There were many inconsistencies in Shipman’s behaviour and recording of the death. He said the patient had been in a coma for forty-five to fifty minutes, yet no nursing staff were called. He said that he had attended to Mr Brewster for the last eighteen hours of his illness, yet the patient had still been at home nine hours earlier. He said the patient had deteriorated in the ambulance en route to the hospital, yet this had not been noted when Mr Brewster was admitted, by the family, the nursing staff or by Shipman himself in his admission notes. The family had not been called, which they probably would have been had Mr Brewster been in a coma. Shipman specifically recorded the phrase ‘no need to report to coroner’ despite the fact that there was a ruling by the local coroner that all deaths within twenty-four hours of admission to the hospital should be reported. All of these inconsistencies, coupled with the fact that Shipman was again present at the death, and the time of death was in the evening, led to the conclusion that this death was a murder.

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