A jury and an inquiry can sit through the same body of evidence and leave with different answers. So can a pair of toxicologists, a coroner and a High Court, a prison psychiatrist and a trial judge. In most criminal cases the disagreement is settled by the verdict and forgotten. In the cases that follow it was not, either because the first conclusion turned out to be wrong, because the second never reached a court, or because both were defensible and the law had to choose between them. What follows concerns eight such splits: an acquittal that followed three trials and two sets of exhumations, a confession that two appeal courts would not entirely accept, a family doctor against whom a police inquiry had turned up nothing months before a jury convicted him, inquests that returned open conclusions and were quashed, a review that condemned a police force while the officer who had arrested and released McArthur was held not guilty of disciplinary charges, death sentences cut to life, a psychiatric dispute that ended in an execution, and a sentence-reduction system that released a man after good-conduct reductions.
The cases do not share a moral. In some, the later conclusion corrected a mistake. In others it replaced a doubt with certainty that the record could not support. What they share is a point at which two bodies, each with expertise and authority, looked at the same facts and reached opposite results, and the person or the public paid for the gap.
Marie Besnard was arrested in July 1949, released from prison in April 1954 and acquitted by a jury at Bordeaux in December 1961. She had been charged in July 1949 with poisoning her second husband, Léon Besnard, a rope merchant in the small town of Loudun, in the Vienne department of western France. As more of her relatives were exhumed and analyzed, the charge grew to twelve deaths, among them both of her husbands, her parents and her parents-in-law. Besnard was never convicted. The case rested on a single question: on what a Marseille laboratory reported detecting in the exhumed bodies, and on whether the substance in question had been swallowed in life or had reached the bodies from the surrounding ground after death.
It began as local talk. On October 17, 1948, a fire destroyed the Massip family’s château at Montpensier. Auguste Massip blamed Marie Besnard and called it revenge for a letter he had sent. Within days, two children of the household’s domestic staff were identified as the ones who had started the fire while playing with matches. Massip, still convinced, drew up a list of twelve deaths and worked with the investigators: Commissioner Nocquet and Inspector Normand of the judicial police, whom the toxicologists Jean-Pierre Anger and Jean-Pierre Goullé describe as young and ambitious, and the investigating magistrate at Loudun, Pierre Roger.
On May 11, 1949, on the prosecutor’s order, Léon Besnard’s body was exhumed at Loudun. (Georges Meyer and his co-authors date the order May 10.) The analysis was entrusted to Dr. Georges Béroud, of the police scientific laboratory at Marseille, a sworn expert of the appeal court at Aix-en-Provence. Using the Marsh and Cribier methods, the standard tests of the day, he reported an amount of the substance that he judged well above normal, and he concluded that it had been absorbed before death and that poisoning was plausible. Marie Besnard was arrested in Loudun at nine in the morning on July 21, 1949, and told of the report at the police station in Poitiers. She disputed it. That evening she entered the prison at Poitiers, charged with poisoning her husband.
Her defense counsel, Henri Cluzeau of the Poitiers bar and René Hayot of the Paris bar, asked on August 1, 1949, for a second, independent expert examination. It was refused. Meanwhile the twelve people on Massip’s list were exhumed and analyzed at Béroud’s laboratory. On October 31, 1949, he reported the substance in eleven of the twelve bodies and none in the cemetery soil. On the strength of that report she was charged with eleven further deaths. Meyer and his co-authors put the total number of bodies exhumed by the police at 13, counting Léon’s. From her arrest until the eve of her first trial she was examined repeatedly by psychiatrists; one of them described her as "anormalement normale," abnormally normal, and judged her responsible for her actions.
The defense assembled its own scientists, among them a chemist attached to the Paris appeal court, Perperot, and Georges Schuster, a member of the Académie de Pharmacie, and its lawyer Albert Gautrat pressed one argument above all: that a sound analysis had to measure the substance in the soil around each plot. If the ground could not reach a body, he asked, why test the soil at all? The question would matter a great deal.
The first trial opened on February 20, 1952, before the assize court of the Vienne at Poitiers, 30 months after her arrest. The presiding judge, Edgar Favard, questioned her over several days, and the prosecution called about 80 witnesses. On the fourth day Béroud took the stand. The court raised problems with the handling and transport of the material he had analyzed, and he could not answer them. Asked about his methods, he gave confused replies. Then came the moment that defined the case. Béroud had stated that he could not mistake the substance for a look-alike element; in the Marsh test the two leave similar deposits on glass. Gautrat produced six test tubes prepared the night before by Dr. Roger Lebreton, each containing a deposit of the look-alike. Accounts of what followed differ in detail. Anger and Goullé write that Béroud said three of the six contained the substance he was looking for; Meyer and his co-authors write that he hesitated and handed two to the court usher as such. In both accounts none of the tubes held it, and the expert’s standing was badly damaged.
The next day Béroud was absent, citing illness, and a colleague, Aimé Médaille, took his place; his answers satisfied no one. Inconsistencies in Béroud’s work came to light, including labeling errors and contradictions between his reports. On February 24 the defense’s experts told the court that the analyses lacked rigor. Béroud returned, supported by two gendarmes, and refused to debate with Schuster. Perperot testified that he had detected the substance in the soil of the Loudun cemetery, contrary to Béroud’s results. He also pointed out that one report attributed a death to a lead compound although no one had tested for lead. The defense asked for a new expert examination so that the court could rule on sounder reports, and the court agreed. There was no verdict. Meyer and his co-authors write that Béroud’s career as an expert ended at Poitiers. Marie Besnard went back to prison.
On March 22 and 23, 1952, the bodies were exhumed a second time. Three Paris professors were appointed, Émile Kohn-Abrest, René Fabre and Henri Griffon, who headed the laboratory of the Paris police prefecture, and the forensic doctor René Piedelièvre took part. Besides the old tests they used a new technique, neutron activation, a nuclear method that Griffon had pioneered for this purpose in 1951. Meyer and his co-authors write that the exhumation was carried out in chaotic conditions. After about a year, the experts delivered a report that located the substance in the cemetery soil, contradicting Béroud. The questions the case now turned on were scientific ones that the earlier inquiry had not addressed. Was the substance in the Loudun soil soluble? Could it pass from the soil into a body after death? Could rainwater carry it from one plot to another?
In 1953 the case was transferred from Poitiers to the assize court at Bordeaux, on grounds of public order. The second trial ran from March 15 to April 1, 1954, with Henri Pourquery de Boisserin presiding. The advocate general told the court that only six of the eleven deaths still remained in question; for the others, prosecution was barred by time or the levels were too low. From March 24 the experts took the stand. Fabre, Kohn-Abrest and Griffon reported large amounts. Under questioning, Fabre admitted that he did not know whether the substance dissolves in a decomposing medium. Kohn-Abrest held that it had been absorbed before death, but his figures for Marie Besnard’s mother implied a quantity that Anger and Goullé describe as implausible. The defense challenged Griffon’s figures, arguing that uncertainties had accumulated through his methods of calculation. A report by the physicist Frédéric Joliot-Curie also supported the finding of high levels, and Piedelièvre confirmed the 1952 results, though in more qualified terms than Béroud had used. The court ordered new expert reports, and she was released on April 12, 1954.
A third trial opened at Bordeaux on November 20, 1961, and ran into December. The jury answered no on her guilt in each of the deaths, and she was acquitted. She returned to Loudun and died there in 1980. Anger and Goullé, who re-examined the file in 2006, titled their study a quarrel of experts that ended in an acquittal. Three scientists writing in L’Actualité Chimique in 2003 drew a sharper conclusion: that the presence of the substance in a body or in hair does not by itself prove poisoning, and that rumor rather than evidence had driven the prosecution. Two sets of experts, working on the same bodies, had reached opposite results, and it took twelve years and three trials for a jury to answer.
Between 1973 and 1979, eleven fires in and around Hull, in northern England, killed 26 people. All but one were recorded at the time as accidents. In 1980 a 19-year-old man who called himself Bruce Lee confessed to the one fire that had plainly been set on purpose, a blaze in December 1979 that killed three brothers, and then, over the following weeks, to ten others. He was born Peter Dinsdale and later used the names Peter Mawson and Peter Tredget, according to the Criminal Cases Review Commission. At Leeds Crown Court on January 20, 1981, he pleaded guilty to 26 counts of manslaughter on the ground of diminished responsibility and to 11 counts of arson, and was ordered to be detained without limit of time at Park Lane Hospital, Liverpool, under the Mental Health Act 1959.
The case against him was his own confession. The prosecution relied mainly on his statements, with no identification or forensic evidence tying him to any fire, according to the Commission and the arguments reported from his 2021 appeal. And at the time of several of the fires, other bodies had already reached the opposite conclusion. The inquest on the first child to die, in June 1973, recorded death by misadventure. A public inquiry had concluded that the fire at Hessle, in January 1977, was accidental before he confessed to it. The fire brigade and a Home Office forensic officer had put the April 1977 fire in Hull down to accidental causes. In each of these a formal inquiry into the facts had concluded that nobody set the fire; then a young man in police custody said that he had.
His circumstances in 1980 are set out in the Court of Appeal’s 2022 judgment. A crime intelligence sheet described him as semi-paralyzed down one side. The senior detective, Detective Superintendent Sagar, recorded in September 1980 that he was educationally subnormal and had attended special schools. His IQ was put at about 73, and psychologists who examined him for the later appeal described severe deprivation and abuse in childhood. He was brought in for questioning in Hull on June 6, 1980, during an operation in which a number of local men were questioned, and interviewed at a Hull police station by Sagar, with two other officers present. The interview began at 8:05 in the evening and ended at 1:25 the next morning, about five and a half hours in all. No solicitor and no responsible adult was present, his barrister told the Court of Appeal in 2021. He confessed to setting the December 1979 fire and was then formally arrested and cautioned again.
Whether he had been under arrest earlier became a point of dispute. A custody record said one of the detectives had arrested him in Hull; Sagar later added a handwritten amendment recording the arrest at 11:30 that night. The court noted that Sagar gave varying accounts over the years: that the young man had asked to be held, that he had been invited, that he had been arrested and brought in, or that he had been detained along with other men. The Commission concluded that there was not enough evidence to show the arrest was unlawful.
The explanations he gave for the fires changed repeatedly. They included money, being the accomplice of a more skilled arsonist, a hatred of people, and a liking for fire engines; his counsel told the 2021 hearing that he had also blamed his upbringing, drink, and the relief fire gave him. Doctors who saw him soon afterward recorded the same instability. Dr. Snowden, reporting in June 1981, determined that he wavered between accepting responsibility for all of the fires, some of them, or none. Dr. Neill, reporting in November 1982, described him as "highly suggestible, unreliable."
The Court of Appeal first looked at the case in December 1983, in R v Bruce George Peter Lee, before Lord Justice Ackner, Mr. Justice Glidewell and Mr. Justice Leggatt. It quashed the convictions for the fire at Hessle, one count of arson and eleven of manslaughter, and left the rest standing. The Commission referred the remaining convictions to the Court of Appeal in October 2019. In February 2022, Lord Justice Fulford, Mr. Justice Hilliard and Lord Hughes quashed the convictions for two further fires, the June 1976 fire in which a baby of 13 months died and the April 1977 fire in which a girl of 13 and a boy of 7 died. They upheld the rest as safe, and left the hospital order undisturbed. In June 1976 he had been living in care in Driffield, about 30 minutes by train from Hull, the judgment records. For the rest, the court’s reasoning was that he had pleaded guilty in open court with legal advice. Twelve manslaughter convictions and eight arson convictions stand. ITV News reported him held in a secure mental hospital as of February 2022.
The case shows the two conclusions side by side. A coroner, a public inquiry and fire investigators saw accident. A young man’s own words saw otherwise, and for two of the fires an appeal court ruled four decades later that the words could not be trusted. For the remaining eight, a guilty plea in open court with legal advice carried more weight than the doubts.
Harold Shipman was a family doctor in Hyde, a town on the eastern edge of Greater Manchester. On January 31, 2000, a jury at Preston Crown Court convicted him of murdering 15 of his patients and of forging the will of the last of them, Kathleen Grundy. He was 54. The judge, Mr. Justice Forbes, passed 15 life sentences and told him: "In your case, life must mean life. You must spend the remainder of your days in prison."
Two years earlier, the police had looked at him and reached the opposite conclusion. A police inquiry in the spring of 1998 turned up nothing against him. He was caught that summer only because he typed a will leaving an 81-year-old patient’s estate to himself, and her daughter, a solicitor, refused to believe it. He was arrested on September 7, 1998, charged with the murder of Kathleen Grundy and with forging her will. The Shipman Inquiry, chaired by the High Court judge Dame Janet Smith, devoted its Second Report to the police investigation of March 1998 and published it on July 14, 2003.
The inquiry’s own conclusions about the extent of what he did were far larger than anything a jury had been asked to decide. Its First Report in July 2002 concluded that he had killed at least 215 patients, with a "real suspicion" over 45 more and too little evidence to decide 38. In January 2005 her final report went further: "My overall conclusion, therefore, is that Shipman killed about 250 patients between 1971 and 1998, of whom I have been able positively to identify 218." These are the findings of an inquiry, not convictions. Shipman never admitted a single killing. He died by suicide at Wakefield prison on January 13, 2004, the day before his 58th birthday. The Prisons and Probation Ombudsman reported on the death in 2004.
The two records, the jury’s and the Inquiry’s, stand a long way apart: 15 deaths proved at trial, and about 250 attributed to him by a judge who examined his whole career. Dame Janet concluded that he had probably caused the deaths of 10 to 15 patients at Pontefract General Infirmary, where he was a junior doctor between 1970 and 1974, and the British Medical Journal reported that she judged he "probably began to kill patients within a year of leaving medical school." The Inquiry identified his first victim in Todmorden: Eva Lyons, 70, who had cancer, died in March 1975. Peter Devine, who went through the registrar’s records, later wrote in the Yorkshire Post that the Inquiry concluded Eva Lyons had been murdered, identified a suspicion of unlawful killing in six other cases, and judged the evidence insufficient in five. Shipman signed 22 death certificates in Todmorden, eight of them over five days in 1975.
His career also offers an earlier, smaller case of two bodies reaching different conclusions. In 1976 he was convicted of offenses involving the misuse of pethidine and reported to the General Medical Council. He was fined. He was not struck off. After he sought treatment, the Council took no further action, the British Medical Journal recorded, and he was allowed to keep practicing. In 2007 Chris McCafferty, the MP for Calder Valley, which includes Todmorden, put the local view bluntly in a debate at Westminster Hall: he had been caught abusing drugs in Todmorden and was then "able to ... carry on practising in Hyde, with no monitoring at all."
The Inquiry’s findings by period show how the totals accumulated. At the Donneybrook practice in Hyde, where he was a partner from 1977 to 1992, it concluded that he killed 71 patients, The Week reported. For his later years at his own surgery, from 1992 to 1998, it concluded that he killed 143. The Chief Medical Officer had commissioned an audit of his practice from Professor Richard Baker of the University of Leicester, who determined that the excess of deaths among his patients was evident from his first years in practice and continued throughout his career. A prospective audit of all patients registered with him from 1987 recorded 98 more deaths among women than expected between 1987 and 1998, and 12 fewer than expected among men. Baker calculated that Shipman was present at about 20 percent of the deaths he certified, against a norm of 0.8 percent, and relatives present at 40 percent, against 80 percent for other doctors, the Canadian Medical Association Journal reported.
The inquiry’s six reports led to changes in how deaths are certified and controlled drugs monitored. The government published its response in February 2007. In September 2024 the Welsh Government announced the coming into force of death certification and medical examiner reforms. A police inquiry that turned up nothing, a trial that proved fifteen, and a public inquiry that attributed some two hundred and fifty: the same doctor and the same patients, three answers.
Stephen Port, a chef who lived in Barking, in east London, was convicted by a jury at the Central Criminal Court on November 23, 2016, of the murders of four young men, Anthony Walgate, Gabriel Kovari, Daniel Whitworth and Jack Taylor, and of 18 further offenses against other young men: eight sexual offenses and ten counts of administering a substance with intent. Mr. Justice Openshaw ordered on November 25, 2016, that he would never be released. The four deaths had occurred between June 2014 and September 2015. For more than a year the Metropolitan Police treated them as separate, non-suspicious cases.
The first coroner to look at two of them drew a cautious conclusion. On June 19, 2015, the East London coroner held inquests into the deaths of Kovari and Whitworth and recorded open conclusions in both. A police officer told her that Whitworth’s family had identified his handwriting on a note left with him. The coroner said she could not be satisfied that Kovari had been unlawfully killed, and that her concerns about a third party’s involvement in Whitworth’s death "cannot be allayed by the evidence." She raised those concerns with police; the coroner who heard the later inquests said they should have prompted officers to reassess their work. The note, it later emerged, had been written by Port himself.
Port was arrested in October 2015, after the fourth death, when a CCTV still of Taylor walking beside a tall man at Barking station was recognized as Port. The first inquests, held before anyone knew he was responsible, stood on a record that was now incomplete. The East London Senior Coroner asked the High Court to quash them. On November 28, 2017, Lord Justice Holroyde and Mr. Justice Green did so, quashing the 2015 inquisitions into the deaths of Kovari and Whitworth and ordering fresh investigations, saying the new evidence made them "both necessary and desirable in the public interest" and that it would be sensible to hear all four deaths together. The court stressed that the earlier coroner was not at fault; she had not had the full picture. The High Court also recorded that information from a false name Port had used in correspondence with Kovari’s former partner in Spain had reached the original inquest.
The fresh inquests, led by a judge appointed by the Chief Coroner, heard evidence in the autumn of 2021 at Barking. They examined most closely the investigation into Walgate’s death, for which Port had been arrested on June 27, 2014, on suspicion of perverting the course of justice, and for which he was jailed for eight months in March 2015. Port’s laptop had been seized, but it was not sent for forensic analysis for about ten months. When the material came back, in June 2015, the officer who reviewed it reported only selfies, videos and messages as relating to Port’s "lifestyle" and did not locate the internet searches that mattered. "It was there on his laptop and we should have got it," the senior detective on the case, Detective Sergeant Martin O’Donnell, told the inquests. He called his failure to log a 2012 allegation against Port "a terrible mistake." Officers had run a check on Walgate on the Police National Database, but not on Port; that check would have shown the 2012 allegation and a British Transport Police record from June 2014 concerning Port at Barking station. The Crown Prosecution Service was not told that Port was a suspected sex offender when it ruled out a homicide charge. Requests by borough officers for the Met’s specialist murder teams to take over were turned down. Kovari’s death was classed as non-suspicious within five hours; the coroner later noted that an inspector admitted he did not know the cause.
On December 10, 2021, the jury concluded that all four men had been unlawfully killed, and returned narrative conclusions for three of them. It concluded that failings in the police investigations probably contributed to the deaths of Kovari, Whitworth and Taylor. "We believe there were fundamental failures in these investigations, which were at a basic level," the jurors wrote. They acknowledged the pressures on borough officers but said the failings "cannot be overlooked." They described "a complete breakdown of oversight of the investigation" and said that "basic lines of inquiry were not followed." In January 2022 the coroner, Judge Munro, published a prevention of future deaths report. She said she had been "extremely concerned and disappointed" by the evidence of a series of errors, and she warned that the word "unexplained" in the Met’s policy on deaths "may once again distract officers" from treating a death as suspicious until shown otherwise.
The Met apologized for the failings after the inquest finding, the Barking and Dagenham Post reported, and in August 2022 it settled civil claims with the families of three of the men. The Independent Office for Police Conduct, which had looked at the officers earlier, reopened its inquiry, and in November 2023 it told eight current and former officers that they were under investigation for possible gross misconduct. In 2015 the official record said that unlawful killing could not be established in either of the two cases before the coroner. Six years later another said that all four men had been unlawfully killed and that police failings had probably contributed to three of the deaths.
Bruce McArthur pleaded guilty in a Toronto courtroom on January 29, 2019, to the first-degree murders of eight men: Skandaraj Navaratnam, Abdulbasir Faizi, Majeed Kayhan, Soroush Mahmudi, Kirushna Kumar Kanagaratnam, Dean Lisowick, Selim Esen and Andrew Kinsman. Most had ties to the Church and Wellesley Village, a Toronto neighborhood, and six were immigrants or refugees from South Asia or the Middle East. He was 67, a self-employed landscaper. On February 8, 2019, Justice John McMahon of the Ontario Superior Court sentenced him to life in prison with no chance of parole for 25 years; the Crown had asked for 50.
For years, friends of the men said they believed someone was preying on men from the neighborhood. In November 2012 Toronto police formed a task force, Project Houston, to investigate the cases of Navaratnam, Faizi and Kayhan. On December 17, 2012, it obtained the first of about 40 sealed judicial orders. The task force interviewed McArthur in 2013, and court documents showed that police linked him to three of the victims during that interview, CP24 reported in 2019. The task force closed in 2014. Officers at the time suggested that one of the men had left his family, and his wife, believing he had abandoned them, later divorced him, Global News reported. In June 2016 McArthur was arrested and released without charge after another man reported that McArthur had assaulted him in his van. He was caught only in January 2018, after the name "Bruce" on Kinsman’s calendar gave a second task force its lead.
An earlier conclusion came from a psychologist. After a 2001 assault, McArthur pleaded guilty in January 2003, and a psychologist’s report in March 2003 identified no mental health problem that explained the offense and rated his risk of violence as very minimal, CBC News reported. On April 11, 2003, he received a conditional sentence of two years less a day, to be served in the community, and on June 3, 2014, the Parole Board of Canada granted him a record suspension that in effect removed the convictions from his public criminal record.
The second conclusion came from an independent review led by the retired judge Gloria Epstein. Her report, Missing and Missed, was transmitted to the Toronto Police Services Board on April 9, 2021, and concluded that the police handling of the men’s cases had serious flaws and that systemic discrimination had played a part. The civilian board that oversees the force did not know about Project Houston while it was active, the review said. Global News called the report "damning"; Xtra summarized it as a "profound systemic failure." Four months later, in August 2021, CP24 reported that the Toronto officer who arrested and released McArthur in 2016 had been held not guilty of disciplinary charges. In 2018 the police chief had already released an interview tape to counter claims of victim blaming. The review’s findings concerned the handling of the cases across the force; the disciplinary charges concerned one officer.
Junko Ogata and Futoshi Matsunaga were convicted of the deaths of seven people in Kitakyushu, in Fukuoka Prefecture, Japan, between February 1996 and June 1998. Six of the dead were Ogata’s own family: her father, her mother, her younger sister, her sister’s husband, and her sister’s two children, a girl of 10 and a boy of 5. The seventh was the father of a 17-year-old girl whose escape in March 2002 brought the case to light. The court concluded that Matsunaga was the mastermind and that Ogata carried out his intentions. No bodies were ever recovered.
The case was built in sequence. On March 29, 2002, the couple were indicted for confining and injuring the girl. On April 25 they were indicted for confining and injuring a second woman, and on June 7 for fraud and robbery against the same woman. On September 18, 2002, they were arrested on a murder charge for the first time. Between October 8, 2002, and June 20, 2003, prosecutors filed seven murder indictments, one for each death: the niece, 10, on October 8; Ogata’s father on November 2; her mother on December 27; the nephew, 5, on February 1, 2003; the girl’s father on February 23; her sister on March 18; and her sister’s husband on June 20. A former prosecutor told the journalist Kazuteru Ono that at the indictment stage prosecutors decided to charge every death as murder, without serious debate about reducing any of them to injury resulting in death, though he acknowledged that the evidence on Ogata’s father’s death had weaknesses and that charging it as murder had been a bold choice. Investigators told Ono that Ogata’s confession was the most important single factor in the case; it gave much greater weight to the circumstantial evidence, which Matsunaga had not expected.
The first answer came from the Kokura branch of the Fukuoka District Court on September 28, 2005: death for both defendants. The court’s findings departed from the prosecution’s on one point. It held Ogata’s father’s death to be injury resulting in death, not murder. The prosecution’s theory of seven murders had become six murders and one injury resulting in death.
On September 26, 2007, the Fukuoka High Court gave a second answer. It upheld Matsunaga’s death sentence but replaced Ogata’s with life imprisonment, finding that her position was markedly different from his. Bunshun Online reported that Matsunaga had directed Ogata to kill the boy and that the High Court took into account in sentencing that she had tried to persuade Matsunaga not to. The Supreme Court dismissed the prosecutors' appeal, and Matsunaga’s, on December 12, 2011, which made her life sentence final and his death sentence final on the same day. As of July 2025 Bunshun Online described Ogata as a serving prisoner and Matsunaga as a death-row inmate.
Two courts examined the same record. The district court sentenced both defendants to death; the High Court concluded that Ogata’s position was markedly different from Matsunaga’s. A prosecutor’s assessment of the evidence had been trimmed once, in the father’s case, and a court’s assessment of the sentence was revised again on appeal.
Between August 1988 and June 1989 four girls aged 4 to 7 were killed in Saitama Prefecture and Tokyo: Mari Konno, 4; Masami Yoshizawa, 7; Erika Namba, 4; and Ayako Nomoto, 5. The man responsible was Tsutomu Miyazaki, a 26-year-old photo technician who lived with his family in western Tokyo. He was caught in July 1989 not by the large investigation that had hunted him for ten months but by the father of a 6-year-old girl in a park in Hachioji. Anime News Network, relying on the Mainichi Shimbun, gives the date as July 23, 1989. He was arrested and, under questioning by the First Investigation Division of the Tokyo Metropolitan Police Department, confessed in August 1989.
His trial lasted seven years, and the question that took most of that time was what kind of person the defendant was. The court ordered repeated psychiatric examinations. Amnesty International Japan wrote in its report on mental health and the death penalty that he was diagnosed with dissociative identity disorder or schizophrenia. The writer Ryuzo Saki, quoted by the Mainichi in 2008 as reported by J-CAST News, noted that there had been three differing psychiatric opinions at trial. The Fuji TV news team describes two lengthy evaluations and says the court accepted a finding of personality disorder. On April 14, 1997, the Tokyo District Court sentenced Miyazaki to death. Amnesty International Japan summarizes the ruling this way: the court acknowledged the psychiatric diagnoses but concluded that he had understood the seriousness and consequences of what he was doing, and that he bore criminal responsibility. Japan Today, reporting in 2008, said the court judged him aware of his actions and accountable.
There were thus two conclusions about the same man, and the court chose between them. Psychiatrists who examined him for the court disagreed, and Amnesty International Japan and his lawyer maintained that he was mentally ill. The courts rejected the argument that his responsibility was reduced. Some commentators, among them Saki, believed he feigned illness. The Tokyo High Court upheld the death sentence on June 28, 2001, according to Amnesty International Japan. During the appeal the Tokyo Detention House told the High Court in writing that Miyazaki had been given psychiatric medication continuously since 1996, and that from 1999 he had also been given antipsychotic drugs prescribed for schizophrenia, according to a 2008 written question in the House of Representatives.
In 2017 Fuji TV obtained recordings of about two weeks of his 1989 interrogation and broadcast them for the first time on October 7 of that year. In them Miyazaki chatted with the detectives, at times joked about his poor sense of direction, at times cautiously tested what they wanted, and admitted his crimes. The detectives did not see in him the obsessive the press was describing, and nothing in the interrogation suggested the abnormality he would display in court, the Bunshun Online reviewer of the journalist Hideki Yasunaga’s 2019 book on the tapes wrote. The Fuji TV team said that after hearing the tapes they wondered whether the public had been deceived. No court ruled on what the difference between the man on the tapes and the man in the courtroom meant.
Miyazaki was executed on June 17, 2008. The next day Nobuto Hosaka, a member of the House of Representatives, submitted a written question to the government about the execution. He asked whether Miyazaki’s psychiatric treatment had continued up to the day of his death, who had assessed his fitness to be executed, and whether the minister had considered his mental state himself. A ministry official declined to describe Miyazaki’s recent treatment, citing privacy. The lawyer Maiko Tagusari, writing for the World Coalition Against the Death Penalty, described herself as indignant that her client had been executed without notice, and Amnesty International Japan later used the case in its report on mental illness and the death penalty in Japan, based on research carried out in 2009.
Somkid Phumphuang was convicted of killing five women in five Thai provinces between January and June 2005, in Mukdahan, Lampang, Trang, Udon Thani and Buri Ram. He was tried in five separate cases in the Criminal Court in Bangkok, each under its own case number, and every one of them ended in life imprisonment, although three of them began with death sentences. The Criminal Court sentenced him to death in the Lampang case; on March 2, 2010, the Appeals Court reduced the sentence to life imprisonment. In the Buri Ram case the court also imposed the death penalty and then commuted it to life because he had confessed. In the Mukdahan case he was first sentenced to death, and the sentence became life after he pleaded guilty, Thai PBS reported.
He contested the Trang case. On appeal he argued that the evidence did not prove he was the person who had killed her. The Appeals Court, in a ruling read on July 31, 2013, disagreed. It pointed to witnesses who described his appearance and identified him, and to forensic evidence including a DNA match. It concluded that he had been in the room when she died and that he was the person who killed her. On the theft count it gave him the benefit of the doubt, because no witness could confirm that she had been carrying the cash. It rejected his plea for a lighter sentence, saying he had shown no fear of the law, had fled and made trouble for the police, and had shown no remorse, denying the charges throughout. With that ruling, MGR Online reported, all five cases had been decided. He was 50.
Police and the man himself gave opposite accounts of why he had acted. The Thaiger reported in 2019 that police had concluded the 2005 crimes were premeditated and committed for money, and had rejected his claim that he acted in sudden anger. The same claim came back fourteen years later. When he was arrested in December 2019, Matichon reported, he said he had killed in a fit of rage, and the Bangkok Post carried the same claim.
By then the system that had sentenced him to life had also concluded that he could be released. Under Thailand’s system of sentence reductions for good conduct, he left Nong Khai Provincial Prison in May 2019 after serving about 14 years. In December 2019 a 51-year-old woman, Ratsami Mulichan, died in Kranuan district, Khon Kaen province. The Khon Kaen Provincial Court issued a warrant for premeditated murder on December 15. He was arrested on December 18, 2019, in Nakhon Ratchasima province. His release, and what followed, set off a national argument about how Thailand reduces sentences, with the Bangkok Post reporting that the parole board was under fire and The Nation reporting that the prime minister sought a revision of the sentence-reduction system. In March 2021 the Khon Kaen Provincial Court sentenced him to death for her murder.
The disagreements above resolved in different ways, and none of them was settled in a way that satisfied everyone involved. In Loudun, a jury answered no in every one of twelve deaths after three trials and two sets of exhumations, and an expert’s career had ended at the first. In Hull, appeal courts would not accept the confessions to three of the eleven fires, but held that a guilty plea with legal advice stood for the rest. In Hyde, a police inquiry had turned up nothing, a jury convicted him of fifteen murders, and an inquiry judge concluded that the true number was about 250. In Barking, open conclusions in 2015 were quashed and replaced in 2021 by findings of unlawful killing and of police failure. In Toronto, a review condemned a system and the officer was held not guilty of disciplinary charges. In Fukuoka, a death sentence was reduced for one defendant and left for the other. In Tokyo, a defendant diagnosed by some and doubted by others was executed. In Thailand, a system of reductions for good conduct released a man who within seven months was in custody again.
The open conclusions of 2015 remain part of the Port record, the police inquiry of 1998 part of the Shipman record, and eight of the Hull fires remain the subject of convictions that two appeal courts declined to disturb.
• October 17, 1948: a fire destroys the Massip family’s château at Montpensier; Auguste Massip draws up a list of twelve deaths.
• May 11, 1949: Léon Besnard’s body is exhumed at Loudun.
• July 21, 1949: Marie Besnard is arrested in Loudun and charged with poisoning her husband.
• October 31, 1949: Dr. Béroud reports a toxic substance in eleven of twelve bodies.
• February 20, 1952: the first trial opens at Poitiers; the court orders new expert reports after Béroud’s testimony.
• March 15 to April 1, 1954: the second trial at Bordeaux; new expert reports are ordered, and Besnard is released on April 12, 1954.
• December 1961: the third trial at Bordeaux, opened on November 20, ends in acquittal.
• June 1973 to December 1979: the eleven fires in Hull and Hessle, all but one recorded as accidents.
• March 1975: Eva Lyons, the first victim the Shipman Inquiry identified, dies in Todmorden.
• 1976: Harold Shipman is convicted of offenses involving pethidine and reported to the General Medical Council.
• June 6, 1980: Bruce Lee is brought in for questioning in Hull and confesses to the December 1979 fire.
• January 20, 1981: Lee pleads guilty at Leeds Crown Court and is ordered detained at Park Lane Hospital.
• December 1983: the Court of Appeal quashes the Hessle convictions.
• August 1988 to June 1989: four girls are killed in Saitama Prefecture and Tokyo.
• July 1989: Tsutomu Miyazaki is arrested in Hachioji; he confesses in August.
• April 14, 1997: the Tokyo District Court sentences Miyazaki to death.
• Spring 1998: a police inquiry finds nothing against Shipman; he is arrested on September 7, 1998.
• January 31, 2000: Shipman is convicted of 15 murders at Preston Crown Court.
• June 28, 2001: the Tokyo High Court upholds Miyazaki’s sentence.
• March 29, 2002: Ogata and Matsunaga are indicted for confining and injuring a 17-year-old girl.
• July 2002: the First Report of the Shipman Inquiry concludes that Shipman killed at least 215 patients.
• March and April 2003: a psychologist’s report rates McArthur’s risk of violence as very minimal; on April 11 he receives a conditional sentence.
• January 13, 2004: Shipman dies by suicide at Wakefield prison.
• January 2005: the Shipman Inquiry’s final report puts the figure at about 250.
• January to June 2005: five women are killed in five Thai provinces; Somkid Phumphuang is arrested on June 29, 2005.
• September 28, 2005: the Fukuoka District Court sentences Ogata and Matsunaga to death.
• September 26, 2007: the Fukuoka High Court replaces Ogata’s sentence with life imprisonment.
• June 17, 2008: Miyazaki is executed; a written question follows in the House of Representatives on June 18.
• March 2, 2010: the Appeals Court reduces Phumphuang’s Lampang death sentence to life.
• December 12, 2011: the Supreme Court makes the Ogata and Matsunaga outcomes final.
• November 2012: Toronto police form Project Houston.
• July 31, 2013: the Appeals Court upholds Phumphuang’s Trang conviction.
• 2013 and 2014: McArthur is interviewed by police; the task force closes in 2014.
• June 2014 to September 2015: the four deaths in Barking.
• June 19, 2015: the first inquests record open conclusions for Kovari and Whitworth.
• October 2015: Stephen Port is arrested.
• June 2016: McArthur is arrested and released without charge.
• November 23, 2016: Port is convicted of four murders.
• November 28, 2017: the High Court quashes the 2015 inquests.
• January 18, 2018: McArthur is arrested.
• January 29 and February 8, 2019: McArthur pleads guilty and is sentenced.
• May 2019: Phumphuang is released after sentence reductions.
• October 2019: the Criminal Cases Review Commission refers the Lee convictions to the Court of Appeal.
• December 18, 2019: Phumphuang is arrested again.
• March 2021: Phumphuang is sentenced to death for the 2019 murder.
• April 9, 2021: the Epstein review is transmitted; in August 2021 the Toronto officer is held not guilty of disciplinary charges.
• December 10, 2021: the fresh inquest jury concludes that all four men were unlawfully killed.
• January 25, 2022: the coroner publishes a prevention of future deaths report.
• February 8, 2022: the Court of Appeal quashes two more of the fire convictions and upholds the rest.
• August 2022: the Met settles civil claims with the families of three of the men.
• November 2023: the Independent Office for Police Conduct tells eight officers they are under investigation for possible gross misconduct.
• September 2024: the Welsh Government announces the coming into force of death certification and medical examiner reforms.