Clinical Practice Findings

Summary findings of the review of Harold Shipman's clinical practice 1974-1998

How was the review done?

The review was done in five main stages:

• A review of the records and transcript of the trial summing up in relation to the fifteen convictions
• A review of surviving clinical records of Shipman's patients who had died
• A review of cremation forms completed by Shipman and a comparison group of general practitioners
• A review of death certificates completed by Shipman and the comparison general practitioners
• A review of the total numbers of deaths among people who had been registered patients of Shipman from 1987, including comparison with local and national death rates. This review included deaths in hospitals.

What was found?

1. The Convictions

This review was undertaken to identify features typical of the murders, and that could be used to point to other cases that should be regarded as suspicious. The key features that were most useful in the review were:

• Sudden death, generally at home and in the afternoon
• Older females
• Weak association between clinical history and cause of death
• Shipman present at death, or had attended the patient shortly before

2. Other clinical records

The records of an additional 180 patients whose deaths had been certified by Shipman were available for review. 179 contained sufficient information to judge whether features typical of the convictions were present. 102 were classified as highly suspicious, 39 as moderately suspicious and 38 as not suspicious. 64% of deaths among females were classified as suspicious, and 40% among males. The number of suspicious deaths was greater on weekdays than Saturdays or Sundays.

3. Cremation forms

292 cremation forms completed by Shipman were reviewed and compared to 475 completed by other general practitioners. Cremation forms are retained for a period of 15 years, and therefore forms were available from 1985. The review identified features giving rise to concern about Shipman's activities. 55% of his patients died in the afternoon, but only 25% of the comparison practitioners' patients died in the afternoon. Shipman reported being present at 20% of deaths, the comparison practitioners were present at less than 1% of deaths. He had seen his patients more recently - within 49 hours on average in comparison with 88 hours among the comparison practitioners. His patients died more quickly - 60% dying within 30 minutes in comparison with only 23% among patients of the comparison practitioners. Some of Shipman's entries on cremation forms disclosed features giving rise to concern about the circumstances of death. Of the 499 deaths that Shipman certified when he worked in Hyde (1977-1998), some information was available from either clinical records or cremation forms or both for 317. Of these, 168 (53%) were classified as highly suspicious, 47 (15%) as moderately suspicious, and 102 (32%) as not suspicious.

4. Death certificates

The numbers of certificates issued by Shipman was more than issued by any of the comparison practitioners. In order to decide whether the excess numbers were more than would have been expected, we have to take into account the numbers of patients cared for by Shipman and the comparison GPs, and the numbers in different age groups and the chances that different groups of patients would be more likely to be at risk of serious illness.

In the analysis relating only to those deaths that occurred at home or in the practice, there was an excess of 236. The excess from 1985 was 199, a figure that is very similar to the number of cases classified as suspicious from 1985.

If all death certificates are included, including those for deaths in residential or nursing homes, the excess was 297. However, this figure is higher than the likely the true number about which we should be concerned, since only one death in a nursing or residential home was regarded as suspicious.

The numbers are statistical estimates, and there is always a degree of error in such estimates. The report included these estimates, and some newspapers included them in their headlines. However, these other figures are much less likely to be the true figure. In my view, the true number a bout which we should be concerned is around 236.

The analysis shows that the highest number of excess deaths was among women aged 75 or above; the second highest excess was among women aged 65-74, and the third highest was among men aged 75 or above.

5. Review of all deaths

This review included the years from 1987 only, since information was not available for earlier years. It included all deaths among patients of Shipman, and not only those for which he issued death certificates. The findings confirm that there was an excess. The total excess was less than the number identified from review of certificates issued by Shipman, although this method of analysis is less sensitive than the other methods.

Recommendations

Recommendations were made about systems to monitor death rates the recording of additional information on death certificates review of general practice records monitoring of controlled drugs. The full report is available from The Stationery Office (telephone 0870 5522). The price is £25. However, it can be downloaded from the internet free of charge, the website address is: www.doh.gov.uk/hshipmanpractice

The author of the report is :
Professor Richard Baker
Clinical Governance Research & Development Unit
Department of General Practice & Primary Health Care
University of Leicester, Leicester General Hospital
Gwendolen Rd, Leicester LE5 4PW

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