◆Part 1: The Count

On 31 January 2000 Harold Fredrick Shipman, a family doctor in Hyde, Greater Manchester, was convicted of the murder of 15 of his patients and of forging the will of Kathleen Grundy. He was sentenced to 15 terms of life imprisonment. The trial judge, Mr Justice Forbes, said his recommendation to the Home Secretary would be that Shipman should spend the remainder of his days in prison.

The 15 murders were the cases that reached a jury. In July 2002 the Shipman Inquiry, chaired by Dame Janet Smith, published its First Report. The Inquiry examined 888 cases. It found that Shipman had killed 215 of his patients.

171 of his victims were women. 44 were men. The oldest, Ann Cooper, was 93.

His usual method was a lethal dose of an opiate, most frequently diamorphine. All but 3 of the deaths he caused were entered in the register of deaths on Medical Certificates of Cause of Death that Shipman completed himself.

◆Part 2: The Pethidine

Shipman entered general practice in 1974 at the Abraham Ormerod Medical Centre in Todmorden. By February 1975 the Home Office Drugs Inspectorate and the West Yorkshire Police Drugs Squad had become aware that he was obtaining abnormally large quantities of pethidine from local pharmacies. The police report written at the time concluded: It would seem from the enquiries made into this matter that there is no drug abuse by Dr Shipman.

The Inquiry found that on 17 March 1975 Shipman visited Eva Lyons, a patient with terminal cancer, late at night and gave her an intravenous injection into the back of the hand. It concluded that he was responsible for her death.

In late September 1975 his partners discovered that he was abusing pethidine and had been obtaining it illicitly. He admitted it. He told investigators his consumption had risen to 600 to 700mg a day. In a written statement he wrote: I have no future intention to return to General Practice or work in a situation where I could obtain supplies of pethidine.

On 13 February 1976 at Halifax Magistrates' Court he pleaded guilty to 8 specimen charges of obtaining pethidine by deception, unlawfully possessing pethidine and forging a prescription. He asked for 74 further offences to be taken into consideration. He was fined 600 pounds in all and ordered to pay 58.78 pounds in compensation.

The convictions were reported to the General Medical Council. On 28 April 1976 its Penal Cases Committee decided that no inquiry should be held by the Disciplinary Committee. The Council wrote to Shipman that it took a grave view of offences arising out of an abuse of drugs and of offences involving dishonesty.

Under section 12 of the Misuse of Drugs Act 1971 the Home Secretary had power to prohibit Shipman from possessing, prescribing or administering controlled drugs. Home Office officials decided that no such direction should be given. The Inquiry recorded the result. He was free to continue practising as a doctor without limitation or supervision.

◆Part 3: The Best Doctor In Hyde

In 1977 Shipman applied to the Donneybrook practice, a 7 doctor practice in Hyde. A doctor there checked with the General Medical Council and the Home Office. He was told, correctly, that there were no restrictions in force affecting Shipman's use of controlled drugs. Shipman started on 1 October 1977 and stayed more than 14 years. The Inquiry found that he killed 71 patients while working there.

From 1 January 1992 he practised single handed. In August 1992 he moved to his own surgery at 21 Market Street, Hyde. He was regarded by many as the best doctor in Hyde. By 1998 he had a list of almost 3100 patients.

The Inquiry found that he killed 143 patients in his 6 years at Market Street. 1 in 1992. 16 in 1993. 11 in 1994. 30 in 1995. 30 in 1996. 37 in 1997. 15 in the first 3 months of 1998.

After his 1976 convictions Shipman had declared his intention never to carry controlled drugs again. He was therefore not obliged to keep a controlled drugs register. On 6 June 1996 he collected 12,000mg of diamorphine on behalf of Keith Harrison, a cancer patient who died a natural death that day. None of it was delivered to the patient's home. The Inquiry found that Shipman kept it. That amount alone would have been sufficient to kill about 360 people.

◆Part 4: The Paperwork

Most of the deaths Shipman caused were followed by cremation. Before a cremation could be authorised, a second doctor had to confirm the cause of death and a third doctor employed at the crematorium had to check the documents. These procedures were intended to protect the public against concealment of an unlawful killing.

Shipman's patients frequently died suddenly at home with no previous history of terminal or life threatening illness. Such deaths should be reported to the coroner. Shipman avoided a referral in all but a very few of the cases in which he had killed. He claimed he could diagnose the cause of death and persuaded relatives that there was no need for a post mortem examination.

The Inquiry found many types of lie on the cremation Forms B that Shipman completed. He lied about the time of death and the time of his last visit. He claimed that a relative or neighbour had seen the patient alive after he left. He frequently claimed to have seen a patient within 14 days before the death when the other evidence strongly suggested he had not.

The Inquiry's finding was direct. Even with those procedures in place, Shipman was able to kill 215 people without detection. The procedures provided no safeguard at all.

◆Part 5: The Warning

On 24 March 1998 Dr Linda Reynolds of the Brooke Practice, which worked from premises opposite Shipman's surgery, reported her concerns and those of her partners to John Pollard, HM Coroner for the Greater Manchester South District.

She told him that Shipman had signed 16 cremation Forms B in the previous 3 months. The Brooke Practice, with 9500 patients, had 14 patient deaths in the same period. Shipman's list was about a third of that size.

The deaths shared features. Elderly women. Found dead at home, apparently alone, fully dressed. They did not appear to have been ill. Shipman often found them dead.

Martha Marley, 88, died at home on 24 March 1998, the day Dr Reynolds made her report. The Inquiry found that Shipman killed her.

The coroner asked Greater Manchester Police to investigate in confidence. The case went to Detective Inspector David Smith under the supervision of Chief Superintendent David Sykes. In oral evidence to the Inquiry, Smith admitted for the first time that Dr Reynolds had told him she thought Shipman was killing his patients and that, if he was murdering them, he was doing it with some sort of drug.

The Inquiry found that Dr Reynolds also told Smith that 2 bodies were at funeral directors and available for autopsy. They were Lily Higgins and Ada Warburton. Shipman had killed both. Smith did not pursue an autopsy with the coroner. Lily Higgins was cremated on 25 March 1998. Ada Warburton was cremated on 30 March 1998.

◆Part 6: 24 Days

Smith asked the Tameside register office for copies of the death entries certified by Shipman over the previous 6 months. Shipman had certified 31 deaths in that period. Smith worked from 19 or 20 copies. The Inquiry found it more likely that the register office had handed over an incomplete bundle.

Dr Alan Banks, medical adviser to the West Pennine Health Authority, examined 14 sets of medical records. 13 of the 14 dead were women. Shipman had been present around the time of death in 10 of the 14. Banks did not draw that to Smith's attention. The Inquiry found that the overall impression he created was one of reassurance.

Smith made no check on the Police National Computer. It would have shown Shipman's previous convictions for drug offences involving dishonesty.

On 16 April 1998 Smith told Dr Reynolds he had found no evidence to confirm her suspicions. On 17 April he spoke to the coroner by telephone. The coroner accepted that the police enquiry had revealed nothing of concern. The investigation ended. Smith submitted no written report.

Shipman killed 3 more patients. Winifred Mellor died on 11 May 1998. Joan Melia died on 12 June 1998. Kathleen Grundy died on 24 June 1998. The Inquiry concluded that if the police and the coroner had moved with reasonable expedition, the lives of those 3 victims would probably have been saved.

◆Part 7: The Will

Kathleen Grundy was 81 and had enjoyed good health. Her death was sudden and unexpected. Shipman certified the cause of death as old age.

A will dated 9 June 1998 had been sent to a firm of Hyde solicitors who did not know her. It left her entire estate to Shipman. The estate was worth about 386,000 pounds. Shipman had typed the will on his own typewriter. The Inquiry described the forgery of her signature and of the witnesses' signatures as very poor.

Her daughter, Angela Woodruff, was a solicitor. She reported her suspicions to the police on 24 July 1998. Greater Manchester Police quickly realised that the beneficiary was the doctor who had been investigated a few months earlier. Kathleen Grundy's body was exhumed on 1 August 1998. Tests found morphine at levels consistent with death by overdose. A forensic document examiner found that the signatures on the will had been forged. On 7 September 1998 Shipman was arrested.

On 10 August 1998 a Home Office inspector told the police that Shipman had previous convictions. It was the first time Greater Manchester Police became aware that he had a criminal record.

◆Part 8: The Record

On 11 February 2000 the General Medical Council erased Shipman's name from the medical register. On 18 February 2000 the Director of Public Prosecutions announced that no further criminal proceedings would be brought against him.

After the arrest, Smith submitted 2 written reports on the March 1998 investigation. The Inquiry found that in them he sought to diminish the seriousness of Dr Reynolds' original concerns. On the basis of those reports alone, senior officers of Greater Manchester Police concluded that the investigation had been appropriate at that time. In 2002, on the first day of the Inquiry hearings into that investigation, the force conceded that it had been seriously flawed. The Inquiry found that for more than 3 years the force had accepted Smith's own account and subjected it to no critical analysis whatsoever.

On 13 January 2004 Shipman died at Wakefield Prison.

On 27 January 2005 the Inquiry published its final report. It found that Shipman had begun killing patients while working at Pontefract General Infirmary, before he entered general practice. Its overall conclusion was that Shipman killed about 250 patients between 1971 and 1998. 218 could be positively identified.

Shipman certified nearly all of the 215 deaths himself. The cremation checks provided no safeguard. A neighbouring practice counted the deaths and went to the coroner. The police investigation ended 24 days later. 3 more patients died. The forged will led directly to his downfall.

The Shipman Inquiry, Chairman Dame Janet Smith DBE. First Report, Volume One, Death Disguised, July 2002. Second Report, The Police Investigation of March 1998, Cm 5853, July 2003. Sixth Report, January 2005.