Introduction

Mrs Mavis Mary Pickup died at her home, 9 Spring Avenue, Gee Cross, Hyde on Monday, 22^nd September 1997 at the age of 79. She had been widowed about four weeks earlier and was living alone. Mr and Mrs Pickup had been patients of Shipman since his arrival in Hyde in 1977 and had followed him when he moved to the Market Street Surgery. They both thought the world of him. Mrs Pickup's regard for and gratitude towards him is confirmed by the fact that she left him £250 in her will.

Shipman certified that the cause of Mrs Pickup's death was cerebrovascular accident.

Mrs Pickup's death was one of those brought to the attention of the police during the March 1998 investigation and it was, therefore, one of the first to be investigated in August 1998. The police took statements from Mr James Kenneth Pickup (Mrs Pickup's son), Mrs Joyce Kenyon Turner, Mrs Kathleen Mary Dyson, Mrs Shirley Anne Harrison and Miss Jane Elizabeth Fletcher (Mrs Pickup's friends and neighbours), Mr David John Cook and Mr Robert Denton Howell (both funeral directors), Mr Michael Langford (a paramedic), PC Tina Maria Llewellyn, Mrs Carol Chapman (a receptionist at the Market Street Surgery) and Dr Jeremy Michael Dirckze (a general practitioner).

Shipman was not prosecuted for causing the death of Mrs Pickup but an inquest into her death was opened and adjourned by the South Manchester Coroner on 18^th May 2001.

The Inquiry has taken statements from Mr James Pickup, Mr Cook and Mrs Harrison. Mr James Pickup and Miss Fletcher gave oral evidence at a hearing on 29^th October 2001. The Inquiry has also had access to Mrs Pickup's general practitioner records and to appointments sheets, visits books and other practice documents for the relevant period, as well as to the Medical Certificate of Cause of Death (MCCD) and the cremation documentation.

Personal Background

Mrs Pickup underwent a hysterectomy in 1992 for cancer of the uterus but had no recurrence thereafter. In 1993, she had a laparoscopic cholecystectomy. She saw Shipman regularly for a variety of conditions including persistent digestive problems, which were diagnosed as irritable bowel syndrome and diverticulosis. From time to time, she had episodes of depression and was treated with antidepressants and sedatives. She also had episodes of back pain. In 1995, Shipman diagnosed very mild Parkinson's disease for which he did not think treatment necessary. The diagnosis seems to have been based on a slight tremor of the hands. However, her son, Mr James Pickup, says that the tremor had been present for as long as he could remember and it may well be that Shipman's diagnosis was wrong. In 1996, Mrs Pickup suffered a fall when playing golf, resulting in an injury to her mid-thoracic spine and shoulder, and she was treated by an orthopaedic surgeon.

In the year of her death, Mrs Pickup underwent physiotherapy for persisting back pain and bursitis of the knee. On several occasions she was prescribed nitrazepam, a sedative. In April 1997, she had a road traffic accident resulting in chest wall injuries for which she was prescribed pethidine. She was also treated by the orthopaedic surgeon. In June 1997, she underwent a general check-up at the surgery. Her blood pressure was 130/80 and all blood tests were normal. On 14^th August 1997, there was a consultation in connection with a muscle strain and digestive problems. That was the last consultation prior to the day of death. In particular, it is noteworthy that Mrs Pickup had no history of raised blood pressure. Such readings as were taken were well within normal limits for a woman of her age.

The Events of the Weeks Leading up to Death

Mrs Pickup's husband, Mr Kenneth Pickup, died on 27^th August 1997. He had had a history of heart disease and had undergone surgery. At the time of his death, he had recently had a pacemaker fitted and was feeling well enough to take some exercise. He collapsed and died while out for a walk on Werneth Low. The sudden death of her husband after 47 years of happy marriage hit Mrs Pickup hard. Her husband had been a strong, even dominant personality and she was devastated at the loss and apprehensive at the prospect of coping alone. At first she seemed unable to accept that he was dead and her family was very concerned. However, she was a capable woman with a wide range of interests and some good friends. She also had a close and supportive family. Her two sons were both married. Mr James Pickup, his wife and their children lived not far away. Her other son, his wife and newborn baby lived in Scotland. She still had a great deal to live for.

Soon after Mr Pickup's death, Mr James Pickup went to see Shipman at his surgery. Mr James Pickup wanted to discuss with Shipman the cause of his father's death and to thank him for the care he had provided. The conversation soon turned to Mrs Pickup and both men recognised that she was, at the time, in a very vulnerable state. Shipman was anxious to assure Mr James Pickup that if his mother had a problem of any kind he would be only too pleased to help. He stressed that this was not limited to medical help. He would, he said, 'always be there for her'.

It was not long before Mrs Pickup had a problem. About a week or so after her husband's death, Mrs Pickup began to suffer harassment from local youths who, late at night, would run up to the house and bang very loudly on the door. Mrs Pickup was frightened. She reported the problem to the police but had little satisfaction, as by the time the police attended, the boys had run away. One of her concerns was that her telephone was in the hall and that, while using it, she was visible through a glass panel in the front door.

During the weekend before Mrs Pickup died, Mr James Pickup fitted some security lights to the house and took her to buy a cordless telephone. She was rather depressed during the outing and even voiced her doubts about whether there was any point in going on. However, on the Sunday evening, she used her new telephone to speak to Mr James Pickup, who had by that time travelled to London ready for work the next day. She apologised for being 'down' over the weekend and said that she now felt much better.

The Day of the Death

On the morning of Monday, 22^nd September, Mrs Turner, a friend and neighbour, telephoned Mrs Pickup. She had intended to visit that day but Mrs Pickup explained that she was not feeling well, had a headache and was going to call her doctor out. A visit would not be convenient. She sounded in rather low spirits and admitted that she was having a bad day. She said she had been writing letters to thank people who had attended her husband's funeral.

Mrs Dyson, who has died since giving her statement to the police, lived nearby. She was a good friend and Mrs Pickup's most frequent social contact. Her impression of Mrs Pickup that day was that she seemed bright and cheerful when she came round for coffee at Mrs Dyson's home at about noon. Mrs Pickup told her that she had driven into Gee Cross village that morning to do some shopping. Towards the end of her visit, however, she said that she had a headache and was going home to have a lie down.

Shortly after leaving Mrs Dyson's house, Mrs Pickup telephoned Shipman's surgery. The call was timed at 12.42pm. It was taken by Mrs Chapman, and Mrs Pickup told her about the local youths who had been knocking on her door and causing her annoyance. She was so upset that Mrs Chapman transferred the call to Shipman who spoke to Mrs Pickup and agreed to visit her. Mrs Chapman gave Shipman the Lloyd George notes to take with him. The visits book shows that this was the only visit to be made that day.

When Mr James Pickup's wife, Mrs Grizelda Pickup, returned home from work, she found a message from Shipman on the answerphone. From the surgery billing record, it can be seen that the call was made at 6.04pm. In the message, Shipman said that he had been to see Mrs Pickup that day and was worried about her because she had had a slight stroke overnight. She had refused to go to hospital. He asked the family to speak to her to persuade her to change her mind.

I interpose to say that in evidence Mr James Pickup said that, on reflection, he found this suggestion quite incredible. His mother's regard for Shipman was such that she would have accepted any advice he had given without question.

Mrs Grizelda Pickup tried to contact her mother-in-law but with no success. At 6.38pm, she telephoned Shipman. He told her not to worry, as Mrs Pickup was probably round at the home of her neighbour, Mrs Dyson. That in itself seems an odd thing to say of a woman who was supposed to be ill enough to warrant hospital admission. Having spoken to Shipman, Mrs Grizelda Pickup then telephoned her husband and told him what had happened. Mr James Pickup tried to contact his mother but there was no reply. He telephoned Mrs Dyson and established that his mother was not there. He says that he did not ask her to go to his mother's home, as by this time he was worried and sensed that whoever went to the house might find a distressing scene. He contacted some neighbours whose daughter, Miss Fletcher, had been a police officer and asked if she would go to the house.

Both Mrs Dyson and Miss Fletcher went separately to Mrs Pickup's home. Mrs Dyson must have arrived first and found Mrs Pickup lying on the kitchen floor. Mrs Dyson must have returned home and telephoned for an ambulance. The call was made at 7.04pm. Meanwhile, Miss Fletcher rang the bell at the front door and, when there was no response, went to the back of the house. She found the door unlocked and Mrs Pickup lying on her back on the kitchen floor. She was obviously dead. There was vomit on her sweatshirt and she was cold to the touch. Her feet were adjacent to a chair near the cooker. Mr James Pickup has explained that this chair, which was a wooden kitchen chair without arms, was his mother's usual resting place during the day.

Miss Fletcher returned home and telephoned for the police and ambulance. Her call to the police is timed at 7.08pm. Miss Fletcher then telephoned Mr James Pickup and broke the news of his mother's death. He in turn telephoned Shipman who said, in a very matter of fact way, that he would go to the house immediately. He did not express any sympathy, even for the fact that Mr James Pickup had lost both parents within the month. Mr James Pickup made arrangements for undertakers to attend and caught the first available train back to Hyde.

Miss Fletcher met Mrs Dyson and another neighbour, Mrs Harrison, and they went back to Mrs Pickup's home. The ambulance crew was present at 7.20pm and diagnosed the fact of death. The form completed at the time contains the following comment:

'PATIENT FOUND ON KITCHEN FLOOR. NEIGHBOURS PRESENT >(more than) 20 MINUTES. PATIENT COLD AND UNRESPONSIVE. NO RIGOR MORTIS PRESENT. DOCTOR/GP HAD SEEN PATIENT THIS AM'.

By about 7.30pm, Shipman had arrived. He told Miss Fletcher that the death was not unexpected, that he had seen Mrs Pickup earlier that day when she was not well and had had a mild stroke. He indicated to the police that he was willing to certify the cause of death. Miss Fletcher said that he seemed in quite a jolly mood and chatted freely. His son, who at the time was aged about 11 or 12, was sitting in the car outside the house. While they were waiting for the funeral director to arrive, Shipman went out to the car to persuade his son to come in to see the body. The boy refused and Shipman came back in alone. There was no mention of a post-mortem examination then or at any subsequent time.

Shipman's manuscript note of his visit that day reads as follows:

'22/9/97

feels very emotional shaky Eating bowels poor Resp : ( illegible ) 120/80 HS I II 2/6 (a systolic murmur, graded on a scale of 1 (very soft) to 6 (very loud)) feels (L) arm weak   walks poorly from today only Speech slurred confused T/P/P(time, person, place) O/E Power tone coordination (meaning reduced) Clearly (L) CVA (cerebrovascular accident) not TIA (transient ischaemic attack) improvement (?) so little

The full version of the computerised note reads as follows:

'feels shaky 120/80 hs I II soft systolic 2/6 lse resp nad abdo ok cns weak left arm leg speech slurred confused re date time person thinks all started last night clinically tia ? stroke says better than was this morning NO to hospital tluk review'.

An audit trail by Detective Sergeant John Ashley showed that that note was made at 3.43pm that day.

I interpret the note to indicate that Mrs Pickup began by saying that she felt very emotional and shaky. Shipman must have asked her about her appetite, which she said was satisfactory, and her bowels, which she said were poor. Shipman then appears to have begun an examination, in which he recorded that respiration was satisfactory. Blood pressure was 120/80 which is very good. Heart sounds were normal save for a slight systolic murmur, the significance of which is not clear. Shipman then recorded that Mrs Pickup said that her left arm felt weak. She was walking poorly. These symptoms had begun that day only or had started the night before. Shipman recorded that her speech was slurred and that she was confused in time, place and person. On examination he found that the power, tone and co-ordination of her limbs was reduced. Mrs Pickup was claiming that she was now better than she had been that morning. She refused to go to hospital and was to let Shipman know if she changed her mind. Shipman was to review her the next day.

Mr James Pickup said in evidence that he could not believe that his mother had had a stroke overnight. Had she had any symptoms such as are described in this note, she would certainly not have taken her car out that morning. She was a timid and reluctant driver at the best of times and would not have driven if she was unwell. In any event, he believes she would have contacted him or his wife if she had anything like the symptoms of a stroke. I add that it is unlikely that Mrs Dyson would have failed to notice such symptoms had they been present when she saw Mrs Pickup quite shortly before Shipman's visit.

I note that the manuscript entry begins with a concern that is entirely unsurprising, that Mrs Pickup was feeling very emotional and shaky. The references to appetite and bowels are also not surprising. Nor are the heart sounds. Then the note moves into a different phase, where anyone who knew Mrs Pickup or had seen her recently would find it hard to believe that the account was true. This is a feature that I have noticed many times in Shipman's medical notes relating to a consultation that had taken place shortly before a death. He would begin with the genuine complaint and move onto a fabricated account of an illness or condition, which was later to be used as an explanation for the subsequent unexpected death.

There is a further reason why this note cannot be genuine. If Shipman really did think Mrs Pickup had suffered a stroke and was in need of hospital attention, which she had refused, he would not have left her unattended. I have come across many cases in which Shipman has claimed that a patient has refused admission to hospital. He has then left them unattended but supposedly alive, and they have died soon afterwards. This conduct does not ring true. In the present case, Shipman supposedly left Mrs Pickup alone. He did not even leave a message on Mr and Mrs James Pickup's answerphone until after 6pm. Had he wished to do so, he could quite easily have contacted Mr James Pickup through his work. But a simpler solution to the immediate problem would have been to ask Mrs Dyson to come and sit with Mrs Pickup. That Shipman would leave alone this patient, for whom he would 'always be there', is incredible.

Shipman did not record Mrs Pickup's death in the manuscript notes but there is an entry in the computerised record, which was made early the following morning:

This entry is far from clear in its meaning but it appears that Shipman was saying that Mrs Pickup had been found dead by a neighbour, possibly at 4pm. Paramedics attended. Rigor mortis was setting in. At 8pm, he confirmed the fact of death. He formed the view that she had been dead for four hours at that time. The cause of death was cerebrovascular accident.

It can be seen from the appointments sheet for the day that Shipman had a window of opportunity for making his visits between about 1pm and 3.30pm. Mrs Pickup's house was about a 20 minute drive from the surgery.

The Aftermath

The MCCD records that Shipman last saw Mrs Pickup on the day of her death. The cause of death is stated to be cerebrovascular accident with an approximate interval between onset and death of 12 hours.

Shipman also completed Form B of the cremation certificate. He claimed that the death occurred at 'About 1600 hrs'. He said that he had attended Mrs Pickup for '4-6 hours' during her last illness and to have last seen her alive 'About 4 hours before death'. It is difficult to see how these periods can be reconciled. The note would tend to suggest that Shipman had been with her for about two hours before leaving at approximately noon. Given that it is known that the telephone call requesting his visit was not made until 12.40pm, that is plainly wrong. In my view, this is unlikely to be a genuine error and much more likely to be a deliberate lie, designed to increase the time between his visit and the death.

Shipman stated that he saw the body about four hours after death and made a complete external examination. He said that the mode of death was 'Collapse' lasting 'seconds' and went on to state:

Whilst stating that no one was present at the moment of death, Shipman added:

Dr John Grenville has explained that it is not possible to estimate the time of death either by reference to rigor mortis or body temperature, unless measured rectally. Shipman often purported to estimate the time of death by reference to these factors. The process is not scientific. It appears to me that Shipman has probably estimated the time of death at the latest time consistent with the onset of rigor mortis. By so doing, he would make it appear that a considerable time had elapsed between his visit and the death.

The Inquiry is aware of no evidence of a sighting by a neighbour after Mrs Pickup left Mrs Dyson. In evidence, Mr James Pickup said that he was sure that he would have learned of such a sighting if it had occurred. His mother was part of a close-knit group of friends, who were distraught at the suddenness of her death, so soon after her husband's. It appears to me that, in completing Form B, Shipman was seeking to give the impression that he had visited Mrs Pickup earlier than he did, that he had been able to assess the time of death from the body temperature and that someone had seen Mrs Pickup alive some considerable time after he had visited her. In my view, Form B was a pack of lies.

Conclusion

The evidence in this case is very clear and I am satisfied that Shipman must have killed Mrs Pickup.

Mrs Pickup was in good physical health when she last saw her doctor in August 1997 for a routine check. In particular, her blood pressure was and always had been within normal limits. There was no reason to suppose that she would have a stroke.

I find Shipman's suggestion that Mrs Pickup had had a stroke overnight or in the morning of 22^nd September to be quite incredible. Had she done so, she would have told a member of her family; she would have telephoned Shipman much earlier; she would not have gone out in the car; and the signs would have been apparent to Mrs Dyson. I am quite sure that Shipman's claim that she had had a stroke, as recorded in the medical notes, was false. I have already said that I have noticed that he would sometimes begin a record with genuine observations and would then move on to a fabricated account, designed to explain the death. That is clearly what he has done here.

Shipman's visit almost certainly took place in the early afternoon. Nobody saw Mrs Pickup alive or spoke to her after his visit. That in itself is a highly suspicious factor, especially when, as here, Shipman fabricated evidence that someone had seen her alive after his visit. In fact, there is nothing in the evidence which shows that she did not die at the time of his visit.

I have already said that Shipman's entries on Form B were a pack of lies, designed to make it appear that he had visited Mrs Pickup earlier than he did and that he was able to state that her death had occurred several hours later.

All the evidence points to the conclusion that Shipman killed Mrs Pickup, almost certainly by giving her an intravenous injection of diamorphine. I think it likely that he visited her in the early afternoon and that she told him that she felt very emotional and shaky. I have little doubt that he said that he would give her an injection to settle her nerves, which is what she wanted. She would have agreed without hesitation. After the injection, she would have been unconscious within a very short time. She was almost certainly sitting on her usual chair in the kitchen and would have fallen from it, as there were no supporting arms. She would have been dead within minutes.