10 May 2001
 |
 |
|
1 Thursday, 10th May 2001
2 DAME JANET: On 31st January 2000, Harold Fredrick
3 Shipman was convicted by a jury at Preston Crown Court
4 of murdering 15 former patients and of forging a will of
5 one of them. He killed them by administering lethal
6 doses of diamorphine. He was sentenced to serve 15
7 concurrent terms of life imprisonment and in passing
8 sentence, Mr Justice Forbes told him that in his case,
9 life imprisonment meant that he would remain in prison
10 until his death.
11 All 15 of Shipman's victims had lived in Hyde.
12 Shipman had been a well respected general practitioner
13 until his arrest for the murder of Mrs Kathleen Grundy
14 in September 1998. As the evidence emerged during the
15 trial, there were many who could not believe that
16 Shipman would ever have harmed a patient. The sense of
17 shock and disbelief following the convictions
18 reverberated around the world but nowhere was it felt
19 more deeply than in Hyde. Many more people in Hyde
20 besides the friends and families of the 15 known victims
21 were concerned that the deaths of their loved ones might
22 not have been natural.
23 There was also a general concern that a doctor
24 had been able to amass large quantities of diamorphine
25 and to kill so many patients without detection. Why had
0001
1 the regulations which require a record to be made of the
2 acquisition and supply of all controlled drugs failed to
3 prevent Shipman from obtaining diamorphine illicitly?
4 Why had this not been noticed, especially in view of his
5 convictions for drug abuse in 1976? Why had our systems
6 of death certification with the availability of
7 post-mortem examination and Coroner's inquest failed to
8 detect and arrest the progress of this serial killer?
9 In response to these concerns, in February
10 2000 the Secretary of State for Health set up an inquiry
11 under the National Health Service Act 1977. Although its
12 report was to be made public, the panel which was to be
13 chaired by Lord Laming of Tewyn was to sit in private.
14 Many people in Hyde were dissatisfied with that aspect
15 of the Inquiry. A group of relatives of known or
16 suspected victims of Shipman applied to the High Court
17 for Judicial Review of the Secretary of State's
18 decision. Associated Newspapers Limited and other media
19 groups made a similar application.
20 In July 2000, those applications succeeded and
21 in September the Secretary of State announced that the
22 Laming Inquiry had been disbanded. Instead, he would
23 invite Parliament to set up a public inquiry under the
24 Tribunals of Inquiry Evidence Act 1921. In December 2000
25 I was invited to conduct that public inquiry. On 31st
0002
1 January this year, Parliament appointed me as Chairman
2 and confirmed the Inquiry's terms of reference.
3 I want to stress that although the Inquiry was
4 set up by Parliament at the invitation of the Secretary
5 of State for Health and although the Inquiry will be
6 funded from the budget of the Department of Health, it
7 is wholly independent of Government. I am a High Court
8 judge and I am entirely independent. I shall receive the
9 advice of counsel who are barristers in independent
10 practice in Manchester Chambers but the decisions taken
11 will be mine and mine alone.
12 The terms of reference are these:
13 (1) after receiving the existing evidence and
14 hearing such further evidence as necessary, to consider
15 the extent of Harold Shipman's unlawful activities;
16 (2) to enquire into the actions of the
17 statutory bodies, other organisations in response to
18 individuals concerned in the procedures and
19 investigations which followed the deaths of those of
20 Harold Shipman's patients who died in unlawful or
21 suspicious circumstances;
22 (3) by reference to the case of Harold Shipman
23 to enquire into the performance of the functions of
24 those statutory bodies, authorities, other organisations
25 and individuals with responsibility for monitoring
0003
1 primary care provision and the use of controlled drugs;
2 (4) following these enquiries, to recommend
3 what, if any, steps should be taken to protect patients
4 in future and to report to the Secretary of State for
5 Home Affairs and to the Secretary of State for Health.
6 The terms of reference encompass suspicious
7 deaths which occurred at any time during Shipman's
8 professional career, including the period he spent in
9 the 1970s working in Todmorden in West Yorkshire.
10 Over a year has now passed since Shipman was
11 convicted. Many of those present today will be concerned
12 about the passage of time and will regret that the
13 Inquiry has not yet begun its public hearings. I want to
14 explain what has been happening since January when my
15 appointment was confirmed.
16 The Inquiry has taken over offices formerly
17 occupied by the Laming Inquiry at Gateway House near
18 Piccadilly Station. From there, the investigative work
19 for the Inquiry has been taking place. The legal and
20 administrative teams have been assembled. Miss Caroline
21 Swift, Queen's Counsel has been appointed as leading
22 counsel to the Inquiry and she is assisted by
23 Christopher Melton, Queens Council and Junior Counsel,
24 Anthony Mazzag and Michael Jones. The solicitor to the
25 Inquiry is Henry Palin assisted by Ita Langan and
0004
1 Julie Denham. The firm of Eversheds has been appointed
2 as solicitor agents to provide the substantial number of
3 experienced personnel needed to take the large number of
4 witness statements in a short time. The administrative
5 team is led by Andrew Griffiths, the secretary to the
6 Inquiry and his assistants Oonagh McIntosh and Helen
7 Owen.
8 I have appointed Doctor Aneez Esmail, PhD to
9 be my adviser on matters relating to public health and
10 general practice. He was until recently the Head of the
11 School of Primary Care at the University of Manchester,
12 a Senior Lecturer in General Practice and a Principal in
13 general practice at the Rusholme Health Centre. He was a
14 member of the Laming Inquiry. He has academic and
15 practical experience in many of the areas into which I
16 shall enquire. He will sit with me on some but not all
17 occasions. For the sake of openness, I shall state
18 publicly the topics on which he has advised me and will
19 ask him to prepare a written summary of the advice he
20 has given. Before the end of the hearings, there will be
21 an opportunity for interested parties to question him on
22 those topics.
23 It was decided that the public hearings will
24 take place here at the Town Hall in Manchester and that
25 the proceedings should be relayed by Closed Circuit
0005
1 television to a building in Hyde, so that the many
2 people who will no doubt wish to follow the proceedings
3 may do so without inconvenience. A room has been
4 equipped at the back of the public library in Hyde; I
5 have been to see it and I hope that it will prove
6 satisfactory. The public hearings will take place in the
7 main Council Chamber which has been equipped with
8 sophisticated Information Technology.
9 Voice activated cameras will focus on the
10 person speaking whose face will be projected on to one
11 of two large screens which will be situated behind me.
12 Documents referred to will be projected on to the other
13 screen and on to the laptop computers provided for the
14 legal teams and some of the media positions. All present
15 and those watching from Hyde will be able to see the
16 document display as will the media in their working
17 annex. This should make the proceeding far more
18 intelligible than is often the case with court
19 proceedings where only the judge, the parties and the
20 witness have copies of the document under consideration.
21 Several thousand pages of documentation have already
22 been scanned into the system and there are many more to
23 come. I hope that the use of this document retrieval
24 system and display screens will enable the proceedings
25 to move more quickly than by reference to paper files.
0006
1 Stenographers will record the proceedings
2 using LiveNote and all documents received in evidence
3 and a transcript of each day's proceedings will be
4 posted on the Inquiry's website which is in operation
5 from today. I hope that by the use of modern technology,
6 the process of the Inquiry will be made entirely open.
7 All the evidence on which my conclusions are based will
8 be in the public domain.
9 The conference facilities in this building are
10 extremely limited and what is available is far from
11 ideal. We have therefore arranged for conference rooms
12 to be available for use by legal representatives in
13 offices in Mount Street. They are almost immediately
14 opposite the Inquiry main entrance. These rooms can be
15 booked through the Inquiry's administrative team.
16 Arrangements for media seats in the chamber will be
17 allocated to media organisations covering the Inquiry
18 and a special room will be provided in which journalists
19 may work and to which the proceeding will be relayed.
20 Counselling services will be provided by Tameside Victim
21 Support who have provided and indeed continue to provide
22 very valuable help and comfort for the families.
23 Counsellors will be available at the Town Hall here and
24 at the library in Hyde.
25 In the conduct of the Inquiry, I shall seek to
0007
1 achieve fairness and openness by reliance on the
2 principles advocated by Lord Justice Salmon in the
3 report of the Royal Commission on Tribunals of Inquiry.
4 That is not to say that I shall adopt all his suggested
5 procedures. More recent Inquiries such as the Scott
6 Inquiry on the Export of Arms to Iraq and the Phillips
7 Inquiry into BSE have sought to refine the Salmon
8 principles. I hope to draw on the experience gained in
9 those Inquiries. The overriding principles will be
10 fairness and openness but the Inquiry must not pursue
11 proceedings which impose an undue burden on the
12 interested parties, the Inquiry team or the public
13 purse. Many of the detailed decisions on procedure have
14 not yet been taken and I am prepared to hear submissions
15 today on such matters at least in relation to Phase 1.
16 I have decided that the Inquiry should take
17 place in three phases. The first phase will investigate
18 how many patients Shipman killed, the means employed and
19 the period over which the killings took place. Professor
20 Richard Baker has conducted a statistical analysis of
21 data drawn from Shipman's practice in comparison with
22 other general practitioners practising in the same
23 areas. He also examined the medical records of a large
24 number of Shipman's former patients. From his review of
25 the medical records and information reports, where
0008
1 available, he formed the view that the most likely
2 number of deaths about which there should be concern is
3 236.
4 However, Professor Baker's report could not
5 provide the answer which many people from Hyde and
6 Todmorden wanted which was whether or not their relative
7 or friend was a victim. Until the Inquiry's
8 investigations are underway, the team did not know
9 whether it would be feasible for me to attempt to reach
10 a decision on individual deaths. I wished to do so
11 because I recognise the need for the families to know
12 the truth.
13 Now that the investigative work is well
14 advanced I have decided that I shall attempt to reach a
15 decision in each individual case. There is another
16 important reason that these decisions should be taken.
17 The second and third phases of the Inquiry will be
18 carried out more effectively if the factual basis of
19 Shipman's unlawful activities has already been
20 established.
21 The number of cases of the Inquiry database is
22 very large and includes those files delivered to us in
23 the last week by West Yorkshire and Greater Manchester
24 Police. Investigations into 110 deaths have been
25 completed and the files closed for a variety of reasons
0009
1 but many because there was no reason to suspect that the
2 death was unnatural. Where possible, I shall write to a
3 relative in each of those cases to tell them that the
4 file has been closed. A list of closed files will be
5 published at a later date. If any concern is raised or
6 further information forthcoming, we will reopen the file
7 and investigate further.
8 There are 152 deaths in which Shipman signed a
9 medical certificate of cause of death which we cannot
10 investigate at present because the only information
11 available to us is a copy of the entry in the Register
12 of Deaths. The Inquiry will seek to contact a relative
13 in each of those cases with a request for further
14 information. Due to the passage of time, it may be
15 difficult to locate many of those relatives.
16 Accordingly, a list of those cases with the dates of
17 death will be published with a request that anyone with
18 further information should come forward.
19 Currently we are examining 466 deaths, but
20 this number may increase if further information is
21 forthcoming. I stress this number is not an estimate of
22 the number of people Shipman might have killed. At this
23 stage it would be quite wrong for me to speculate about
24 the number of deaths for which he was responsible. I am
25 prepared to say that I anticipate that there will be
0010
1 many cases in which I would be able to say that there is
2 no cause for suspicion. However, it will not be possible
3 in every case for me to provide a definite answer one
4 way or the other. Much will depend on the availability
5 of evidence, particularly the medical records and
6 cremation certificates. The medical records of many of
7 those patients who died before 1991 had been routinely
8 and lawfully destroyed before Shipman's activities were
9 brought to light in 1998. In other cases, records have
10 been lost. In the case of deaths before 1994, hardly any
11 cremation certificates have survived and only the
12 information -- the limited information -- in the
13 Register of Deaths is available. In such cases there
14 will be insufficient evidence and there may be other
15 reasons why a decision may not be possible. But I shall do
16 my utmost to put an end to the uncertainty that has
17 prevailed for so long and which has caused such
18 distress.
19 As I have said, the Inquiry is investigating a
20 very large number of cases. Each case file contains or
21 will contain the evidence obtained by the police in
22 their investigation, the statements taken for the
23 purposes of this Inquiry, the Death Registration and,
24 where appropriate, Cremation Certificates, the relevant
25 entries from the Surgery Appointment Books and visits
0011
1 records and some medical records. Expert evidence mainly
2 on medical issues has been obtained.
3 The whole process has been very
4 time-consuming. It is now well advanced but much remains
5 to be done. Although in recent weeks many statements
6 have been taken for the Inquiry, I am anxious that
7 anyone who has not yet given a statement and who thinks
8 that he or she may have relevant information should
9 contact the Inquiry and ask for assistance in providing
10 the statement.
11 I do want to emphasise that there is no need
12 to seek legal representation. Many people wishing to
13 provide a statement or give information to the Inquiry
14 have been assisted by the Inquiry team and this facility
15 remains and will remain available. The inquiry
16 has written to Shipman and to solicitors instructed on
17 his behalf. His solicitor indicated that he does not
18 wish to take part in the Inquiry. At the appropriate
19 stage, but before any decisions are taken, the Inquiry
20 will identify to him those deaths for which he is
21 suspected of being responsible. We will then allow
22 reasonable time for him to respond.
23 It is intended that the oral hearings will
24 begin on 20th June. By that time the work investigation
25 of all the deaths will not be complete. The expert
0012
1 evidence and the first tranche of 70 cases will be
2 ready. I have decided that the hearing should begin in
3 this building while the preparatory work continues at
4 Gateway House. Much of the evidence gathered for Phase 1
5 is likely to be uncontroversial but some will require
6 explanation and clarification.
7 The expert witnesses will be called to give
8 oral evidence. The evidence of many lay witnesses will
9 be received in writing. Evidence received in writing
10 will be made public and will carry no less weight than
11 evidence received orally. It is proposed that initially
12 counsel to the Inquiry will select those witnesses who
13 are required to give oral evidence. Interested parties
14 may request that particular witnesses should be called.
15 If there were to be any disagreement about who should be
16 called, I will decide. The address of lay witness will
17 not normally be disclosed.
18 In Phase 1, it is proposed that those lay
19 witnesses who give oral evidence will be called by
20 counsel to the Inquiry. Some will be represented by
21 their own counsel who will have the opportunity to ask
22 further questions. All witnesses will be assisted by the
23 Inquiry team and everything will be done by the team and
24 by me to make the experience of giving evidence as easy
25 as is possible in the circumstances. At this stage, I do
0013
1 not wish to restrict questioning by counsel from
2 interested parties. I prefer to rely on the co-operation
3 and good sense of the experienced counsel who will be
4 appearing.
5 However, this is an inquiry following an
6 inquisitorial procedure and not a trial following an
7 adversarial procedure. There will be no
8 examination-in-chief, cross-examination, re-examination;
9 we will have questions. In general, counsel with the
10 Inquiry will ask them. Insofar as counsel for other
11 interested parties ask questions, they must not
12 duplicate those asked by counsel to the Inquiry. I very
13 much hope that it will not be necessary for me to lay
14 down procedural rules governing questions by other
15 counsel but of course I shall not hesitate to do so if I
16 find that time is being wasted.
17 During Phase 1 it is my present intention to
18 sit on four days of each week: Monday, Tuesday,
19 Thursday, Friday, from 10.00 in the morning until 1.00
20 and from 2.00 until about 4.15. That timetable will not
21 be adhered to rigidly. Some flexibility must be
22 maintained. It will not be possible to complete the
23 Phase 1 hearings before the summer recess, so as many
24 people will have taken holiday during August and
25 September, the hearings will be adjourned by 27th July
0014
1 at the latest and will not resume before 24th September.
2 We will then sit continuously until Phase 1 is
3 completed.
4 At the end of Phase 1 hearings there will be
5 an opportunity for represented parties to make
6 submissions. I then intend to make decisions in as many
7 cases as the evidence will allow and to write an interim
8 report of my findings before proceeding to the next
9 phase of the Inquiry. I am reluctant to forecast when
10 the interim report will be ready for publication.
11 However, I hope it will be published by the end of the
12 year. In a short while I shall hear applications from
13 representatives of those who wish to be recognised as
14 interested parties to the Inquiry. Insofar as I have not
15 had advance notice of those applications I may not be
16 able to give a decision today, although where I have had
17 notice, I hope to do so.
18 The first tranche of evidence for Phase 1 will
19 be disclosed to accredited representatives of interested
20 parties today. It is on a read-only CD-ROM. There will
21 be an opportunity this afternoon for training in gaining
22 access to and using the CD-ROM. Receipt of the evidence
23 in advance will be subject to an undertaking by the
24 recipient not to disclose the material to anyone other
25 than the relevant legal team and clients and to return
0015
1 to the Inquiry any material not then in the public
2 domain once the proceedings are over. The full terms of
3 the undertaking are available now from Henry Palin or
4 Ita Langan. I think copies have already been sent by fax
5 to those parties of whom we were aware were likely to
6 want to receive the CD-ROMs today.
7 Phase 2 of the Inquiry will cover the second
8 and third paragraphs of the terms of reference. The
9 Inquiry has consulted on potential issues and the list
10 of issues is published today. I hope those persons and
11 occupations whose activities will come under scrutiny
12 are already aware of the topics to be covered.
13 I can now say that it is my intention that
14 Phase 2 should be broken down into four stages. The
15 first will deal with post death procedures including
16 death and cremation certification, the role of the
17 police and ambulance services in the investigation of
18 sudden and unexpected deaths; the functions of the
19 coroner; and the roles of the Office of National
20 Statistics, the registrar, the coroner and health
21 authorities in the collection and analysis of mortality
22 rates.
23 The second stage will cover the March 1998
24 police investigation into the first concerns expressed
25 about Shipman.
0016
1 The third will deal with controlled drugs,
2 including the procedures for prescribing, dispensing,
3 storing and disposing of such drugs in community
4 medicine and the monitoring of those procedures by the
5 police and the Home Office.
6 In the final stage of Phase 2, the Inquiry
7 will deal with the systems for dealing with complaints
8 against general practitioners, whistle-blowing the
9 disciplinary control of general practitioners and the
10 monitoring of their work. When considering the ways in
11 which concerns can be brought to the attention of those
12 in authority, we will include in the Inquiry the
13 position of the staff employed in Shipman's practices
14 and staff employed in sheltered accommodation and
15 residential and nursing homes. I am satisfied that the
16 actions of those persons in such positions fall within
17 the terms of reference and I have authorised to include
18 them in their investigations for phase 2.
19 I do not propose to say a great deal more
20 today about the conduct of Phase 2, save that I do not
21 envisage that it could begin until January 2002. I shall
22 hold another preliminary meeting to deal with procedural
23 matters nearer the time. I shall then issue procedural
24 directions in the light of the experience gained during
25 Phase 1.
0017
1 In Phase 3, the Inquiry will consider
2 proposals for change to the existing systems. I shall
3 invite the interested parties to make written
4 submissions, possibly accompanied by a further expert
5 report which will then be discussed at a series of
6 public seminars at which there can be an exchange of
7 views.
8 I want to say a few words about inquests. As
9 many of you will know, the South Manchester Coroner, Mr
10 John Pollard, has conducted inquests into the deaths of
11 27 former patients of Harold Shipman. In 25 cases he has
12 reached a verdict of unlawful killing and in two he
13 brought in an open verdict. All those cases have
14 resulted in amendment of the death certificate. Other
15 families may be wondering whether it would be possible
16 for them to obtain an amended death certificate if the
17 Inquiry concludes that their relative was killed by
18 Shipman. The Home Secretary has granted permission to
19 the coroner to open inquests into about 260 further
20 deaths. However, those deaths are among those which will
21 be investigated by the Inquiry. The Lord Chancellor has
22 now made an order under section 17(a) of the Coroners'
23 Act 1988 directing the coroner to adjourn those inquests
24 when opened until the findings of this Inquiry are made
25 available.
0018
1 I can assure the families that once my interim
2 report is published, the findings will be available to
3 the coroner and he will be able to arrange for any
4 necessary amendment of a death certificate without the
5 need for a full inquest. I believe that this procedure
6 will be welcomed by the families which should provide a
7 speedy answer to the families' questions without need
8 for an individual request in each case and for many
9 families avoiding the need to give oral evidence in
10 public.
11 I want to now say something about the
12 broadcasting of the Inquiry proceedings. A few weeks
13 ago, the Inquiry received applications from a number of
14 broadcasting organisations seeking permission to film
15 the hearings. Although I recognise that there are some
16 good public interest reasons why filming should be
17 allowed, I decided to refuse. My principal reason was
18 that I thought that filming would increase the pressure
19 on the relatives and friends of former patients who will
20 have to give evidence. I recognise that these witnesses
21 will find giving evidence stressful and that the
22 recollection of the events which they will have to
23 recount will be deeply distressing for them. Although
24 the proceedings will have to be filmed for the purposes
25 of CCTV relay to Hyde, my firm view was that those
0019
1 vulnerable witnesses should not be exposed to the much
2 wider publicity which would result from broadcasting by
3 television and possibly on the Internet.
4 Since that decision was communicated, I have
5 given the matter further thought. Those witnesses about
6 whom I was principally concerned will give the most
7 sensitive parts of their evidence during Phase 1 of the
8 Inquiry. In the second phase, those relatives and
9 friends of former patients who give evidence will not be
10 speaking directly about the deaths of their loved ones.
11 Their evidence will be concerned with the procedures for
12 death certification, opportunities for whistle-blowing
13 and topics of that kind. They will be speaking of
14 matters that may be less distressing for them than those
15 in Phase 1. On the other hand, in Phase 2 there will be
16 many witnesses who, although not likely to be
17 emotionally distressed by the proceedings, may be very
18 anxious indeed about the questions they will be asked.
19 So it seems to me that different considerations arise
20 for this decision in respect of Phase 2. There are still
21 good reasons why the proceedings should not be
22 broadcast. However, it seems to me that arguments are
23 more finely balanced. I have decided, therefore, that I
24 should reconsider my decision to refuse permission and
25 that before reaching a final decision I should allow an
0020
1 opportunity for consultation. Accordingly, I am prepared
2 to receive views from anyone who is likely to take part
3 in the Inquiry whether as a witness or as a
4 representative. Although at present I remain of the view
5 that broadcasting would not be appropriate during Phase
6 1, I am prepared to receive submissions on Phase 1 as
7 well as phases 2 and 3. I would like to receive these in
8 writing by the end of May. I would like to hear from as
9 many individuals as possible. A short note is all that
10 is required, but those who are represented may like to
11 give their views directly or through their
12 representatives. If anyone wants to give his or her view
13 through Victim Support, that too is entirely acceptable.
14 I will send my decision to the broadcasting
15 organisations who have applied and I will announce it
16 publicly. I hope to do so by 12th June.
17 I am sure that many of you will would like to
18 know when the final report will be ready for
19 publication. The answer is that I do not know and that
20 any attempt at a reply will entail an element of gazing
21 into a crystal ball. However, I am prepared to say that
22 I would very much like to deliver my report to the
23 Secretary of State during the spring of 2003. That is
24 all I want to say formally and I am now going to hear
25 applications from those parties who claim to have an
0021
1 interest in the proceedings and who want to apply for
2 rights of representation. I am already aware of some,
3 but I wish to hear from them so that I can formally put
4 them on the record. There may be others of whom I am not
5 yet aware. Some interested parties may wish to take part
6 in all phases of the Inquiry, some may prefer to
7 restrict their participation to one or two phases. I
8 would like to know where each interested party stands in
9 that respect, today if possible but otherwise in the
10 near future. I would also like to know what level of
11 representation will be sought and the identity of any
12 counsel already instructed. Some interested parties will
13 wish to apply for funding; others I hope will accept
14 that it is appropriate that they bear their own costs.
15 I was proposing to start with Mr Lissack whom
16 I do not recognise but I do know that he will be here,
17 and I am aware of his forthcoming application.
18 MR LISSACK: I hope I can heard, otherwise I am
19 pointlessly clutching a microphone. That is not my fault
20 so can I just keep talking pointlessly until someone can
21 hear what I say.
22 DAME JANET: Please could the roving microphone be
23 activated or turned up?
24 MR LISSACK: I am instructed on behalf of the Tameside
25 Families Support Group instructed by Alexander Harris
0022
1 and appear together with my learned friends Mr Paul
2 Gilroy, Mr Andrew Spink and Miss Harriet Jones. We have
3 four applications that we would like to make, please.
4 The first concerns procedure but I wonder
5 whether it would be convenient if I was to preface those
6 four applications by a word or two about our position
7 that may cast light upon the applications make in due
8 course.
9 DAME JANET: Certainly.
10 MR LISSACK: Thank you very much. The death of each of Mr
11 Shipman's victims is, of course, a private tragedy for
12 the family concerned. That so many died at his hands has
13 led directly to this Inquiry being set up and turned
14 many private tragedies into a matter of public concern.
15 The families that we represent fully understand that
16 today is neither the time nor the place for accusation
17 or recrimination or prejudging the issues or the
18 conclusions which will be reached upon them. This is a
19 time for measured and quiet reflection on the months
20 which lie ahead. Our clients appreciate the weight of
21 the burden on this Inquiry. It is charged with
22 establishing how, the why and the what: How many did Mr
23 Shipman murder? How and why did the system so terribly
24 fail Mr Shipman's victims? What changes, if any, must be
25 made as to how the medical profession supervises,
0023
1 manages and peoples its own and regulates general
2 practice. What does this case tell us about the changes
3 which must be made to the way other agencies interact
4 and mesh together so as to ensure that this cannot ever
5 happen again to protect the public from the prospect of
6 another Harold Shipman.
7 On this first day of sitting of this Inquiry,
8 the families that we represent have every hope and
9 confidence that this Inquiry will indeed discharge its
10 onerous task and that its investigations will be full,
11 fair, fearless and constructive. Our clients are
12 determined that both through us and directly from them
13 in their oral and written evidence, you will have all
14 the assistance that they can give you in your search for
15 the truth and in your recommendations as to the future.
16 Our clients are desperately concerned that from each of
17 the individual calamities should come some general good.
18 Nothing can bring back the victims of this murderer and
19 we are not here for retribution, but we respectfully
20 submit that we can be of substantial constructive
21 assistance to this Inquiry which we know wishes and
22 intends to contribute to the future shape of healthcare
23 in this country.
24 There can be no memorial more fitting for the
25 dead or their families than for whom we act, for each to
0024
1 be able to say at least they, and we, did not suffer in
2 vain. That, I hope, accurately sets the tone on behalf
3 of our clients for this inquiry and it is a tone we hope
4 to maintain.
5 DAME JANET: Thank you, Mr Lissack.
6 MR LISSACK: May we turn, please, to procedure. You have,
7 I hope, had an opportunity to see the written
8 submissions that we have put in.
9 DAME JANET: I have; I was very grateful.
10 MR LISSACK: Thank you very much. May we express our
11 gratitude to you for the matters you have already made
12 clear this morning which puts a line through
13 three-quarters of it and I need only address you, I am
14 glad to say, on three short points.
15 If I may start with a most respectful
16 question: Are the times and days of sitting fixed or are
17 you open to persuasion?
18 DAME JANET: I am aware, Mr Lissack, that you have
19 expressed a preference that the four day week which we
20 all agree is as much as anybody can cope with, because
21 of the need to do reviewing and preparatory work, I know
22 that you would prefer we should sit Monday to Thursday
23 and not on Friday and I have considerable sympathy for
24 you and your team, particularly as I know you do not
25 live in Manchester and I recognise the desirability from
0025
1 being able to return to base for your preparation. I
2 have discussed this matter at some length with Miss
3 Swift. Her strong preference is that we should take
4 Wednesday off as a general rule. I have felt that I
5 should give preference to her view because, as you will
6 appreciate I know, she will carry the main burden of
7 advancing the evidence.
8 MR LISSACK: Indeed.
9 DAME JANET: The decisions that I have made up to now I
10 certainly do not want to give the impression they are
11 set in stone and in any event they only apply to phase
12 one; everything that I said about procedure only applies
13 to Phase 1. It seems to me sensible to learn from our
14 experience in Phase 1 before we make decisions about
15 Phase 2, but in any event the decisions may be different
16 ones because the material will be different.
17 MR LISSACK: Yes. I do not propose to detain
18 you by making any submissions further as to which day of
19 the week we do not sit. It must be a matter first and
20 foremost for you and then for counsel of the Inquiry who
21 I fully appreciate carries the large share.
22 DAME JANET: Could I just say this: There may be some
23 weeks in which we do sit on Wednesday: For example if we
24 had an expert witness at the table on a Tuesday
25 afternoon, it would be inappropriate to go over to
0026
1 Thursday so I do want to warn the representatives that
2 they may be required to work on the Wednesday here on
3 occasions but I hope we will be able to foresee those
4 eventualities at least a day or two in advance.
5 MR LISSACK: Thank you very much. May I just trespass on
6 your endless patience asking about the hours of sitting?
7 DAME JANET: Yes.
8 MR LISSACK: The hours of sitting, as you know we offered
9 as a thought 9.30 through to 1.30 with two short breaks
10 based upon, if I may say so, experience of 3 recent
11 inquiries and the knowledge of the burden that would be
12 imposed above all on counsel to the Inquiry who will
13 have to do all that work after 4.15 in the afternoon on
14 the present proposal and we would respectfully invite
15 reflection upon that issue and I put it no higher than
16 that.
17 DAME JANET: I think almost certainly there will have to
18 be an adjustment of those hours when we reach Phase 2.
19 Our present view -- and I do not mind explaining to you
20 our thinking --is that Phase 1 will be enormously
21 voluminous but relatively straightforward in forensic
22 terms. We are very anxious to make good progress with
23 that and we think for the time being that we can cope
24 with what I would describe as an ordinary court day. So
25 we propose to impose upon ourselves those rather longer
0027
1 hours than you are suggesting. If it proves too much, if
2 counsel is unable to make preparation, we shall adjust
3 it. We can learn by experience and change things as we
4 go along. Nothing is set in stone, but that is how we
5 would like to start.
6 MR LISSACK: Thank you very much. May I move on to the
7 second matter which is 2.3 of our written submissions:
8 Library.
9 DAME JANET: Yes.
10 MR LISSACK: Forgive me if I was not listening carefully
11 when you dealt with this point but I think that there
12 was no mention of a library of material. May I just
13 explain that we have submitted for the Inquiry's
14 consideration that it would be helpful to maintain a
15 library in written and electronic form which interested
16 members of the public may have the right to visit the
17 library containing only that evidence in the public
18 domain obviously and that that is something which should
19 be available to our clients.
20 May I expand a little. This is quite a deeply
21 felt concern on behalf of some of those who I appear
22 for. They wish to have private access to the evidence in
23 a place within or close by this building.
24 DAME JANET: We had a discussion yesterday about this
25 proposal. Our present view is that it would present
0028
1 considerable logistical difficulties to provide both
2 forms, hard copy and electronic libraries. Our present
3 view is that we should provide one at least or as many
4 as are necessary terminals with assistance for those who
5 are unfamiliar with electronic equipment so that anybody
6 who wants to have a look at a particular document in
7 their own time would be able to do so. The document
8 could be put on screen for them, copied if they wanted
9 and they could take it away.
10 Now, having said that, people really would
11 have to be reasonable about asking for copies; it really
12 would not do for a member of the public to come along
13 and say: I want a personal copy of the document that is
14 700 pages long. It simply is not acceptable. But we do
15 recognise the desire of people to have an opportunity to
16 look at a document in their own time and possibly to
17 take it away. So we do not want to have to copy every
18 single document to produce a hard copy library, but we
19 do intend to make that facility available. Again, if
20 that is not satisfactory, we may have to think again. As
21 I say, these things are likely to develop as time goes
22 on.
23 MR LISSACK: May I leave my submission there, thank you
24 very much for that clarification. I am very grateful.
25 Third and final matter on procedure is point 3
0029
1 in our submissions: Opening statements. It is merely a
2 request for information. Whether it is presently
3 envisaged that after counsel for the Inquiry has opened
4 the Inquiry making that assumption, that parties
5 interested in Phase 1 will be given the opportunity to
6 open.
7 DAME JANET: In principle, I of course am prepared to
8 allow representatives of interested parties to make
9 opening statements. However, in respect of Phase 1, it
10 did appear to me that there would not be perhaps a great
11 deal that could be usefully said because it is so much a
12 factual inquiry. In Phase 2 I think things will be very
13 different and there will be many parties who want to set
14 out their position at the outset. I cannot myself at the
15 moment envisage what position parties would take in
16 respect of phase 1.
17 Mr Lissack, if you particularly wish to make
18 an opening statement, if you would tell Miss Swift and
19 let her know roughly how long you would like to be, I
20 know she is anxious about the timetabling of witnesses
21 at the very beginning for particular reasons because we
22 hope to begin with some expert witnesses so it would
23 assist her if you could let her know how long you will
24 be and that goes for anybody else who was minded to make
25 an opening statement.
0030
1 MR LISSACK: I have already indicated to Miss Swift this
2 morning that I thought 20 minutes to half an hour would
3 be the most that we would want to say and it may well be
4 that it will whittle away to nothing.
5 May I move then to the second of the four
6 matters I wish to mention which is representation or
7 accreditation. You will have seen how we put it on page
8 4 of our submissions and we wish to have the right to
9 appear throughout this Inquiry in all three phases. Do I
10 need to develop that?
11 DAME JANET: I do not think so. I think it is abundantly
12 plain why you would want to do that and I am aware of
13 course also that it is one of your clients who
14 instigated this public inquiry so it is only natural
15 that they would wish to be represented throughout.
16 MR LISSACK: Thank you. That then goes to the third point
17 which is funding set out on page 5 and 6 of our
18 submissions.
19 DAME JANET: I understand that the nuts and bolts of that
20 have been agreed between Miss Alexander and Mr Palin and
21 I am therefore prepared to recommend those agreed
22 matters.
23 MR LISSACK: Thank you very much.
24 DAME JANET: I accept what you say at paragraph 2.2; it
25 is not the number of barristers that is of significance,
0031
1 it is the hours of work that are done at public expense
2 and I am sure that you and those instructing you
3 appreciate that any bill is bound to be subject to
4 scrutiny in the ordinary way.
5 MR LISSACK: Of course and as I recognise, in point 1 of
6 the points the proposition which follows is of course
7 under constant scrutiny and in the event of any
8 questions arising are honoured in practice that can be
9 dealt with immediately there and then and one of the
10 great virtues of the Public Inquiry it is in the public
11 gaze and quite literally, public money being spent we
12 will be careful about how we do it.
13 That then concludes matters raised in my
14 submissions. May I just mention the fourth and final
15 point, which I am afraid I did not cover in writing,
16 forgive me. It is a concern over the press. This a
17 matter which has been a constant concern to some of
18 those amongst the very large number that we represent.
19 The press interest in this case, as you said earlier on,
20 has been worldwide and many of our clients, for whom
21 this is also a private matter, do not really wish to be
22 troubled by the press. Respecting the legitimate public
23 interest, though, through reporting of these
24 proceedings, may I simply say this and then I am not
25 sure what you can do about it, if I may put it in that
0032
1 way, that on behalf of our clients we would welcome
2 enquiries from the press being channeled through the
3 solicitors instructing us. They have somebody in their
4 employ who is known to many of the press already as a
5 point of contact. If the press wish to have individual
6 interviews with clients of ours, that can be arranged
7 with those who wish to be interviewed thereby ensuring,
8 firstly, that there is no unseemly incident of the sort
9 that sometimes happens where enthusiastic journalists
10 chase a reluctant witness; and, secondly, that nobody is
11 frightened of coming forward for fear that by being a
12 witness they then lay themselves open to the gaze of the
13 general public through publicity.
14 DAME JANET: That, of course, is why I was anxious to
15 explain that the private address of a witness will not
16 be disclosed. When they give evidence, it will not be
17 disclosed. It will not be on their statement.
18 MR LISSACK: We are perfectly willing to assist the press
19 in their legitimate interest being maintained but we
20 invite them to contact us in an orderly fashion.
21 DAME JANET: I have little doubt they will hear what you
22 say, Mr Lissack.
23 MR LISSACK: If they listen; we will see.
24 DAME JANET: Of course, it is entirely a matter for your
25 clients what relations they have with the press and what
0033
1 assistance they give.
2 MR LISSACK: Thank you very much. May I just check there
3 is nothing else I need mention. (Pause) Thank you.
4 DAME JANET: Now, Mr Shorrock.
5 MR SHORROCK: May it please you ma'am, I have been
6 instructed by the Greater Manchester Police together
7 with Miss Kate Blackwell to represent their interests.
8 Sandra Pope is the solicitor for the instructing GMP
9 Solicitor for these purposes.
10 We would like to appear throughout in all three
11 phases, although I anticipate our presence in Phase 1
12 will merely be a token presence. I feel that we
13 probably need to have a watching brief throughout that
14 period. I do not wish to say any more other than the
15 attitude of the Greater Manchester Police throughout
16 since the Inquiry has been set up has been an
17 instructive one and one where we seek to co-operate
18 entirely with the Inquiry team. That, I believe, we have
19 done so far and will continue to do so.
20 DAME JANET: Indeed very much so. The team have been very
21 grateful for the speed with which the police evidence
22 and information has been transmitted to us and other
23 assistance of that kind.
24 MR SHORROCK: I am very grateful for those words. I do
25 not think I need say anything further.
0034
1 DAME JANET: Thank you very much. Mr McDermott, I know
2 you have an interest. We have come to the end of those
3 who I know and recognise who wish to apply.
4 MR McDERMOTT: Jeremy McDermott, leading counsel
5 instructed for West Hyde Health Authority instructed by
6 Mr Charles Howarth of George Davis & Co and my junior Mr
7 David Edwards.
8 Ma'am, we would like to take this quite shortly.
9 We would like to be represented throughout the Inquiry.
10 The level of that representation may vary but certainly
11 both in Phase 1 and particularly in Phase 2 there are
12 obvious interests to us as the Health Authority
13 responsible for this area. Again, like Mr Shorrock, we
14 are anxious that as an Authority and, I believe, as
15 individuals, to do all that we can to assist the Inquiry
16 in its task.
17 DAME JANET: Thank you, Mr McDermott. Who else
18 wishes to apply?
19 UNIDENTIFIED SPEAKER FROM THE FLOOR: I appear before you
20 as Solicitor to the General Medical Council. Madam, we
21 would like to be represented as an interested party
22 throughout all phases of the Inquiry, although clearly
23 it is anticipated that in the fact-finding part, Phase
24 1, we would likely merely be watching, as in the case of
25 my learned friend for the Health Authority. Madam, I am
0035
1 content to deal with matters briefly unless there is
2 anything I can help you with.
3 DAME JANET: Thank you very much.
4 MR HOLROYD: Madam, Nick Holroyd, Russell Jones & Walker
5 solicitors. My firm have received independent
6 instructions from Inspector David Smith, a police
7 officer of the Greater Manchester Police. My learned
8 friend, Mr Shorrock, is aware of my interest. On his
9 behalf I would ask that Inspector Smith be granted
10 separate and independent legal representation throughout
11 the Inquiry. I do accept that perhaps his interests are
12 most properly represented in the second stage but I
13 would perhaps repeat Mr Shorrok's comments about stage 1
14 by way of watching brief. If you were minded to grant
15 representation to Inspector Smith as an interested
16 party, I would indicate it would be my intention to
17 instruct a junior counsel, I think, properly
18 throughout proceedings and I would ask you to consider
19 in his case that costs be ordered in his favour.
20 DAME JANET: Yes. I was not aware that there would be an
21 application for funding on behalf of Mr Smith and I am
22 not going to make a decision about that today. It does
23 seem to me, just thinking about it very briefly, that he
24 has a particular interest in respect of part of Phase 2,
25 but whether I could justify separate representation for
0036
1 him at public expense during Phase 1 and Phase 3 I am by
2 no means sure. So I will consider your application.
3 Is there anything further that you want to say,
4 either now or in writing, in support of the application
5 given my initial reaction to it?
6 MR HOLROYD: Madam, if I can say that I clearly make the
7 application in respect of Phase 1 and Phase 2
8 particularly for costs but, clearly, if you are not
9 minded to award costs in respect of Phase 1, I would
10 nevertheless hope that you would be in agreement that he
11 should have representation even if that would be at
12 other expense.
13 DAME JANET: I would not object to representation at any
14 stage of the Inquiry if those who are in a position to
15 support him are prepared to support it. The limitation
16 that I am considering relates only to funding. I am sure
17 you understand that I have a duty not to spend more
18 public money than is properly appropriate. It seems to
19 me your client should be entitled to funding at least
20 for stage 2 of Phase 2 but just considering, for
21 example, stage 4 of Phase 2, I cannot at the moment see
22 any reason why he would need representation at all
23 during that time. If he chooses to have it, I would not
24 stop him.
25 MR HOLROYD: I do not propose to argue further.
0037
1 DAME JANET: Can we leave it like that for the moment. If
2 you want to put in any other submission, do so in the
3 next day or two; otherwise I will make a decision some
4 time next week.
5 MR HOLROYD: I am grateful. I would only endorse the
6 fact that, despite seeking independent representation,
7 it is Inspector Smith's full intention to co-operate
8 fully with the Inquiry.
9 DAME JANET: I am grateful for that. Thank you very much.
10 Now is there anybody else?
11 MISS LEVER: I represent Bhailok Fielding Solicitors. We
12 represent only one of the estates of the victims of
13 Harold Shipman but --
14 DAME JANET: Who do you represent?
15 MISS LEVER: Maureen Ward, ma'am. She was one of the 15
16 victims for whom Shipman was convicted.
17 DAME JANET: Who is your client?
18 MISS LEVER: Christine Whitworth, who is a personal
19 representative of that lady. I would therefore expect
20 that Miss Whitworth's evidence will possibly be of
21 relevance or probably will be all relevant at least in
22 Phase 1 of the Inquiry and we would ask for
23 representation purely at the times when Miss Whitworth's
24 evidence is required. We do not expect her to have
25 representation throughout but as and when evidence in
0038
1 respect of Miss Ward is being considered directly, we
2 would ask for the right to have representation at that
3 time and for public funding at that time.
4 DAME JANET: Maureen Ward having been one of those
5 victims in respect of whom Shipman was convicted,
6 I think it is unlikely that there will be any live oral
7 evidence relating to that death. Her death was very
8 fully investigated, as you know, at the trial and I do
9 not think that anything this Inquiry could do could
10 throw more light upon that case than is already known.
11 So it would not be our intention to have live evidence
12 about the death of Miss Ward, I do not think.
13 MISS LEVER: Nonetheless, Miss Whitworth made a statement
14 and it is possible of course that she will be called.
15 DAME JANET: In Phase 2.
16 MISS LEVER: Yes.
17 DAME JANET: I had understood that the Solicitor to the
18 Inquiry had agreed that when the statement was given, a
19 representative of your firm should be present. I think
20 what we will do is leave it at that for the moment. You
21 have that funding and when we see what the statement
22 reveals we can see whether any further representation
23 will be necessary.
24 Anybody else?
25 UNIDENTIFIED SPEAKER FROM THE FLOOR: I am here for the
0039
1 Royal College of Nursing and I would simply ask for our
2 representative to be present at the hearings. We
3 anticipate that any witnesses from our College would be
4 called for Phase 2 but not for the first phase.
5 DAME JANET: Yes.
6 UNIDENTIFIED SPEAKER FROM THE FLOOR: That would be we
7 would be able to make at that stage any submissions in
8 relation to costs that are appropriate.
9 DAME JANET: Yes, very well. Are you seeking to be
10 recognised during Phase 1?
11 UNIDENTIFIED SPEAKER FROM THE FLOOR: Yes madam.
12 DAME JANET: Does that include an application to receive
13 the documentation in the CD-ROM in advance?
14 UNIDENTIFIED SPEAKER FROM THE FLOOR: Yes, it does madam.
15 DAME JANET: Could you give me one or two names of people
16 who are concerned?
17 UNIDENTIFIED SPEAKER FROM THE FLOOR: We are not too sure
18 of any members coming forward at this stage but because
19 of what you said this morning, we might anticipate that
20 staff from the practice or from the nursing homes may
21 indeed be called to the Inquiry and they would need
22 representation from the Royal College.
23 DAME JANET: Yes. I think what I am going to do in your
24 case is to indicate that in principle if you have some
25 members who are likely to be involved to give evidence,
0040
1 then will you let us know.
2 UNIDENTIFIED SPEAKER FROM THE FLOOR: Yes, we will.
3 DAME JANET: In principle I am sympathetic to your
4 application but I think it should be based upon actual
5 members of whom you are aware who are going to be
6 involved, rather than on the expectation that some of
7 your members will be involved in my simply having a
8 watching brief for Phase 1 and if members are called for
9 Phase 2, we would make the relevant application for
10 costs at that stage.
11 DAME JANET: Yes, but you at the moment are asking for
12 advance disclosure as an accredited party would have and
13 I am not at the moment sure whether that is appropriate
14 during Phase 1. It may well be appropriate during Phase
15 2. I would have thought that in the next week or two you
16 are going to find out who is involved. UNIDENTIFIED
17 SPEAKER FROM THE FLOOR: Yes, if we receive names then we
18 will pass them on to the Inquiry.
19 JUDGE DEAN: Very well. Will you be content that you
20 should sign the undertaking at that stage and receive
21 the material on CD-ROMs when you have established that
22 you have some members involved?
23 UNIDENTIFIED SPEAKER FROM THE FLOOR: Yes.
24 DAME JANET: Very well. If you will communicate with
25 Mr Palin as soon as you are aware, then I will deal with
0041
1 your application then. Thank you.
2 Are you making an application? Would you like
3 to come forward. You can take a seat there if it will be
4 easier for you.
5 UNIDENTIFIED SPEAKER FROM THE FLOOR: I represent the
6 Co-op Pharmacy and we may have witnesses called from our
7 pharmacies in Hyde. I would like for them to have the
8 right to representation if they so wish.
9 DAME JANET: Throughout the Inquiry?
10 UNIDENTIFIED SPEAKER FROM THE FLOOR: Just in Phase 2.
11 DAME JANET: Does that include an application for funding
12 because representation is a different matter from
13 funding?
14 UNIDENTIFIED SPEAKER FROM THE FLOOR: We would want it to
15 cover reasonable costs if that is possible.
16 DAME JANET: I think what I will have to do is to
17 consider your application for funding (which I was not
18 aware until this moment was going to be made) in respect
19 of the various stages of Phase 2 because it does not
20 mean that your clients are very much involved in stage
21 3, they may be involved to some extent in stage 4 and
22 not stage 2, I would not have thought, and I am not at
23 the moment sure that they will be properly involved in
24 stage 1. So can we leave that open? If you would like to
25 send in a note of your submissions as to which parts you
0042
1 want to play a part in and why, then I will consider it
2 and let you have a decision. Thank you.
3 Is there anybody else who wants to make an
4 application for representation? After that, I am
5 prepared to take any questions or submissions from
6 members of the public on any matters that they may want
7 to raise. Is there anybody who wants to ask anything,
8 wants anything to be clarified? Well then, I was going
9 to suggest that representatives who are anxious to
10 obtain their CD-ROMs should congregate at the front when
11 I have called the meeting to an end and no doubt
12 provisions can be made and some assistance given. It may
13 be that you are all very familiar with the technology
14 and will only need a moment or two but there it is.
15 Thank you very much.
16 We will many of us no doubt meet again on 20th
17 June. I am grateful to you for coming this morning. I do
18 assure you that there is a great deal of work going into
19 this Inquiry. We are absolutely determined to get to the
20 bottom of things in every way we possibly can and to
21 ensure that changes are made for the future for the
22 better of patients and all the members of the public.
23 Thank you very much.
24 (The Inquiry adjourned until 20th June, 2001)
25
0043
| ||
 Back to Index |
||
Back to top
Published by The Shipman Inquiry
© Crown Copyright 2001