Harold Frederick Shipman was born on 14 January 1946 in the Bestwood council estate in Nottingham, England, the second of the four children of Vera and Harold Shipman, a lorry driver. His working class parents were devout Methodists. Known as “Fred”, he was the favourite child of his domineering mother, Vera. She instilled in him an early sense of superiority that tainted most of his later relationships, leaving him an isolated adolescent with few friends.

One neighbour notes, “Vera was friendly enough, but she really did see her family as superior to the rest of us. Not only that, you could tell Harold was her favourite, the one she saw as the most promising of her three children”. Vera decided who Harold could play with, and when. She wanted to distinguish him from the other boys, he was the one who always wore a tie when the others were allowed more casual dress. His sister Pauline was seven years older, his brother Clive, four years his junior. But in his mother’s eyes, Harold was the one she held the most hope for.

As a student, Shipman was comparatively bright in his early school years, but rather mediocre when he reached upper school level. Nonetheless, he was a plodder determined to succeed, even when it meant re-sitting his entrance examinations for medical school. Strangely, he had every opportunity to be part of the group, he was an accomplished athlete on the football field and the running track. In spite of this, his belief in his superiority appears to have precluded forming meaningful friendships with his contemporaries. Much has been made of the way young Harold Shipman dealt with his mother’s final months and justifiably so. Because his behavior then closely paralleled that of Shipman the serial killer. Every day after classes, he would hurry home, make Vera a cup of tea and chat with her — probably about his day at school. She counted the minutes as she waited, and found great solace in his company.

For his part, this is likely where Shipman learned the endearing bedside manner he would adopt later in his practice as a family physician. Toward the end, Vera experienced severe pain. But, because pumps to self-administer painkillers did not exist at that time, Vera’s sole relief from the agony of cancer came with the family physician. No doubt young Harold watched in fascination as his mother’s distress miraculously subsided whenever the family doctor injected her with morphine. As the disease progressed, the already trim Ms. Shipman grew thinner and frailer until, on June 21st 1963, the cancer claimed her life. Vera’s death left her son with a tremendous sense of loss. After all, his mother was the one who made him feel special, above the rest. Significantly, her passing left him with an indelible image, the patient with a cup of tea nearby, finding sweet relief in morphine.

Devastated by her death, he was determined to go to medical school and two years after his mother died, Harold Shipman was finally admitted to Leeds University medical school. Getting in had been a struggle. In spite of his self-proclaimed superiority, he’d had to re-write the exams he’d flunked first time around. Nonetheless, his grades were adequate enough for him to collect a degree and serve his mandatory hospital internship.

It is surprising to learn that so many of his teachers and fellow students can barely remember Shipman. Some who do remember claim that he looked down on them and seemed bemused by the way most young men behaved. 

Most of his contemporaries, especially from his earlier years, simply remember him as a loner. They also remember the one place where his personality changed, the football field. Here, his aggression was unleashed, his dedication to win intense. Even so, he was more sociable in medical school than his mother had allowed him to be while living at home.

A former teacher said:

“I don’t think he ever had a girlfriend; in fact he took his older sister to school dances. They made a strange couple. But then, he was a bit strange, a pretentious lad.”

But Shipman finally found companionship in a girl and married before most of his contemporaries did. At nineteen, he met Primrose, 3 years his junior. Her background was similar to Fred’s. Her mother restricted her friendships, and controlled her activities. No poster girl, Primrose was delighted to have finally found a boyfriend. Shipman married her when she was 17 — and 5 months pregnant.

By 1974 he was a father of two and had joined a medical practice in the Yorkshire town of Todmorden. In this North England setting, Fred seemed to undergo a metamorphosis; he became an outgoing, respected member of the community in the eyes of his fellow medics and patients. But the staff in the medical offices where he worked saw a different side of the young practitioner. He was often unnecessarily rude and made some of them feel “stupid” a word he frequently used to describe anyone he didn’t like. He was confrontational and combative with many people, to the point where he belittled and embarrassed them. He also had a way of getting things done his way, even with the more experienced doctors in the practice. Not yet thirty, Shipman had become a control freak.

His career in Todmorden came to a sudden halt when he began having blackouts. His partners were devastated when he gave them the reason. He suffered, he said, with epilepsy. He used this inaccurate diagnosis as a cover-up but the truth soon surfaced, when practice receptionist Marjorie Walker stumbled upon some disturbing entries in a druggist’s controlled narcotics ledger. The records showed how Shipman had been prescribing large and frequent amounts of pethidine in the names of several patients. Moreover, he’d written numerous prescriptions for the drug on behalf of the practice. Although this was not unusual (drugs are kept on hand for emergencies and immediate treatments), the prescribed amounts were excessive. Pethidine, a morphine-like analgesic, was initially thought to have no addictive properties. Now, some sixty years after scientists first synthesized it, pethidine’s non-addictive reputation is still hotly debated. 

Following the discovery of Shipman’s over-prescribing, a covert investigation by the practice, including Dr. John Dacre, followed. To his alarm, he discovered many patients on the prescription list had neither required nor received the drug. Dacre challenged Fred in a staff meeting, as one of his partners, Dr. Michael Grieve recalls:

Shortly afterwards, his wife Primrose stormed into the room where his peers were discussing the best way to dismiss him. Rudely, she informed the people at the meeting that her husband would never resign, proclaiming, “You’ll have to force him out!”


She was right. Ultimately he was forced out of the practice and into a drug rehab centre in 1975. Two years later, his many convictions for drug offences, prescription fraud and forgery cost him a surprisingly low fine, just over £600. Shipman’s conviction for forgery is worth noting. As for the pethidine charges, the question remains: Did he really self-inject the drugs (as he claimed) or had he already begun using them to kill unsuspecting patients? This is currently under review.

A couple of years later he was accepted onto the staff at Donneybrook Medical Centre in Hyde, Dr. Jeffery Moysey of the Center explained:

He ingratiated himself as a hard working doctor, who enjoyed the trust of patients and colleagues alike, although he had a reputation for arrogance amongst junior staff. Some of those who worked under him have told of his sarcastic and abusive nature, but he was skilled at masking his patronizing attitude in front of those he chose to impress. As for any signs of addiction, there were no blackouts as before, and no indication of drug abuse. He remained on staff there for almost two decades, and his behaviour incurred only minor interest from other healthcare professionals. 

Local undertaker Alan Massey began noticing a strange pattern: not only did Shipman’s patients seem to be dying at an unusually high rate; their dead bodies had a similarity when he called to collect them. “Anybody can die in a chair,” he observed, “But there’s no set pattern, and Dr. Shipman’s always seem to be the same, or very similar. Could be sat in a chair, could be laid on the settee, but I would say 90% was always fully clothed. There was never anything in the house that I saw that indicated the person had been ill. It just seems the person, where they were, had died. There was something that didn’t quite fit.” Worried enough to voice his unease, Massey decided to confront Shipman, and paid the doctor a visit. Massey recalls:

He showed me his certificate book that he issues death certificates in, the cause of death in, and his remarks were “nothing to worry about, you’ve nothing to worry about and anybody who wants to inspect his book can do”. Reassured by Shipman’s ease at being questioned, the undertaker took no further action. But his daughter, Debbie Brambroffe — also a funeral director — was not so readily appeased. She found an ally in Dr. Susan Booth.

From a neighbouring practice, Dr. Booth had gone to the funeral directors to examine a body. British law requires a doctor from an unrelated practice to countersign cremation forms issued by the original doctor. They are paid a fee for this service which some medics cynically call “Cash For Ash.” Debbie told Dr. Booth she had misgivings.
Booth explained: 

Booth spoke to her colleagues. One of them, Dr. Linda Reynolds contacted coroner John Pollard. He in turn alerted the police. In a virtually covert operation, Shipman’s records were examined and given a clean bill of health because the causes of death and treatments matched perfectly. What the police did not discover was that Shipman had re-written patient records after he killed. The quality of that investigation has been questioned because the police failed to check for a previous criminal record. Nor did they make inquiries with the General Medical Council. Had they done so, Shipman’s past record of drug abuse and forgery might well have led to a more thorough approach.

Kathleen Grundy’s sudden death on June 24th 1998 came as a terrible shock to all who knew her. A singularly active 81-year-old, she was well known to the people of Hyde. A wealthy ex-mayor, she had energy to burn and was a tireless worker for local charities until the day of her death. Her absence was noted when she failed to show at the Age Concern club. There, she helped serve meals to elderly pensioners. Because the wealthy widow was noted for her punctuality and reliability, her friends suspected something was wrong. When they went to her home to check up on her, they found her lying on a sofa. She was fully dressed, and dead.


They immediately called Dr. Shipman.

He had visited the house a few hours earlier, and was the last person to see her alive. He claimed the purpose of his visit had been to take blood samples for studies on ageing, Shipman pronounced her dead and the news was conveyed to her daughter, Angela Woodruff. The doctor told the daughter a post mortem was unnecessary because he had seen her shortly before her death. Following her mother’s burial Ms. Woodruff returned to her home, where she received a troubling phone call from solicitors. They claimed to have a copy of Ms. Grundy’s will. A solicitor herself, Angela’s own firm had always handled her mother’s affairs – her firm held the original document lodged in 1986. The moment she saw the badly typed, poorly worded paper, Angela Woodruff knew it was a fake. It left £386,000 to Dr. Shipman. She later told the Shipman trial:

Initially, she wondered if Shipman was being framed. But after interviewing witnesses to the will, she reluctantly concluded the doctor had murdered her mother for profit. It was then she went to her local police. Her investigation results ultimately reached Detective Superintendent Bernard Postles. His own investigation convinced him Angela Woodruff’s conclusions were accurate. Of the forged will itself, Postles was to later say:

 

To get solid proof of Kathleen Grundy’s murder, a post mortem was required which, in turn, required an exhumation order from the coroner. This is a rare occurrence for any British police force, one the Greater Manchester Police had not experienced. “We did not have one officer who had ever taken part in an exhumation. We asked the National Crime Squad for advice.” Det. Supt. Postles explained. By the time the trial had begun, his team would be uncomfortably familiar with the process. Of the fifteen killed, nine were buried and six cremated. Katherine Grundy’s was the first grave opened. Her body was the first of the ongoing post mortems. Her tissue and hair samples were sent to different labs for analysis, and the wait for results began.

At the same time, police raided the doctor’s home and offices. It was a low-key exercise, but timed so Shipman had no chance of learning a body had been exhumed for a post mortem, Police had to be certain no evidence could be destroyed or concealed before their search. When the police arrived, Shipman registered no surprise. Rather, his approach was one of arrogance and contempt as the search warrant was read out. One item crucial to police investigations was the typewriter used to type the bogus will. Shipman produced an old Brother manual portable, telling an improbable tale of how Ms. Grundy sometimes borrowed it. This unbelievable story was to work against Shipman, especially when forensic scientists confirmed it was the machine used to type the counterfeit will and other fraudulent documents. Searching his house yielded medical records, some mysterious jewelry and a surprise. The Shipman home was littered with filthy clothes, old newspapers and, for a doctor’s home, it was nothing short of unsanitary.

When toxicologist Julie Evans filed her report on the cause of Ms. Grundy’s death, Det. Supt. Postles was astounded. The morphine level in the dead woman’s body was the cause of death. Not only that, her death would have occurred within three hours of having received the fatal overdose. Postles later said Shipman’s use of the drug was a serious miscalculation. A doctor would surely have known morphine is one of the few poisons that can remain in body tissue for centuries. Postles observed: 

Shipman would claim later that the stylish and conservative old lady was a junkie. Even today psychologists speculate on the possibility that he wanted to be caught. Otherwise, why would he hand them the typewriter and use a drug so easily traced back to him? Others believe he saw himself as invincible, believing that, as a doctor, his word would never be questioned. The detective realized the case went far beyond one death, and the scope of the investigation was broadened immediately. Just which deaths to investigate became the priority. To decide, a scale was devised, based on patterns. Those who had not been cremated and had died following a Shipman “house call” took precedence. Other issues were factored in, but obviously only uncremated bodies could yield tissue samples for examination. Slightly different criteria were applied to the next group for police investigation. All cremated, they were investigated, mainly, on the basis of known pre-existing conditions, recorded causes of death, and Shipman’s presence before they died.

Whenever he could, the doctor had urged families to cremate their dead and had also stressed no further investigation was necessary. It may seem strange now that no relatives found this peculiar, but people typically trust their doctors, especially in times of great stress. After all, the causes of deaths Shipman presented were rational, even though bereaved families were often surprised to learn of conditions their loved ones had never mentioned. Even if they had questioned the doctor, he had the computerized medical notes to prove patients had seen him for the very symptoms he cited as leading to causes of death. Police would later know he’d altered computer records to make everything match. Callously, Shipman made most of these changes within hours of his patients’ deaths. Often, immediately after killing, he would hurry to his office and adjust his records. 

In the case of 82-year-old Kathleen Grundy, he reinforced his later statement that she was a morphine junkie by inventing and backdating several entries. His sheer audacity in suggesting this highly respected woman had been scoring hits from drug dealers was overwhelmingly stupid. The moment he made the statement, his credibility crumbled. When Shipman first encountered the computer, he was technophobic. But once he reluctantly agreed to embrace the (then) new technology, he declared himself a computer expert. This was consistent with his need to assert his superiority. But what the self-proclaimed computer wiz didn’t know was that his hard drive recorded to the second every phony alteration he made to a patient’s records. A taped interview with the Greater Manchester Police demonstrates this lack of knowledge:

Police Officer: “I’ll just remind you of the date of this lady’s death — 11th May ’98. After 3 o’clock that afternoon, you have endorsed the computer with the date of 1st October ’97 which is 10 months prior, ‘chest pains'”.

Dr. Shipman: “I have no recollection of me putting that on the machine”.

Officer: “It’s your passcode; it’s your name”.

Shipman: “It doesn’t alter the fact I can’t remember doing it”.

Officer: “You attended the house at 3 o’clock. That’s when you murdered this lady. You went back to the surgery and immediately started altering this lady’s medical records. You tell me why you needed to do that”.

Shipman: There’s no answer.

By now, the trial had gained a momentum that is characteristic, where evidence follows a set pattern over and over. Although the Kathleen Grundy case had taken over a week, those to follow would progress more quickly. What speeded up the trial were emerging characteristics, among them the ambulance-telephone scam. Here, Shipman would pretend to call emergency services. But when he “discovered” a patient dead, he would pick up the phone and pretend to cancel the ambulance. One sad example of this ruse involved a vibrant 77-year-old, Lizzie Adams. She loved dancing with her dance partner, William Catlow. William dropped in to visit Lizzie the day she died. When he arrived, he found Shipman examining her impressive collection of porcelains and crystal. In the next room, Lizzie lay dying. Catlow told the court:

 

But telephone records proved Shipman never phoned the ambulance service that day. 

In another case, that of Nora Nuttall, her son Anthony told how he had left his mother alone for just 20 minutes. He returned to find Dr. Shipman leaving their house. ‘I asked him what was wrong. He said “I have rung an ambulance for her.” I ran in and… she looked like she was asleep in the chair. I took her by the hands and shook her, saying, “Mum, Mum…”‘ Shortly after, Shipman merely touched her neck and told the son, “I’m sorry, she has gone”. Tales of phone calls the doctor never made continued. Norah Nuttall’s sister went to Shipman’s office to examine the dead woman’s records, she wanted details of her sister’s death. Annoyed, Shipman addressed his staff: “I knew it would happen, I told you it would happen.”

Quickly, he fabricated a story of how Norah had called his office to say she was ill. Shipman then claimed he’d been paged and just happened to be nearby. When telephone records proved him wrong, Shipman quickly fabricated a new story. But he outdid himself with the tale of the missing blood samples. His reason for visiting his last victim, Kathleen Grundy, was allegedly to collect blood samples for a study on ageing. When asked what had happened to them, he initially said they had gone for analysis. When the prosecution proved there was no study on ageing, he suddenly “remembered” what happened. He had left the samples under a pile of notes, and, as they were no longer useful he disposed of them. With each new revelation his credibility sank.

Other witnesses told of Shipman’s lack of compassion toward the bereaved. Truck driver Albert Lilley broke down as he recalled the way Shipman announced the death of his wife, 59-year-old Jean Lilley.

He repeated this tactic with Winnie Mellor, a healthy outgoing 73-year-old who still played football with her grandchildren. Excited about a planned trip to the Holy Land, she too, died following a Shipman visit. When he called her daughter Kathleen, he was deliberately obtuse, forcing her to guess her mother had died:

Shipman’s rudeness to a neighbour, Gloria Ellis, was consistent with his personality. But Ms. Ellis was to play an important role in bringing him down. She had witnessed Shipman’s visit to Winnie Mellor just hours before her death. He was to return later, as Detective Chief Inspector Mike Williams explained:

Far from stupid, the neighbour knew to the minute the times Shipman had arrived and left. She brought a smile to the court when she claimed to have been surprised to learn he was a doctor, “I thought he was an insurance man.” In an outrageous example of Shipman’s heartless behaviour, the killer ridiculed dead Ivy Lomas. Of the fifteen deaths Shipman was charged with, only Ms Lomas’ occurred in his offices. Detective Sergeant Philip Reade, a constable at the time, told how he had gone to the doctor’s office to locate Ivy’s next of kin. He recalled his bizarre encounter with Shipman:

Even worse, Shipman told the officer that as he left the room Ivy “could have taken her last breath.” And yet, he had made no effort to resuscitate the woman. Instead, he left her alone while he saw other patients. Medical expert for the defense, Dr Grenville told the court: 

But 63-year-old Ivy would have been past resuscitation. Again, Shipman had murdered with morphine.

Throughout the trial, Shipman’s defense, mainly Angela Davies, backed by junior counsel Ian Winter, valiantly and professionally attempted to portray Shipman as a kind and caring human being. She painted a rosy portrait of a plain old-fashioned family doctor, one prepared to go the extra mile for his patients. His prior record of drug misuse, pethidine addiction and forgery went unmentioned. Instead, Ms. Davies focused on his happy family life with wife Primrose and their four children. But the defense fought an uphill battle from the start. On the one occasion Ms. Davies appeared to be gaining the upper hand, she suddenly lost.

She had been questioning the forensic analyst about the validity of tissue testing for drugs:

Ms. Davis then asked whether finding morphine in tissue samples was proof of single or multiple doses.

It was easy to see where the defense was heading. If it could be proven that the tissue samples might not have resulted from a single dose, perhaps the jury could be convinced the high levels of morphine in the bodies resulted from years of use. It was a desperate long shot. And it failed miserably when Dr. Karch Steven, took the stand. An American whose credentials were as impressive as his evidence, Steven explained a relatively new technique.

He described the test he had performed. It was so new, Britain’s prestigious medical journal The Lancet had covered it just a year earlier. It analyzed hair samples for ongoing drug use. This remarkably accurate test proved conclusively that not one victim was a long-term morphine user. Clearly, any of the narcotic in murdered women’s tissue samples resulted from a single, massive dose. Finally, the trial turned to evidence revealing Shipman’s devious ways of hoarding drugs to kill.

During the trial, Shipman had claimed he never carried morphine, therefore he could not have killed any of his patients. But the family of Molly Dudley (another victim) disproved this assertion. Although Shipman was not charged with Molly’s death in the original trial, he had admitted to giving her morphine. Daughter-in-law Joyce Dudley received a call from Shipman telling her:

Molly was dead when by the time her son Jeffrey and his wife arrived. Shipman told them she had died from a heart attack. Joyce Dudley stated:

This proved Dr. Shipman did carry morphine. Just how he amassed enough of the drug to kill so many would soon be revealed. Shipman told many outrageous stories, but few as ludicrous as his morphine-related tales. He had, he said, prescribed 2000 milligrams of morphine to patient Frank Crompton, who had prostate cancer. Although Mr. Crompton was not in pain, Shipman said he wanted to have it on hand in case pain developed later. He said the patient had told him he “didn’t want to be a drug addict”. So he broke them (the ampoules) and put them in the rubbish. We talked about it again and Mr Crompton agreed to keep them in the house. So, Shipman said, he got him another supply. Of course, since the patient had died, it was impossible to prove Shipman had confiscated both batches.

In another example, Shipman’s staff told how he had confused them regarding drug entries. He explained away some missing morphine with the excuse he was merely giving it to a colleague who had loaned him some for a prior patient emergency. But the doctor vastly overrated the gullibility of the court with one ridiculous story: He said a supply of diamorphine (the medical term for heroin) must have been put through a slot in his office door, because he found it lying on the office doormat when he arrived at work. In most instances, Shipman got his morphine through patients who had never needed it in the first place, or he confiscated unused supplies from patients who had died. Detective Superintendent Bernard Postles explained:

One man who narrowly escaped being an unwitting supplier is Jim King. In 1996 he was incorrectly diagnosed as having cancer. Shipman treated him with massive doses of morphine. Jim King told: 

When Jim’s condition worsened, Shipman made a house call. He diagnosed pneumonia and said he needed to give an injection. Jim looked at his wife, who seemed wary. Perhaps her unease was prompted because both King’s aunt and father had died following Shipman visits. She remembers: 

The Kings learned later that Shipman had killed their relatives.

It took the judge, Mr. Justice Forbes, two weeks to meticulously dissect the evidence heard by the jury. He urged caution, noting that no witness had actually seen Shipman kill. And he also urged the jurors to use common sense in arriving at their verdict. In summing up, he said, in part:

At 4:43 pm on Monday January 31st 2000, the foreman declared all the jury’s verdicts were unanimous: they found Shipman guilty on 15 counts of murder and one of forgery. The disgraced doctor stood motionless and betrayed no sign of emotion as he heard the jurors’ verdicts read. Wearing black, Shipman’s wife, Primrose, also remained impassive. Her boys, one beside her and the other seated behind, looked down and seemed to diminish on hearing the results. In the public gallery, some gasped as Shipman’s previous forgeries were described. Defense counsel, Nicola Davies, asked that sentence be passed immediately.

Mr. Justice Forbes obliged, addressing Shipman:

The judge passed fifteen life sentences for the murders and a four-year sentence for forgery. Then he broke with the tradition that usually involves writing to the Home Secretary about his recommendations on length of the sentence:

Fifteen murders had been dealt with and the fifty-seven day trial was over. But the extent of the killing was yet to be revealed.

British police are so convinced that Shipman’s killing spree started long ago that a special helpline has been set up for those concerned about how friends and relatives died while under the killer’s care. The Baker report, noted earlier, is filled with chilling statistics. When he compared Shipman’s patient list with those of doctors with similar lists, Professor Baker concluded that Shipman had 236 more in-home patient deaths than would normally be expected. Most of these deaths involved women over 75.

Chief Medical Officer Professor Liam Donaldson stated: 

Initially, the government said the inquiry would be held behind closed doors, but in September 2000, concerned relatives won their battle to have it held in public. The audit goes on to estimate that he may have been responsible for the deaths of at least 236 patients over a 24-year period. Separately, an inquiry commission chaired by High Court Judge, Dame Janet Smith, examined the records of 500 patients who died whilst in Shipman’s care, and the 2,000-page report concluded that it was likely that he had murdered at least 218 of his patients, although this number was offered by Dame Janet as an estimation, rather than a precise calculation, as certain cases presented insufficient evidence to allow for certainty.

There were no signs of violence, no sexual overtones, no known motive, except for the one exception, and no ‘smoking gun’. Also, serial killers often like to toy with their victims, to reinforce their self-portrait of power, before they strike. But Shipman’s victims seem to have died peacefully, and in surroundings where they felt safe and comfortable, at home. Endless, contradictory theories abound. Some psychoanalysts speculate he hated older women, citing comments he made about the elderly being a drain on the health system. Others feel he was re-creating his mother’s death scene, in order to satisfy some deep masochistic need. His belief in his own superiority makes this questionable.

That fact that he left so many indelible clues indicates, some say, that Shipman desperately wanted to be discovered and stopped; that he was fighting a compulsion he simply could not control. But the consensus seems to be that he felt he was so superior he could do whatever he wanted with no fear of discovery. Perhaps prosecutor Richard Henriques got it right when he said:

Despite overwhelming evidence of his guilt, the 56-year-old former physician maintained his innocence, continuing to shroud the motives for his extraordinary crimes. The official report speculated that the doctor was “addicted to killing” much like he was addicted to painkillers around the time the murders started. Like other death angels such as Dr. Michael Swango, the American doctor who killed patients in both Africa and the U.S., there was no hint of a sexual interest in his victims. Rather, as South Manchester coroner John Pollard speculated, Shipman “simply enjoyed viewing the process of dying and enjoyed feeling the control over life and death”. A fatal fascination with death, dying and drugs is consistent with the behaviour of the 17-year-old Shipman who spent hours comforting Vera, his cancer-stricken dying mother. In the young man’s mind, there was a powerful emotional connection between the visit of the family doctor and the relief that his injections of morphine brought to her suffering. 

On July 14, 2003, BBC Online reported that officers from the Greater Manchester police department who investigated the Harold Shipman case had come under heavy criticism following the findings of an official enquiry into the case. According to the report, Dame Janet Smith, the judge heading the inquiry, said the enquiry had found that “three of Harold Shipman’s victims could have been saved if police had investigated properly.” In particular, the enquiry criticized the two Greater Manchester Police detectives who investigated the doctor calling them “inexperienced and unfit to handle the case” and indicated that their lack of experience resulted in “many missed opportunities to bring Shipman’s crimes to light.” Judge Smith said:

Chief Superintendent David Sykes, the senior officer on the case was, according to the enquiry “unable to give effective leadership but did not do anything about it,” Dame Janet said. The junior officer, Detective Inspector David Smith, was “out of his depth and made many mistakes but did not ask for help and later lied to cover them up,” Smith said. The enquiry also found that an internal policy inquiry into the two officers’ handling of the investigation was “quite inadequate.”

The report stated that Sykes has since retired from the police department and a misconduct investigation was been launched against Smith. A spokeswoman for Greater Manchester police told reporters that the department examined the report’s recommendations thoroughly. 

The following day The Guardian also carried a report of the findings and paid particular attention to Judge Smith’s criticism of the way in which the coroners had handled the case stating that, in future they:

The enquiry also found that the postmortem examination of victim Renate Overton, who lingered in a coma for 14 months after Shipman apparently gave her a fatal injection in 1994, were inadequate and there should have been an inquest. Judge Smith said:

The enquiry also criticized Alan Banks, the medical adviser to the West Pennine health authority, saying, “his respect for Shipman closed his mind to the fact that his colleague could have harmed a patient.”

On Tuesday, January 13, 2004 , Dr. Harold Shipman, was discovered at 6a.m. hanging in his prison cell. He apparently committed suicide in Wakefield prison, where he had been incarcerated since June of 2003 after being moved from Durham prison. The 57-year-old physician was serving 15 concurrent life sentences for his murders, beginning in January of 2000. It is estimated that he killed between 215 and 260 patients during his 23-year killing spree. His death had opened an inquiry as to how he was able to hang himself in his cell although suicide attempts are not particularly unusual for people facing life in prison. There is no evidence that he was on a suicide watch at Wakefield, even though he had been on suicide watches at Durham. A spokeswoman from Wakefield told BBC News that Shipman used bed sheets to hang himself from the window bars of his cell. “‘He was showing no signs whatsoever of pre-suicidal behavior at all,’ she said.” The Guardian reported that Shipman was “obnoxious and arrogant to the prison staff. Just before Christmas his enhanced status was reduced to basic. He was deprived of the television set in his cell and had to wear prison uniform rather than his own clothes.” Some of his privileges were given back to him shortly before he died.

To many of Shipman’s victims his suicide was a kind of final betrayal: not only will they never know why he killed their loved ones, but he escaped his punishment of spending the rest of his natural life in prison. Danny Mellor, whose mother was one of Shipman’s victims, told Reuters that Shipman was a coward, Mellor said:

The closest that anyone came to understanding what motivated Shipman was Dr. Richard Badcock, psychiatrist at Rampton Special Hospital. After speaking at length with Shipman, Dr. Badcock told the Telegraph that:

Having complete control over life and death, “that can give a sense of power and omnipotent invulnerability in itself,” Dr. Badcock theorized. Shipman’s wife and four children have never accepted that he was guilty. Primrose Shipman was very devoted to her husband. His transfer to Wakefield prison made it easier for her to visit him. At her home the woman who may have some answers, remains resolutely silent. She lives off her husband’s pension, which she has received ever since his suicide. Occasionally, she’s seen driving around in her small, battered car. But, in the main, she leads a reclusive life, out of sight and far away from the place where the man she loved caused such devastation.

Whatever the final count, there is no immediate plan to try the killer on future findings, nor would it serve much purpose because he’s already serving 15 concurrent life sentences. Instead, other cases are being investigated as they come to light, with coroners’ verdicts of unlawful killing continuing to mount. As they do, the question most asked is this: Why wasn’t he stopped sooner? Whatever the exact number, the sheer scale of his murderous activities meant that Shipman was catapulted from British patient killer to the most prolific known serial killer in the world. 

There remains some mystery about the whereabouts of his remains, with some claiming that his body is still in a Sheffield Morgue, while others believe that his family have custody of his body, believing that he may have been murdered in his cell, and wishing to delay his interment pending further tests. Shipman’s former patients are grateful indeed he was finally stopped. The feeling “I could have been next” will always haunt them.