Previous Index  Next Statement by Dame Janet Smith, Chairman of The Shipman Inquiry, given on publication of her First Report. Fri 19 Jul 2002 The Inquiry's Terms of Reference required me to consider the extent of Harold Fredrick Shipman's unlawful activities but left it to me to decide how this should be done. Within a very short time, I came to realise that the only way in which to satisfy the reasonable expectations of the families of Shipman's former patients and to provide a solid base for the rest of the Inquiry's work, was to provide, so far as I could, a decision in each individual case in which suspicion arose. The work of investigation and decision writing proved to be far greater than I had anticipated and has taken longer than I had hoped. That work has resulted in my being able to set out in this First Report as complete and accurate an account of Shipman's criminality as I believe it will ever be possible for anyone, other than Shipman himself, to give. Although the Report reveals the number of patients Shipman killed, this Phase of the Inquiry has not been primarily concerned with numbers. Instead, our efforts have been concentrated on gathering all the available evidence about the circumstances of each individual death and on reaching a conclusion as to the true cause of the death. The Inquiry has considered 887 deaths and one incident involving a living person. I have written a decision in respect of 493 deaths. The remaining 394 cases were closed without a written decision because, in each case, there appeared to be compelling evidence that the death was natural and, in cases where the Inquiry was in contact with relatives, the family had no concerns about the death. Of the 493 deaths in which I have written a decision, I have found that Shipman killed 200 patients. That number is in addition to the 15 patients of whose murder Shipman was convicted. So, the total number of deaths in respect of which there was sufficient evidence to support a finding of unlawful killing is 215. In a further 45 cases, there was some evidence that Shipman might have caused the death. In other words, there was reason to suspect Shipman, but the evidence was not sufficiently clear to enable me to reach a decision. I very much regret that the families of those patients will be left in a state of uncertainty. I have found that the deaths of 210 patients were due to natural causes. That is in addition to the 394 cases closed without a written decision. I hope that the anxieties of those families will have been allayed. That leaves 38 deaths about which I have been unable to form any view. In most cases, this has been because the deaths occurred a long time ago and there was very little evidence to consider. Sometimes, there was evidence but it was conflicting or inconsistent with the surviving contemporaneous documents. I regret that the families of those patients will also be left in uncertainty. It should be realised that the figure of 215 killings may not represent the true total. Among the deaths which I have found suspicious and those in which I have been unable to form any view, there may be some patients who died at Shipman’s hand. I warned at the outset that it was inevitable that there would be some cases in which I would be unable to provide an answer for the relatives. I hope that the families of those patients will understand why I have been unable to reach a conclusion and will at least draw some comfort from the knowledge that their relative’s death has been looked into as far as was possible. Shipman first killed in March 1975, while working in Todmorden. His first victim was Mrs Eva Lyons, who was suffering from terminal cancer and was in great pain. The evidence persuaded me that Shipman deliberately hastened her death by the administration of an excessive dose of strong opiate, probably morphine or diamorphine. She was the only patient whom I found that Shipman killed while in Todmorden. There were other deaths there which aroused my suspicion but I was unable to reach a positive conclusion in those cases. While a member of the seven-doctor Donneybrook Practice in Hyde, between 1977 and 1991, Shipman killed 71 patients. In the last six years before his arrest, while working as a sole practitioner at the Market Street surgery in Hyde, he killed 143: one in 1992, 16 in 1993 and 11 in 1994. In both 1995 and 1996, he killed 30 patients and in 1997, no less than 37. In the first three months of 1998, he killed 15. There was then an interval of about seven weeks before he went on to kill three more. As is well known, his last victim was Mrs Kathleen Grundy, who died on 24th June 1998. Of the 215 known victims, 171 were women and 44 were men. Shipman’s typical victim was an elderly person living alone. In general, women live longer than men so there are more elderly women than men living alone. For that reason, Shipman found most of his potential victims among his female patients. However, he killed men when the opportunity arose. Shipman's oldest victim, Miss Ann Cooper, was 93; his youngest, Mr Peter Lewis, was only 41. He, like Mrs Lyons, was suffering from terminal cancer and was in great pain. The evidence persuaded me that Shipman deliberately hastened his death by the administration of an overdose of diamorphine. Most of Shipman’s victims were not terminally ill and were not suffering from any immediately life-threatening condition. Most deaths were unexpected. The youngest victim to die an unexpected death was Mr David Harrison, who was only 47 years old. Only three victims were killed in residential and nursing homes. I believe that the presence of staff in such homes provided a substantial degree of protection for residents. There is no convincing evidence that Shipman killed by any method other than the administration of an overdose of a drug. In all but a very few cases, it is clear that the drug used was either morphine or diamorphine. During the 1990s, for which years controlled drugs records have survived, I am satisfied that the drug used was diamorphine. A Shipman killing usually followed a typical pattern. Shipman would visit an elderly patient, usually one who lived alone. Sometimes, the visit would be at the patient’s request, on account of an ailment of some kind; sometimes, Shipman would make a routine visit, for example to take a blood sample or to provide a repeat prescription; sometimes he would make an unsolicited call. During the visit, Shipman would kill the patient by administering a lethal injection. Afterwards, he would behave in one of several typical ways. Sometimes, he would stay at the patient’s home and would contact relatives immediately. He might say that he had found the patient dead when he arrived. If asked how he had gained entrance, he would say that the patient had been expecting him and had left the door ‘on the latch’. Sometimes, he would say that he had found the patient close to death; or he might say that the patient had been well when he arrived but had collapsed and died, quite suddenly, in his presence. Sometimes, he would leave the patient’s home after the killing, closing (and thereby locking) the door behind him. Either then or later, he would find a neighbour who held a key, or the warden if the patient lived in sheltered accommodation. He would say that he had called upon the patient but there was no reply and he was concerned. Together they would go to the patient’s home and ‘discover’ the body. On other occasions, he would leave the body unattended and would wait for a relative or friend to find it. He always had a ready account of what had occurred and, however sudden and unexpected the death, the shocked and bereaved relatives would accept his explanation and his assurance that there would be no need for a post mortem examination. As I have said, this Phase of the Inquiry has not been concerned merely with numbers and statistics. Its objective has been to give individual answers to as many of the families and friends of Shipman’s patients as has been possible. The evidence about the death of each individual patient has been of a deeply personal, private and often moving nature. Each killing represents a tragedy for family and friends. Each finding that a death was natural will, I hope, bring relief from anxiety, although the loss will still be felt. The First Report comprises six volumes. Volumes Two to Six contain the individual decisions. Volume One, which has 14 Chapters, begins with the background to the Inquiry, the investigation methods adopted, the evidence relating to Shipman’s practice, the existing procedures for death registration and cremation certification and the medical evidence. Chapters Seven and Eight cover the evidence about the drugs Shipman used to kill and the ways in which he acquired them. Chapter Nine explains my approach to the individual decisions and the standards of proof I have applied. Chapter Ten describes Shipman’s activities while working in Todmorden. Chapters Eleven and Twelve give accounts of his unlawful activities in the Donneybrook and Market Street years. In Chapter Thirteen, I have examined the evidence relating to Shipman’s possible motivation in killing his patients. I regret that I have reached no clear conclusions. Save for the case of Mrs Grundy, for whom he forged a will in his own favour shortly before her death, I have found no evidence that Shipman killed for monetary gain. Even in her case, I am not convinced that his motivation was simply a wish to inherit her considerable estate. His selection of a victim whose daughter was a solicitor, his incompetent forgery of the will and the arrangements he made for its delivery to a solicitor made discovery inevitable. It is hard to resist the inference that Shipman was driven by a need to draw attention to himself and his crimes. I have found no evidence of any other obvious motive. Shipman did not interfere with the bodies of his victims and there is no suggestion of any form of sexual depravity. In Chapter Thirteen, I have also sought to draw together all the available evidence about Shipman’s personality, in the hope that the reader will be able to gain some insight into what might have lain behind his serial crimes. Finally, in Chapter Fourteen, I have set out my conclusions. I have noted the compatibility between the results of the Inquiry’s investigation and the estimate of the number of deaths attributable to Shipman made by Professor Richard Baker in his review, published in January 2001. His analysis of the Inquiry’s findings is at Appendix A within Volume One. I have also drawn attention to the failure of the existing systems of death and cremation certification and controlled drugs regulation. These failures will be further investigated in Phase Two of the Inquiry. When sentencing Shipman on 31st January 2000, Mr Justice Forbes said this: ‘None of your victims realised that yours was not a healing touch. None them knew that in truth you had brought death, death which was disguised as the caring attention of a good doctor’. I have entitled the First Report ‘Death Disguised’ because it seems to me that, with those words, Mr Justice Forbes encapsulated the essence of Shipman’s crimes. He disguised his character and the true nature of his actions so as to deceive not only his victims and their families but also his professional colleagues and those responsible for death registration and cremation certification procedures. Deeply shocking though it is, the bare statement that Shipman has killed over 200 patients does not fully reflect the enormity of his crimes. As a general practitioner, Shipman was trusted implicitly by his patients and their families. He betrayed their trust in a way and to an extent that I believe is unparalleled in history. The way in which Shipman could kill, face the relatives and walk away unsuspected would have been dismissed as fanciful if it had been described in a work of fiction. Although it is now known that Shipman killed at least 215 patients, the true number of victims is far greater and cannot be counted. I include as victims the thousands of relatives, friends and neighbours who have lost a loved one or a friend before his or her time, in circumstances that will leave their mark for ever. Shipman has also damaged the good name of the medical profession and has caused many patients to doubt whether they can ever again trust their own family doctor. This trust forms the basis of the relationship between doctor and patient. I believe that the overwhelming majority of patients will, on reflection, realise that they can indeed trust their doctor, as they always have done, but there will inevitably be some who will remain uncertain. The investigation of Shipman’s crimes has at times been harrowing, but there is one particular respect in which it has been positively heart-warming. I want to express my admiration and respect for the way in which the people of Hyde and Todmorden care so affectionately for their relatives and neighbours. I have heard and read of countless families where a son or daughter, son-in-law or daughter-in-law, niece, nephew or grandchild has cared devotedly for an elderly relation, sometimes visiting several times a day, often while looking after his or her own family and frequently while coping with a job. I have heard many accounts of kindliness by neighbours as well. I would like to express my deepest sympathy and that of the Inquiry team to all those who have been bereaved or distressed by Shipman’s actions. The process of the Inquiry has been welcomed by some but not by all. For many, this Report will provide the answers they have expected or feared; for many more, it will provide reassurance. I regret that there are some who must remain in uncertainty. I wish to express my gratitude to the Inquiry team and to all the witnesses who have assisted the Inquiry by providing statements and giving evidence. For some, I believe the experience has been cathartic and beneficial. For many, it was deeply distressing. I am grateful to them all. Previous Index  Next Published by The Shipman Inquiry © Crown Copyright 2001