Shipman inquiry calls for major changes in death certification

Sweeping changes are needed to plug loopholes in the systems of death and cremation certification that allowed the English GP Harold Shipman to murder more than 200 patients, the Shipman inquiry says in a discussion paper this week.

Shipman, from Hyde, Greater Manchester, who became Britain's most prolific serial killer, killed 215 patients, according to the inquiry's findings. Many of the victims, mainly middle aged and elderly women, died unexpectedly, without any history of terminal or life threatening illness.

Shipman avoided referrals to the coroner by claiming that he was in a position to certify the cause of death and by persuading relatives that no postmortem examination was necessary.

“In order to afford the public a proper degree of protection,” the inquiry concludes, “measures must be devised to ensure that all unexpected deaths are reported and their cause properly investigated.”

The inquiry, chaired by High Court judge Dame Janet Smith, is asking for responses by 25 November 2002. A series of seminars will follow next January. Work by the inquiry so far has revealed two “major underlying weaknesses” in the current system.

Firstly, no exchange of information takes place between those involved in death certification and registration and those taking part in cremation certification. The patient's medical records are not compared with the information on the death certificate, and the lack of communication means no single person has an overview of the circumstances surrounding the death.

Secondly, the deceased's family is not involved in providing information about or evaluating the cause of death, or in the cremation authorisation.

“Because he knew that the family would never be told what he had said or written about a death, it was possible for Shipman repeatedly to lie on cremation forms B, to the doctors completing the forms C [which must be completed by a second doctor] and, when necessary, to the coroner's office,” says the paper.

The inquiry recommends that any new system of death certification should apply to deaths in hospital as well as in the community. Any new system must minimise any risk of the successful concealment of an unlawful death but should also “provide a safeguard against attempts to conceal incidents of medical error or lack of proper medical care which result in death, as well as unlawful acts by persons other than health professionals,” says the paper.

The inquiry proposes a new body of “medical coroners,” responsible for investigating and determining all issues relating to the cause of death, leaving the “judicial coroner” to determine factual issues and disputes surrounding the death. Doctors who certify death would have to report all unexpected deaths to the medical coroner, and a new form of death certificate would include details of the deceased's recent medical history and consultations.

Figure.

JOHN GILES/PA

Official: death certificates must change post-Shipman