10 May 2001
Given by Dame Janet Smith DBE, Chairman, at a Public Meeting in Manchester Town Hall
On 31st January 2000, Harold Fredrick Shipman was convicted by a jury at Preston Crown Court of murdering 15 former patients and of forging a will of one of them. He had killed them by administering lethal doses of diamorphine. He was sentenced to 15 concurrent terms of life imprisonment and in passing sentence Mr Justice Forbes told him that in his case life imprisonment would mean that he would remain in prison until his death.
All 15 of Shipman's victims had lived in Hyde. Shipman had been a well-respected general practitioner until his arrest for the murder of Mrs Kathleen Grundy in September 1998. As the evidence emerged during the trial, there were many who could not believe that Shipman would ever have harmed a patient. The sense of shock and disbelief following the convictions reverberated around the world. Nowhere was it felt more deeply than in Hyde. Many more people in Hyde besides the friends and families of the fifteen known victims were concerned that the deaths of their loved ones might not have been natural.
There was also general concern that a doctor had been able to amass large quantities of diamorphine and to kill so many patients without detection. Why had the regulations which require a record to be made of the acquisition and supply of all controlled drugs, failed to prevent Shipman from obtaining diamorphine illicitly? Why had this not been noticed, especially in view of his convictions for drug abuse in 1976? Why had our systems of death certification with the availability of post mortem examination and coroner's inquest failed to detect and arrest the progress of this serial killer?
In response to these concerns, in February 2000 the Secretary of State for Health set up an Inquiry, under the National Health Service Act 1977. Although its report was to be made public, the panel, to be chaired by Lord Laming of Tewin, was to sit in private.
Many people in Hyde were dissatisfied with that aspect of the Inquiry. A group of relatives of known or suspected victims of Shipman applied to the High Court for judicial review of the Secretary of State's decision. Associated Newspapers Limited and other media groups made a similar application. In July 2000, those applications succeeded and in September, the Secretary of State announced that the Laming Inquiry would be disbanded. Instead, he would invite Parliament to set up a public inquiry under the Tribunals of Inquiry (Evidence) Act 1921. In December 2000, I was invited to conduct that public inquiry. On 31st January this year, Parliament appointed me as Chairman and confirmed the Inquiry's terms of reference.
I want to stress that although the Inquiry was set up by Parliament at the invitation of the Secretary of State for Health and although the Inquiry will be funded from the budget of the Department of Health, it is wholly independent of government. I am a High Court Judge and am entirely independent. I shall receive the advice of counsel, who are barristers in independent practice in Manchester Chambers, but the decisions taken will be mine and mine alone.
The terms of reference are:
1. After receiving the existing evidence and hearing such further evidence as necessary, to consider the extent of Harold Shipman's unlawful activities.
2. To enquire into the actions of the statutory bodies, authorities, other organisations and responsible individuals concerned in the procedures and investigations which followed the deaths of those of Harold Shipman's patients who died in unlawful or suspicious circumstances.
3. By reference to the case of Harold Shipman, to enquire into the performance of the functions of those statutory bodies, authorities, other organisations and individuals with responsibility for monitoring primary care provision and the use of controlled drugs.
4. Following these enquiries, to recommend what, if any, steps should be taken to protect patients in future; and to report to the Secretary of State for Home Affairs and to the Secretary of State for Health.
The terms of reference encompass suspicious deaths which occurred at any time during Shipman's professional career, including the period he spent in the 1970s working in Todmorden in West Yorkshire.
Over a year has passed since Shipman was convicted. Many of those present today will be concerned about the passage of time and will regret that the Inquiry has not yet begun its public hearings. I want to explain what has been happening since January when my appointment was confirmed.
The Inquiry has taken over offices formerly occupied by the Laming Inquiry at Gateway House near Piccadilly Station. From there, the investigative work of the Inquiry has been taking place. Legal and administrative teams have been assembled. Miss Caroline Swift QC has been appointed as Leading Counsel to the Inquiry and she is assisted by Christopher Melton QC and junior counsel Anthony Mazzag and Michael Jones. The solicitor to the Inquiry is Henry Palin, assisted by Ita Langan and Julie Denham. The firm of Eversheds has been appointed as solicitor agents to provide the substantial number of experienced personnel needed to take a large number of statements in a short time.
The administrative team is led by Andrew Griffiths, the Secretary to the Inquiry, and his assistants Oonagh McIntosh and Helen Owen.
I have appointed Dr Aneez Esmail PhD to be my adviser on matters relating to public health and general practice. He was until recently the Head of the School of Primary Care at the University of Manchester, a Senior Lecturer in General Practice and a Principal in general practice at the Rusholme Health Centre. He was a member of the Laming Inquiry. He has academic and practical experience in many of the areas into which I shall inquire. He will sit with me on some but not all occasions. For the sake of openness, I shall state publicly the topics on which he has advised me and will ask him to prepare a written summary of the advice he has provided. Before the end of the hearings there will be an opportunity for interested parties to question him on those topics.
It was decided that the public hearings will take place here at the Town Hall in Manchester and the proceedings should be relayed by closed circuit television link to a building in Hyde so that the many people from there who will no doubt wish to follow the proceedings may do so without inconvenience. A room has been equipped at the back of the Public Library. I have been to see it and I hope it will prove satisfactory.
The public hearings will take place in the main Council Chamber, which has been equipped with sophisticated information technology. Voice activated cameras will focus on the person speaking, whose face will be projected onto one of the large screens behind me. Documents referred to will be projected onto the other screen and onto the lap top computers provided for the legal teams and some of the media positions. All present and those watching from Hyde will be able to see the document display, as will the media in the working annexe. This should make the proceedings far more intelligible than is often the case in court proceedings, where only the judge, the parties and witness have copies of documents under consideration. Several thousand pages of documentation have been scanned into the system and there are more to come. I hope that the use of this document retrieval system and display screen will enable the hearings to move more quickly than by reference to paper files.
Stenographers will record the proceedings using Live Note. All documents received in evidence and a transcript of each day's proceedings will be posted on the Inquiry's website, which is in operation from today. I hope that by the use of modern technology, the process of the Inquiry will be made entirely open. All the evidence on which my conclusions are based will be in the public domain.
The conference facilities in this building are extremely limited and what is available is far from ideal. We have therefore arranged for conference rooms to be available for use by legal representatives in offices in Mount Street. These are almost immediately opposite the Inquiry's main entrance. These rooms can be booked through the Inquiry's administrative team.
Arrangements for the Media. Seats in the Chamber will be allocated to media organisations covering the Inquiry. A special room will be provided in which journalists may work and to which the proceedings will be relayed.
Counselling services will be provided by Tameside Victim Support, which has provided and continues to provide considerable help and comfort for the families. Counsellors will be available at the Town Hall and at the Public Library in Hyde.
In the conduct of the Inquiry, I shall seek to achieve fairness and openness by reliance on the principles advocated by Lord Justice Salmon in the Report of the Royal Commission on Tribunals of Inquiry. That is not to say that I shall adopt all his suggested procedures. More recent Inquiries, such as the Scott Inquiry on the Export of Arms to Iraq and the Phillips Inquiry into BSE have sought to refine the Salmon principles. I hope to draw on the experience gained in those Inquiries. The over-riding principles will be fairness and openness but the Inquiry must not pursue procedures which impose an undue burden on the interested parties, the Inquiry team or the public purse. Many of the detailed decisions on procedure have not yet been taken and I am prepared to hear submissions today on such matters.
I have decided that the Inquiry will take place in three phases.
The first phase will investigate how many patients Shipman killed, the means employed and the period over which the killings took place.
Professor Richard Baker has conducted a statistical analysis of data drawn from Shipman's practice in comparison with other general practitioners practising in the same areas. He also examined the medical records of a large number of Shipman's former patients. From his review of the medical records and the cremation forms where available, he formed the view that the most likely number of deaths about which there should be concern is 236. However, Professor Baker's report could not provide the answer which many people from Hyde and Todmorden wanted, which was whether or not their relative or friend was a victim. Until the Inquiry's investigation was under way, the team did not know whether it would be feasible for me to attempt to reach a decision on individual deaths. I wished to do so because I recognised the need for families to know the truth.
Now that the investigative work is well advanced, I have decided that I shall attempt to reach a decision in each individual case. There is another important reason why these decisions should be taken. The second and third phases of the Inquiry will be carried out more effectively if the factual basis of Shipman's unlawful activities has already been established.
Investigations into 110 deaths have been completed and the files closed for a variety of reasons, but mainly because there was no reason to suspect that the death was unnatural. Where possible, I shall write to a relative in each of those cases to tell them that the file has been closed. A list of the closed files will be published at a later date. If any concern is raised and further information is forthcoming, we will reopen the file and investigate further.
There are 152 deaths in which Shipman signed a medical certificate of cause of death, which we cannot investigate at present because the only information available is a copy of the entry in the register of deaths. The Inquiry will seek to contact a relative in each of those cases with a request for further information. Due to the passage of time, it may be difficult to locate many relatives. Accordingly, a list of those cases, with the dates of death, will be published, with a request that anyone with further information or concern should come forward.
Currently we are examining 466 deaths, but this number may increase if further information is forthcoming. This number is NOT an estimate of the number of people Shipman might have killed. At this stage, it would be quite wrong for me to speculate about the number of deaths for which Shipman is responsible. I am prepared to say that I anticipate that there will be many cases in which I will be able to say that there is no cause for suspicion. However, it will not be possible in every case for me to provide a definite answer, one way or the other.
Much will depend on the availability of evidence, particularly the medical records and cremation certificates. The medical records of many of those patients who died before 1991 had been routinely and lawfully destroyed before Shipman's activities were brought to light in 1998. In other cases, the records have been lost. In the case of deaths before 1984, hardly any cremation certificates have survived and only the limited information in the register of deaths is available. In such cases, there will be insufficient evidence and there may be other reasons why a decision will not be possible.
But I shall do my utmost to put an end to the uncertainty that has prevailed for so long and has caused such distress.
As I have said, the Inquiry is investigating a large number of cases. Each case file contains or will contain the evidence obtained by the police in their investigation, the statements taken for the purposes of this Inquiry, the death registration and, where appropriate, cremation certificates, relevant entries from the surgery appointments books and visits records and some medical evidence. Expert evidence, mainly on medical issues, has been obtained. The whole process has been very time consuming. It is now well advanced but much remains to be done.
Although in recent weeks many statements have been taken for the Inquiry, I am anxious that any one who has not yet given a statement and who thinks he or she may have relevant information should contact the Inquiry and ask for assistance in providing a statement. I do want to emphasise that there is no need to seek legal representation. Many people wishing to provide a statement or give information to the Inquiry have been assisted by the Inquiry team and this facility remains and will remain available.
The Inquiry has written to Shipman and to solicitors instructed on his behalf. His solicitor has indicated that he does not wish to take part in the Inquiry. At the appropriate stage, but before any decisions are taken, the Inquiry will identify to him those deaths for which he is suspected of being responsible. We will then allow a reasonable time for Shipman to respond to the information if he so wishes.
It is intended that the oral hearings will begin on 20th June. By that time, the work of investigation of all the deaths will not be complete. The expert evidence and the first tranche of 70 individual cases will be ready. I have decided that the hearings should begin in this building while the preparatory work continues at Gateway House. Much of the evidence gathered for Phase 1 is likely to be uncontroversial, but some will require explanation or clarification. The expert witnesses will be called to give oral evidence. The evidence of many lay witnesses will be received in writing. Evidence received in writing will be made public and will carry no less weight than evidence received orally. It is proposed that, initially, Counsel to the Inquiry will select those lay witnesses who are required to give evidence. Interested parties may request that particular witnesses should be called. If there were to be any disagreement about who should be called, I will decide. The address of a lay witness will not normally be disclosed.
In Phase 1, it is proposed that those lay witnesses who give oral evidence will be called by Counsel to the Inquiry. Some will be represented by their own counsel, who will have the opportunity to ask further questions. All witnesses will be assisted by the Inquiry team and everything will be done by the team and by me to make the experience of giving evidence as easy as it can be in the circumstances.
At this stage I do not wish to restrict questioning by Counsel for interested parties. I prefer to rely on the co-operation and good sense of the experienced counsel who will be appearing. However, this is an Inquiry following an inquisitorial procedure and not a trial following an adversarial procedure. There will be no examination-in-chief, cross-examination and re-examination. We will have questions. In general, Counsel to the Inquiry will ask them. In so far as Counsel for other interested parties ask questions, they must not duplicate those asked by Counsel to the Inquiry. I very much hope it will not be necessary for me to lay down procedural rules governing questions by other Counsel but I shall not hesitate to do so if I find that time is being wasted.
During Phase 1, it is my present intention to sit on 4 days each week, Monday, Tuesday, Thursday and Friday from 10am until 1pm and from 2pm until about 4.15. That timetable will not be adhered to rigidly. Some flexibility must be maintained.
It will not be possible to complete the Phase 1 hearings before the summer recess. As so many people will be taking holidays during August and September, the hearings will be adjourned by 27th July at the latest and will not resume before 24th September. We will then sit continuously until Phase 1 is completed.
At the end of the Phase 1 hearings, there will be an opportunity for represented parties to make submissions. I then intend to make decisions in as many cases as the evidence will allow and to write an interim report of my findings before proceeding to the next phase of the Inquiry. I am reluctant to forecast when the interim report will be ready for publication. However, I hope that it will be published by the end of the year.
In a short while I will hear applications from representatives of those who wish to be recognised as interested parties to the Inquiry. In so far as I have had advance notice of those applications, I hope to be able to make immediate decisions. If there are unexpected applications, I may have to reserve my decision.
The first tranche of evidence for Phase 1 will be disclosed to accredited representatives of interested parties today. It is on a read-only CD-ROM. There will be an opportunity this afternoon for training in gaining access to and using the CD-ROM. Receipt of the evidence in advance will be subject to an undertaking by the recipient not to disclose the material to any one other than the relevant legal team and client and to return to the Inquiry any material not then in the public domain once the proceedings are over. The full terms of the undertaking are available now from Henry Palin or Ita Langan.
Phase 2 will cover the second and third paragraphs of the terms of reference. The Inquiry has consulted on potential issues and a revised List of Issues is published today. I hope those persons and organisations whose activities will come under scrutiny are already aware of the topics to be covered. I can now say that it is my intention that Phase Two should be broken down into four stages. The first will deal with post-death procedures, including death and cremation certification, the role of the police and ambulance services in the investigation of sudden and unexpected deaths, the functions of the coroner and the roles of the Office of National Statistics, the registrar, the coroner and health authorities in the collection and analysis of mortality rates. The second will cover the March 1998 police investigation into the first concerns expressed about Shipman. The third will deal with controlled drugs, including the procedures for prescribing, dispensing, storing and disposing of such drugs in community medicine and the monitoring of those procedures by the police and the Home Office. In the final stage of Phase 2, the Inquiry will deal with the systems for dealing with complaints against general practitioners, whistle-blowing, the disciplinary control of general practitioners and the monitoring of their work. When considering the ways in which concerns can be brought to the attention of those in authority, we will include in the Inquiry the position of the staff employed in Shipman's practices and staff employed in sheltered accommodation and residential and nursing homes. I am satisfied that the actions of persons in such positions fall within the terms of reference and I have authorised the team to include them in their investigations for Phase 2.
I do not propose to say a great deal more today about the conduct of phase 2, save that I do not envisage that it could begin until January 2002. I shall hold another preliminary meeting nearer the time. I shall then issue procedural directions in the light of the experience gained during Phase 1.
In Phase 3, the Inquiry will consider proposals for changes to the existing systems. I shall invite the interested parties to make written submissions, possibly accompanied by further expert reports, which will then be discussed at a series of public seminars at which there can be an exchange of views.
I want to say a few words about Inquests. As many of you will know, the South Manchester Coroner, Mr John Pollard, has conducted inquests into the deaths of 27 former patients of Harold Shipman. In 25 cases, he has reached a verdict of unlawful killing and in 2 brought in an open verdict. All cases have resulted in amendment of the death certificate.
Other families may be wondering whether it will be possible for them to obtain an amended death certificate if the Inquiry concludes that their relative was killed by Shipman. The Home Secretary has granted permission to the Coroner to open inquests into about 260 further deaths. However, those deaths are among those which will be investigated by the Inquiry. The Lord Chancellor has now made an order under Section 17A of the Coroners Act 1988 directing the Coroner to adjourn those inquests until the findings of this Inquiry are made available.
I can assure the families that once my Interim report is published, the findings will be available to the Coroner and he will be able to arrange for any necessary amendment of death certificates without the need for a full inquest. I believe that this procedure will be welcomed by the families. It should provide a speedy answer to the families' questions, without the need for an individual inquest in each case and, for many families, avoiding the need to give oral evidence in public.
I want now to say something about the broadcasting of the Inquiry proceedings. A few weeks ago, the Inquiry received applications from a number of broadcasting organisations seeking permission to film the hearings. Although I recognised that there are some good public interest reasons why filming should be allowed, I decided to refuse. My principal reason was I thought that filming would increase the pressure on the relatives and friends of former patients who will have to give evidence. I recognise that these witnesses will find giving evidence stressful and that the recollection of the events which they will have to recount will be deeply distressing for them. Although the proceedings will have to be filmed for the purpose of the CCTV relay to Hyde and possibly to an overflow room in this building, my firm view was that these vulnerable witnesses should not be exposed to the much wider publicity which would result from broadcasting by television and possibly on the internet.
Since that decision was communicated, I have given the matter further thought. Those witnesses about whom I was principally concerned will give the most sensitive parts of their evidence during Phase 1 of the Inquiry. In the second phase, those relatives and friends of former patients who give evidence will not be speaking directly about the deaths of their loved ones. Their evidence will be concerned with the procedures for death certification, opportunities for whistle-blowing and topics of that kind. They will be speaking of matters that may be less distressing than those in Phase 1. On the other hand, in Phase 2 there will be many witnesses who, although not likely to be emotionally distressed by the proceedings, may be very anxious indeed about the questions they are to be asked. So, different considerations arise for this decision in Phase 2. There are still good reasons why the proceedings should not be broadcast. However, it seems to me that the arguments are more finely balanced.
I have decided, therefore, that I should reconsider my decision to refuse permission and that, before reaching a final decision, I should allow an opportunity for consultation. Accordingly, I am prepared to receive views from anyone who is likely to take part in the Inquiry, whether as a witness or representative. Although at present I remain of the view that broadcasting would not be appropriate in Phase 1, I am prepared to receive submissions and views on Phase 1 as well as on Phases 2 and 3. I wish to receive these in writing by the end of May. I would like to hear from as many individuals as possible. A short note is all that is required. Those who are represented may give their view either directly or through their representatives. If anyone wishes to give his or her view through Victim Support, that too would be acceptable. I will send my decision to the broadcasting organisations that have applied and will announce it publicly.
I am sure that many of you would like to know when the final report will be ready for publication. The answer is that I do not know and that any attempt at a reply will entail an element of gazing into a crystal ball. However, I am prepared to say that I would very much like to deliver it to the Secretaries of State during the Spring of 2003.
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