terms of time by suggesting, wholly contrary to the recollection of Mrs Hibbs, that six hours had passed between his last visit and Mr Woodhead's death. Having said that, there would be no obvious sinister reason why he should suggest that death occurred at 5.45pm rather than some time after 7pm, when I am satisfied that it did occur. It is possible that he gave that time in error. I think it likely that Shipman lied in saying that Mr Woodhead had been in a coma for 'Hours' before his death. He was not in a coma when Mrs Hibbs left in the afternoon. That she and Mrs Woodhead seemed to think that they were going to have Mr Woodhead with them for another two days (after being given the news that he had only about 48 hours to live), suggests to me that their expectation was that he would continue to be able to converse with them for a little longer. I think it is fairly clear that Shipman also lied in saying that Mrs Woodhead was present at the moment of death. It appears that she went into the room and found Mr Woodhead already dead.

My conclusion is that, when he visited in the early evening of 14^th December, Shipman probably gave Mr Woodhead a large dose of diamorphine which hastened his death. There is no evidence that Mr Woodhead's pain was breaking through, despite the diamorphine he was receiving through the syringe driver. I think it likely that Shipman gave Mr Woodhead an injection of 100mg of diamorphine, using one of the ampoules from the previously unopened box. He then took the rest of that box away. The nurses noticed that a box of ampoules had gone. I could not possibly say that I am sure of my conclusion in this case, as Mr Woodhead could have died naturally on that day. I must also stress that he would inevitably have died within a very short time.