Chapter 1: Unheeded warnings, the nurses’ concerns and their context

In order to understand the context of events as they emerge from the documents reviewed, it may be helpful to recall that the case of Dr Harold Shipman coincided with this period.

Dr Shipman was a GP from 1974. Throughout his career as a GP, Dr Shipman enjoyed a high level of respect within the communities in which he worked. In Hyde in Greater Manchester, he was extremely popular with his patients, particularly his elderly patients. 

In September 1998, Dr Shipman was arrested, interviewed and charged with the murder of Mrs Kathleen Grundy, and with other offences associated with the forgery of her will, under which he was to be the sole beneficiary of her estate. He was subsequently suspended from practice and charged with 14 further murders. 

In January 2000, Dr Shipman was convicted of 15 counts of murder and one of forging Mrs Grundy’s will. He was sentenced to 15 terms of life imprisonment and, for the forgery, a concurrent term of four years’ imprisonment. The trial judge said that his recommendation to the Home Secretary would be that Dr Shipman should spend the remainder of his days in prison. 

The Professional Conduct Committee of the General Medical Council subsequently erased Mr Shipman’s name from the medical register.

Between August 2000 and April 2001, the Coroner for South Manchester conducted inquests into the deaths of 27 patients of Dr Shipman, recording verdicts of unlawful killing in 25 cases and open verdicts in the remaining two. In January 2001, the Secretary of State for Health established the Shipman Inquiry, chaired by Dame Janet Smith DBE. On 18 May 2001, the Coroner opened inquests into a further 232 deaths. The Shipman Inquiry published six reports between July 2002 and January 2005. Mr Shipman died in 2004 by hanging himself in his cell at Wakefield Prison.

One further point of context concerns Graham Pink, a nurse at Stepping Hill Hospital in Stockport. Nurse Pink worked in wards for elderly patients and complained about the poor standards of care resulting from insufficient staffing from 1989 to 1993 and other concerns, including record keeping. 

Nurse Pink was dismissed from his post as he was accused of breaching patients’ confidentiality when his letters of complaint to an MP became public. The circumstances of Nurse Pink’s allegations and his sacking attracted publicity, drawing attention to the risk of dismissal for NHS staff who might voice concerns publicly. Nurse Pink was successful at a subsequent industrial tribunal, where Stockport Health Authority sought to justify its position by saying that the defence of patient confidentiality was the golden rule of nursing.