The Shipman Inquiry - Third Report - The Confirmatory Medical Certificate: Form C

The Certificate of Medical Attendant: Form B

Print Version

The Authority to Cremate: Form F

The Confirmatory Medical Certificate: Form C

The Choice of Doctor to Complete Form C
11.26	Despite conflicting views about its value, completion of the Confirmatory Medical Certificate (Form C) remains a requirement for all cremations where the coroner has not issued Form E following a post-mortem examination and/or the opening of an inquest. The doctor completing Form C receives a fee set at the same level (currently £45.50) as for Form B.
11.27	In order to be able to give a Form C, the certifying doctor must have been registered in this country for not less than five years. There has been ongoing controversy over the precise meaning of this requirement. The Regulations drafted in 1989 would have included within the five-year period any period of provisional or limited registration, provided that full registration had been achieved at the time the Form C was completed.
11.28	The Form C doctor must also be independent, to the extent that s/he must not be a relative of the deceased or a relative or partner of the Form B doctor. The word 'partner' is inappropriate to the completion of Form C in a hospital setting. Indeed, it may be inappropriate in some general practices, where no partnership exists. In the early 1980s, an official from the Home Office wrote to medical referees, explaining the Department's view that the Form C doctor should be 'demonstrably independent' of the Form B doctor. The Home Secretary was said to take the view that, in the case of a death occurring in hospital, the Form C doctor should not have been in charge of the patient or directly concerned in his/her treatment. The letter indicated that the 'spirit of the Regulations' would usually prohibit two doctors from the same firm (i.e. the hospital team responsible for the care of the patient) from completing Forms B and C in the same case. The Forms C issued by some crematoria contain notes at the head of the form, reflecting this view. No such note appears on the version of the Form C issued by the Dukinfield crematorium.
11.29	In practice, following a death in hospital, Form C is frequently completed by a pathologist, even where there has been no autopsy. Examination of the Dukinfield cremation register revealed that the same doctors employed at the Tameside General Hospital appeared time and time again as signatories of Forms C for deaths at the hospital. It appears that many hospitals have a small pool of doctors who complete Forms C on a rota system. The fees consequent upon membership of the pool can, it would appear, be quite significant. The Form C doctor must state the office (on the Dukinfield crematorium form, the word 'appointment' is used) that s/he holds.
11.30	When a death occurs in the community, it is usually the attending (Form B) doctor who chooses which of his/her colleagues should complete the Form C. Occasionally, the choice will lie with the funeral director. This might happen if the body is lying at a funeral director's premises some distance from the attending doctor's surgery and from his/her local colleagues. In those circumstances, it may be more convenient for the funeral director to select a Form C doctor who practises nearby and can attend to view the body without inconvenience.
11.31	Where the Form B doctor is responsible for the choice, it is often one of convenience. It is often the case that two doctors, or two general practices, operate a reciprocal arrangement whereby each signs the other's Forms C. Sometimes, the arrangement is more complex. Shipman, for example, used members of the Brooke Practice to sign virtually all his Forms C, save where it would have been geographically inconvenient for them to do so. Three members of the Brooke Practice reciprocated by asking Shipman to sign their Forms C; the other two members went elsewhere. The relationship between the Form B and Form C doctors is often a close one, sometimes social as well as professional. Such a relationship does not encourage the Form C doctor to approach the task of assessing the evidence about cause of death with a critical eye. Instead, s/he is likely to embark upon his/her assessment with a degree of confidence that all will be well. Indeed, even if s/he were tempted to probe (e.g. by inspecting the medical records), s/he is likely to be discouraged from doing so for fear of appearing to question the judgement (or even the honesty) of a friend and/or colleague. Furthermore, the doctor who undertakes a minute examination of the medical history before completing Form C may well find that, in the future, the task of completing Form C goes to one of his/her less conscientious colleagues.
11.32	Evidence heard by the Inquiry suggests that, although doctors are aware of and comply with the requirement that the Form C doctor should be independent of the Form B doctor, most doctors have not thought about the reasons for it and have not appreciated the need for true independence of mind. It appears that the requirement for independence is regarded by most as a technical matter.
11.33	As I have already explained in Chapter Three, the original concept of the Form C doctor was of a practitioner holding a prestigious public appointment that would have set him/her apart from the doctor who had completed Form B. Such a practitioner would - or should - have had the necessary detachment, authority and confidence to express disagreement with the Form B doctor, had s/he thought it right to do so. The position of such a practitioner would have been very different from that of a doctor in the community performing the same function today.
The Personal Inquiry
11.34	Before completing Form C, the doctor should examine Form B and make a 'personal inquiry' into the death. The nature of that 'personal inquiry' is identified in the series of questions posed in Form C. I have already set out (at paragraph 3.25) the eight questions that appear in Form C, as prescribed in the 1930 Regulations. I shall now consider these questions, and the way in which doctors answer them, in greater detail.
Questions 1-4
11.35	The first question asks whether the doctor completing Form C has seen the body of the deceased. The evidence received by the Inquiry suggests that, in the community setting, the Form C doctor always attends at the premises of the funeral director to view the body and complete Form C. Payment of the fee for completing the form is often made at the time of this visit.
11.36	The second question asks whether the Form C doctor has 'carefully examined the body externally'. Although that question is invariably answered in the affirmative, it is evident that the nature and extent of the examination undertaken varies widely. Often, conditions at the funeral director's premises are not conducive to a full and careful examination. At one of the Inquiry's seminars, Dr John Grenville, a general practitioner, gave a graphic account of the conditions that had prevailed at the premises of a busy funeral director when he had attended there the previous day. Those conditions would have made a thorough examination of the naked body difficult, if not impossible. Sometimes, the body to be examined is already dressed and in a coffin and there is a reluctance on the part of the funeral director to remove and strip it. According to the funeral directors who provided evidence to the Inquiry, the extent of the examination varies from doctor to doctor. Some carry out a thorough examination of the front and back of the body. At the other extreme, some confine their examination merely to checking the identifying tag or bracelet and viewing the face. The rest fall somewhere in between. The variations in practice described by the funeral directors were confirmed by the evidence of doctors accustomed to completing Forms C.
11.37	Even if carried out conscientiously, a physical examination will not, in the majority of cases, assist in diagnosing the cause of death. Signs of emaciation may tend to confirm a diagnosis of death caused by terminal cancer. Yellowing of the skin may indicate liver disease. Surgical scars may confirm a history of recent illness requiring operative treatment. But an examination will not shed any light on whether a person died of a coronary thrombosis, a cerebrovascular accident or as a result of any one of a number of other natural causes. It would not have led to a correct diagnosis of the cause of death of one of Shipman's victims. It may well be that it is because they realise that an examination is unlikely to yield any useful information that many doctors regard it as a mere formality which can safely be dispensed with.
11.38	A thorough physical examination, made in appropriate conditions, could be expected to reveal signs of violence such as wounds, bruising and (possibly) petechiae (the tiny haemorrhages which are often observed after a death from suffocation or strangulation) or signs of possible neglect, such as pressure sores and malnutrition. There is no way of knowing how frequently such signs have gone unnoticed in the past because no proper physical examination has taken place. However, the examination by the Form C doctor is not the only opportunity to observe signs of violence or neglect. In many (if not most) cases, the funeral director will see the body unclothed in the course of preparation for burial or cremation. He or she is in a good position to notice any abnormal signs and the Inquiry was told that it is not unusual for a funeral director to refer a death to the coroner if abnormal signs are observed. Some of the doctors who gave evidence suggested that a representative of the funeral director would usually be present when they attended to view the body and they would expect that person to mention any unusual signs that had been noticed.
11.39	The third question on Form C asks whether the certifying doctor has made a post-mortem examination. Unless the doctor is a pathologist who has undertaken a hospital post-mortem, this will rarely be answered in the affirmative. The Inquiry is aware of one general practitioner in Hyde who regularly gave an affirmative answer to this question, on the basis that an external examination made after death was, strictly speaking, 'a post-mortem examination'. He was, however, the exception. Where a hospital post-mortem has been carried out and the result is known to the Form B doctor, this should of course be indicated in response to question 8A of Form B and no Form C is then necessary. Fewer hospital post-mortems have been carried out in recent years and they are, in any event, rare where a patient dies in the community.
11.40	Question 4 of Form C asks whether the certifying doctor has seen and questioned the Form B doctor. For practical reasons, such conversations frequently take place on the telephone and doctors answer the question in the affirmative even when they have not met the Form B doctor face to face. Forms B and C are delivered to, or collected by, the Form C doctor, who takes them (in fact, they are often joined in a single document in booklet form) to the funeral director's premises. Alternatively, the forms may be left with the funeral director for the Form C doctor to view when s/he attends.
11.41	The evidence received by the Inquiry suggests that some discussion between the certifying doctors invariably takes place. Most Form B doctors know the type of explanation of the clinical history which is expected of them and provide the necessary information.
11.42	It is clear from the evidence available to the Inquiry that it is not usual practice for a doctor completing Form C to inspect the deceased's medical records before giving the certificate. Dr Ian Morgan, Medical Referee at the Robin Hood crematorium, Solihull, told the Inquiry that to request to see another practitioner's medical records in a general practice setting would imply a degree of suspicion. It would not be seen as a neutral enquiry. He contrasted that with the position at the hospice where he is Medical Director. There, the records are left out, as a matter of course, for the Form C doctor to examine. In my view, this is good practice.
11.43	There is no statutory requirement that any of the questions contained in Form C must be answered in the affirmative if a cremation is to be authorised. The Regulations drafted in 1989 would have introduced such a provision in relation to questions 1, 2 and 4; those Regulations never became law. However, as I have already said, the version of Form C issued by every crematorium in the country (so far as the Inquiry is aware) contains a note to that effect.
11.44	Affirmative answers to questions 1, 2 and 4 usually indicate that the doctor has seen the deceased's body and examined it to a greater or lesser extent. That examination may have provided confirmatory evidence of the diagnosis of cause of death (e.g. in the terminal cancer case). More likely, the examination will have been too superficial to reveal anything of significance, or the cause of death will be one that would not give rise to evidence, even on a thorough physical examination. Thus, the examination will have provided no independent evidence upon which the Form C doctor can rely. The Form C doctor will also have heard the account of the clinical history and the reasons for the diagnosis of cause of death, as propounded by the Form B doctor. That account will not have been confirmed by inspection of the medical records.
11.45	The pathologist who has given an affirmative answer to question 3 will, of course, be in a completely different position. He or she will have undertaken an autopsy and will have had the opportunity of comparing the findings of that examination with the clinical history given by the Form B doctor.
Questions 5-8
11.46	Questions 5-8 of Form C ask whether the certifying doctor has seen and questioned:
	any other medical practitioner who attended the deceased any person who nursed the deceased during his/her last illness any person who was present at the death any of the deceased's relatives any other person.
	The doctor is also asked to give names and addresses and is asked whether s/he has seen the person(s) alone.
11.47	The obtaining of evidence from a source separate and independent from the Form B doctor was an important element of the system described in the 1903 Departmental Committee Report. It constituted the only effective check on the Form B doctor. It seems, however, that the significance of this evidence, and therefore the importance of questions 5-8, was rapidly forgotten, certainly after the relaxation of the rules (as a result of the 1930 Regulations) governing those qualified to complete Form C. Even in 1935 (see paragraphs 3.24 to 3.29), it was reported that some Form C doctors invariably failed to question anyone except the Form B doctor; indeed, it was claimed that some did not even do that. The Home Secretary's letter of that year, which emphasised the need for affirmative answers to questions 1, 2 and 4, made no mention of questions 5-8.
11.48	From time to time over subsequent years, as I have explained in Chapter Three, various individuals and organisations drew attention to the fact that the investigations referred to in questions 5-8 afforded the Form C doctor an important opportunity to obtain evidence from an independent source and therefore provided an essential safeguard. In 1960, Dr John Havard, then Assistant Secretary of the BMA, claimed on behalf of the Association that potential criminals were deterred by the knowledge that an independent doctor questioned relatives, nurses and other persons in every case. In reality, even at the time Dr Havard made that claim, it is evident that many members of the BMA were carrying out no such questioning.
11.49	Despite these references, attention was more generally directed at the reported failure of doctors to carry out even the investigations required in order to answer questions 1, 2 and 4 affirmatively and at ways (e.g. by means of the draft Regulations circulated in 1962) in which they might be compelled to carry out their duties (i.e. to see and carefully examine the body and to question the Form B doctor) properly.
11.50	The Brodrick Committee, which reported in 1971, also recognised the potential importance of the questioning of persons other than the Form B doctor. The Committee found that many Form C doctors were not taking the opportunity to carry out their own investigations. This fact, coupled with evidence that the physical examination carried out was frequently inadequate or non-existent, led the Committee to the conclusion that Form C was valueless and should be abolished as soon as possible. The Committee does not appear to have considered the imposition of a requirement that independent investigations should be made in every case. It may be that members of the Committee did not believe that, even with such a requirement, effective investigations would be made. In any event, their view must have been coloured by the fact that they did not accept that there was a real risk of cremation being used to conceal evidence of homicide.
11.51	In July 2002, the Inquiry received a letter from Dr Derek North, a general practitioner from Gosport, Hampshire. He enclosed a copy of the Form C used at the Portchester crematorium, which serves his local area. He pointed out the note on that form which reads as follows:
	'The Medical Referee requires that at least one of the questions No. 5-8 should be answered in the affirmative.'
11.52	Dr North had visited the Inquiry website and noticed that the cremation forms from the Dukinfield crematorium that appeared there did not bear a similar note. In his letter, he commented as follows:
	'This simple requirement on the crem[ation] form I am sure would have made it much harder for Harold Shipman to commit his murders. I and my partners have never signed a form C without having answered at least one of those questions in the affirmative. I have been a GP for 20 years and I have always ensured that I could answer one of the questions in the affirmative. I was quite amazed to see that as recently as 1997 that [sic] Doctors filling in form C were answering No to all of those questions'.
11.53	The Inquiry had previously been aware that some of the doctors practising in Todmorden in the 1970s had, before completing Form C, questioned relatives of the deceased in most cases. This had become evident when examining the cremation forms completed by Shipman during his time at Todmorden. Cremation forms dating from his time in Hyde revealed very few instances of a Form C doctor questioning anyone other than Shipman. The Inquiry team assumed that the practice of questioning persons other than the Form B doctor had lapsed with time.
11.54	Once Dr North's communication had been received, further enquiries were made. They revealed a number of other crematoria with a similar requirement to that imposed by the Portchester crematorium. Enquiries of those crematoria have shown that, in some cases, a marginal note setting out the requirement has appeared on their Forms C for as long as anyone can remember. However, the Halton Medical Referee, Dr David Robertson, was responsible for its introduction at the Warrington crematorium, and (with a colleague) at the Widnes crematorium, in the 1990s. He gave his reasons for the change as:
	'... dissatisfaction on my part with the standard of information being provided and the level to which many forms failed in my view to accurately confirm the facts on Form B. There was no third party corroboration and the only dialogue reported was that between the two doctors. Potentially scope was present for abuse and collusion.'
11.55	The Darlington Medical Referee, Dr Louis Rosin, introduced a similar requirement in about 1970, for similar reasons. Conversely, the Medical Referee at the Carlisle crematorium, Dr Peter Tiplady, removed the requirement recently, after objections from doctors from neighbouring areas who were not accustomed to it.
11.56	Enquiries have been made of those employed at the crematoria concerned, as well as of the Home Office and the Cremation Society of Great Britain, in order to discover whether any advice or guidance was issued which may have prompted the decision by some crematoria to impose the requirement of an affirmative answer to one of questions 5-8. No evidence of any such advice or guidance has been found although the similarity of the wording on the forms issued by different crematoria strongly suggests a common source. It seems that officials currently employed in the relevant section of the Home Office were unaware that any crematoria imposed this requirement until informed by the Inquiry.
11.57	Investigations by the Inquiry suggest that, where a local requirement to answer one of questions 5-8 in the alternative is imposed, it is complied with in all but a few cases; those few cases may well relate to deaths occurring in neighbouring areas where no such requirement exists. Often, a medical referee will not enforce the requirement where a doctor has completed a Form C issued by a different crematorium in good faith. Such a doctor may not realise that there is a local requirement at the crematorium where the cremation is to take place. Where no local requirement is in force, questions 5-8 are answered in the negative in most cases. Crematoria in one area have had a requirement since about 1996 that one of the questions 6-8 should wherever possible 'contain details of an enquiry sufficient to help satisfy the Medical Referee that sufficient enquiry has been made'. The Medical Referee has told the Inquiry that general practitioners usually provide satisfactory information, but hospital doctors invariably fail to comply.
11.58	Where the crematorium requires the Form C doctor to question someone other than the Form B doctor, a significant proportion of Form C doctors question relatives, as opposed to the other categories of person named on the form. This is no doubt because, if a deceased person has not been in hospital and has not received nursing care from persons other than family, there will be no one else available with knowledge of the death. If the death occurs in a nursing home or similar setting, questions may be asked of the staff.
11.59	The Inquiry obtained evidence from a number of doctors who practise in areas where the local crematorium requires an affirmative answer to one of questions 5-8. They were asked about their experience of speaking to relatives. It had previously been suggested to the Inquiry that it was impracticable to question relatives because it would cause undue distress. In general, the experience of the doctors who provided evidence was that, so long as relatives are informed in advance that another doctor would be contacting them, and so long as they fully understand the purpose of the contact, they are happy to assist. In practice, the Form B doctor usually informs relatives that another doctor will be in touch with them. The doctors did not report any difficulty with speaking to relatives, nor any signs of hostility, resentment or distress at the approach. Many of them saw the contact as offering a valuable opportunity for relatives to voice any concerns or doubts that they might have about the death.
11.60	In Scotland, the Form C prescribed by the Cremation (Scotland) Regulations 1935 requires the form to be completed by a doctor who has seen and examined the deceased's body and spoken to the Form B doctor. In other words, the equivalent of an affirmative answer to questions 1, 2 and 4 of the Form C prescribed for England and Wales is a prerequisite to completing the Scottish form. The questions which the Form C doctor has to answer relate only to whether s/he has performed a post-mortem examination (question 1) and whether s/he has questioned a third person, other than the Form B doctor (questions 2-5). There is no statutory requirement that any of the questions on the form should be answered in the affirmative. However, marginal notes indicating a requirement for one (sometimes two) affirmative answer(s) appear on the Forms C used by many Scottish crematoria. The importance of the requirement for at least one of the questions to be answered in the affirmative was emphasised in a letter sent by the Scottish Office Home and Health Department to all medical referees and deputy medical referees in Scotland in September 1995.
11.61	The Dukinfield crematorium imposes no local requirement for affirmative answers to any of questions 5-8 and it is the local practice for questions 1, 2 and 4 only to be answered in the affirmative. It is clear from the Inquiry's investigations that the practice at Dukinfield is typical of that prevailing in the majority of crematoria throughout England and Wales.
Prevalent Attitudes to Form C
11.62	Evidence heard by the Inquiry suggests that many doctors regard the completion of Form C as a technical requirement only. Just as they have never thought about why it is necessary for the Form C doctor to be independent of the Form B doctor, they have never thought about what Form C is designed to achieve. They do not see themselves as carrying out an independent investigation of the cause and circumstances of the death. A common perception, among doctors who I am sure are in other respects entirely conscientious, is that they must listen to the history and decide whether the Form B doctor's conclusion as to the cause of death is a reasonable one. If they know the doctor to be inexperienced, they might approach the task with some expectation that s/he might be wrong. However, if they know the doctor and believe him/her to be competent, the strong expectation will be that the Form B doctor will be right. The doctors who gave oral evidence to the Inquiry admitted, when pressed about the matter, that they had never previously thought that they were in any way 'policing' their colleagues. Most had never thought that they were supposed to consider whether their colleagues might have concealed wrongdoing of any kind, whether deliberate or through lack of care. This lack of understanding of the purpose of Form C and the doctors' function in completing it is not altogether surprising since it appears that doctors do not receive any formal education or guidance about the purpose or completion of Form C. However, it is disappointing that they do not have a greater understanding. The BMA has been stressing the importance of Form C in representations made on behalf of its members to Government Departments and independent committees of enquiry for over 50 years.
11.63	The Inquiry heard evidence about the degree of care and attention that Form C doctors apply to their task. It appears that it is quite common for the Form C doctor to rely almost completely on the oral account given by the Form B doctor and not to scrutinise what has been written on Form B in any detail. This seems to come about in part because, quite often, the Form C doctor does not see either Form B or Form C until s/he reaches the premises of the funeral director where s/he is to view the body. By that time, s/he will have heard the oral account and will have made up his/her mind that the death was natural and that the cause of death was as explained by the Form B doctor. What the doctor has put on Form B does not, by then, appear important. When Shipman's forms were examined, it was found that the Form C doctor had often failed to notice that Form B contained internal inconsistencies that would have been obvious on careful examination.
11.64	It appeared from the evidence that many, although not all, Form C doctors regard the physical examination of the body as a mere formality, no more than a hoop to be jumped through before signing the form. As I have explained, this attitude is to some extent understandable, as examination of the body is unlikely to provide much information relevant to the cause of death. However, it might provide evidence of injury, ill treatment or lack of care. Once again, it is disappointing that doctors appear to have so little understanding of what they should be looking for or why, particularly given that their representative body has in the past laid such stress on the importance of the Form C procedure.
Attitudes to Questions 5-8
11.65	As I have said, some crematoria require that one of questions 5-8 should be answered in the affirmative. Where this is so, the Form C doctor must question someone with knowledge of the death who is independent of the Form B doctor. In areas where the provision of an affirmative answer to one of questions 5-8 is not compulsory, it is unusual (although not unheard of) for a Form C doctor to make any enquiry of a person independent of the Form B doctor. Some doctors say that they would question a relative or carer if they had any doubts about the cause of death but that this rarely, if ever, occurs. Others say that they never do it, as questioning would be intrusive and would cause additional distress to relatives. However, the evidence of those who practise in areas where such enquiries are made suggests, as I have already said, that relatives do not find such questions intrusive or distressing. Of course, much will depend on the sensitivity of the questioner. However, it appears that, if the bereaved family knows that a doctor will contact them to ask questions about the death and that this is normal procedure, no offence is caused.
Could Questions 5-8 Provide a Useful Safeguard?
11.66	As I have said, the Dukinfield crematorium was not one of those where a positive answer was required to one of questions 5-8. In the vast majority of cases, the doctors who completed Forms C for Shipman did not question anybody independent of Shipman. They trusted him as a respected colleague. He lied to them; they believed his account of the death and they confirmed his dishonest opinion of the cause of death. The Form C procedure, as operated, served no useful purpose as a deterrent or as a means of detecting Shipman's activities. The question is whether it would have been useful in either respect if there had been a requirement that one of questions 5-8 should be answered in the affirmative.
11.67	During Phase One of the Inquiry, it became apparent that Shipman frequently explained a death to the deceased's family in one way and described the circumstances on Form B in quite a different way. He would often pretend that the death was expected by the family, who had been in attendance. On Form B, he would name or describe a particular person, a relative, carer or warden, who, he said, had been present at the death. If the Form C doctor had been obliged to ask questions of a person independent of Shipman, it is highly likely that s/he would have spoken to that person. In many cases, there would have been a real prospect that the Form C doctor would have discovered that Shipman had not told the truth about a purely factual matter.
11.68	By way of example, in the case of Miss Maureen Ward, whom Shipman was convicted of killing and who lived in sheltered accommodation, Shipman claimed that the warden was present at the death. Had the warden been asked, she would have told the Form C doctor that she most certainly was not present at the death and that Shipman had come to find her to tell her that he had found Miss Ward dead in her flat. She would also have added that she was most surprised about the death because she had seen Miss Ward earlier that day, out and about and apparently quite well. This would have been quite inconsistent with Shipman's claim that Miss Ward had died as the result of carcinomatosis resulting from a secondary tumour in the brain.
11.69	In the case of Mrs Joyce Woodhead, whom I found that Shipman killed, Shipman stated on Form B that Mrs Woodhead had died as the result of a coronary thrombosis and that her sister had been present at the moment of death. In fact, her sister, Mrs Freda Hibbs, was not present and, had the Form C doctor questioned her, she would have said so and would have added that she had been very surprised to find her sister dead in bed. She might also have added that her sister looked very peaceful. If questioned, she would have said that, so far as she knew, her sister had no previous history of heart disease. The Form C doctor should then have realised that Shipman had not only told a lie on Form B, but also appeared to have certified the cause of death on inadequate grounds.
11.70	Another example is the case of Mrs Eileen Crompton. Shipman killed her by giving her a lethal injection in the presence of Mrs Patricia Heyl, the Deputy Manager of Charnley House, a residential home for the elderly. Shipman stated on Form B that 'the Matron' was present at the death. Had the Form C doctor spoken to Mrs Heyl, she might have learned the surprising information that, before administering the injection, Shipman had said that he was giving a 'kill or cure' injection. That information should have puzzled and alarmed the Form C doctor.
11.71	Quite apart from the cases in which Shipman told demonstrable lies on Form B, there are a very great number of cases in which a relative, when questioned sympathetically by a Form C doctor, would have confided that s/he was extremely surprised by the suddenness of the death. I think it likely that many would have given an account of the deceased's previous state of health which would have caused the Form C doctor to question Shipman's ability to certify the death. I do not suggest that all the relatives would have expressed their concerns; some were so completely taken in by Shipman's explanation for the death that they would have done no more than repeat it to the Form C doctor. However, I believe there were many who would have confided their surprise and concern if questioned directly. There is a world of difference between giving a relative a direct opportunity to express a concern and merely leaving it to the relative to contact the coroner or the police. Most people would not approach the coroner or the police unless they had strong suspicions or concerns based on specific factors. On the other hand, if given the opportunity, a relative might well express surprise or puzzlement about a death, even in the absence of actual suspicion of wrongdoing.
11.72	I do not suggest that, merely because a Form C doctor discovered that some aspect of Shipman's account was factually inaccurate, or heard an expression of concern from a relative, s/he would immediately suspect wrongdoing. However, if conscientious, s/he could not merely complete Form C. He or she would at least have to speak to Shipman again and ask further questions. He or she might well feel it necessary to refuse to sign Form C and to advise Shipman to report the death to the coroner. If a Form C doctor had had to query cases with Shipman on a regular basis, this should have attracted notice. What would have happened if a Form C doctor had refused to sign the certificate is not clear. Shipman would not have wished to approach another doctor to sign Form C as, when s/he consulted the family member or carer, s/he would be likely to hear the same information as the first Form C doctor, together with the fact that another doctor had been asking questions. Shipman might have promised to speak to the coroner and have returned with the claim (which might or might not have been true) that the coroner had approved the cause of death. He might have had to report the death to the coroner and risk the possibility that an autopsy might not provide a plausible cause of death and that toxicology would follow.
11.73	I cannot say precisely how the Form C doctors would have responded to the discovery that Shipman's Forms B contained serious inaccuracies or that he appeared willing to certify deaths in a number of cases where relatives and carers were concerned, surprised or puzzled. However, I do think that it would have been much more difficult for Shipman to deceive. I think it likely that he would have appreciated the difficulties he would face if he told lies on Form B or gave a different account to the relatives from that given to the Form C doctor. I think he would have recognised the risk he would run that either the Form C doctor or a relative or carer might realise that he had lied and that he had been present alone with the deceased at the moment of death. I think this recognition would have acted as a real deterrent. As I explained in my First Report, Shipman was able to control his urge to kill when he perceived himself to be at risk of discovery. If there had been a requirement at Dukinfield crematorium that the Form C doctor should answer at least one of questions 5-8 in the affirmative, I think it likely that Shipman would have killed fewer patients.
11.74	Further, if Shipman had taken the risk of killing despite the knowledge that the Form C doctor would be likely to question relatives and carers, I believe that the chances of his being detected would have been increased. I cannot say that, on the first occasion on which a doctor declined to complete a Form C for Shipman, the death would have been reported to the coroner, an autopsy and toxicology would have followed and that morphine would have been found and he would have been discovered. But, if he had taken the risk often enough, the chances of detection would have been greatly increased. Quite apart from the actual process of a report to the coroner, autopsy and toxicology, the Form C doctors should have noticed that relatives often had concerns about a death involving Shipman. I cannot say that they would have done but, if they had heard a similar story, often repeated, their suspicions might well have been aroused. The kind of report that Dr Linda Reynolds made to the Coroner in March 1998 might have been made earlier and with much greater attendant detail. I cannot say when this would have happened but I think it likely that questioning relatives and carers would have led to Shipman's detection at some stage, whereas the system as operated never did.

The Certificate of Medical Attendant: Form B

Print Version

The Authority to Cremate: Form F

The Choice of Doctor to Complete Form C

The Personal Inquiry

Questions 1-4

Questions 5-8

Prevalent Attitudes to Form C

Attitudes to Questions 5-8

Could Questions 5-8 Provide a Useful Safeguard?