The creation of a team of coroners' investigators trained to “think dirty” about the causes of death, and new powers for coroners to order raids on premises such as GPs' surgeries to seize documents or drugs, were among radical reforms to the coroners' system in England and Wales recommended this week by the official inquiry into the crimes of the serial killer Dr Harold Shipman.
Figure 1.
Harold Shipman: responsible for 215 deaths
Credit: MANCHESTER POLICE/AP
Dame Janet Smith, the appeal court judge heading the inquiry, said that the 100 year old system for death registration and the procedures for cremation certification and coroner investigation were inadequate and had failed to deter Shipman from killing his patients or to detect his killings afterwards.
Her findings will give an extra push to government plans to reform the coroners' system. A report of the fundamental review of coroner services and death certification—commissioned by the Home Office—identified similar inadequacies and recommended comprehensive reform when it was published in June. A draft bill is expected next summer, with legislation in 2004-5.
The home secretary, David Blunkett, said he had asked the review's chairman, Tom Luce, to look at links between his report and the findings of the Shipman inquiry. He said that Home Office officials were discussing “as a matter of urgency” proposals to strengthen procedures for cremation certification and to improve practices in coroners' offices. He also said that “guidance to deliver more robust procedures and practices” would be issued as soon as possible.
The inquiry found that the death certification and investigation procedures were fundamentally flawed because they depended solely on the honesty and competence of the single medical practitioner who attends a death in the community.
Dame Janet recommended that in future all deaths should be reported to the coroner, who would be given three sources of information: a form completed by the doctor, nurse, or paramedic present at the death; a form completed by a doctor who had treated the deceased person or had access to the medical records; and a statement from a relative of the deceased person. These safeguards would “eliminate the flaw that enabled Shipman to escape detection,” she said.
The former GP is serving 15 life sentences for the murder of 15 patients. The inquiry has found that he killed at least 215 patients, mainly elderly women.
In a separate report, Dame Janet criticised the bungled police investigation, which failed to uncover evidence of Shipman's killing spree at his single-handed practice in Hyde, Greater Manchester, and allowed him to kill three more patients.
The mistakes were compounded by Dr Alan Banks, medical adviser to the West Pennine Health Authority, who examined the records of 19 patients, the report says. Dr Banks knew Shipman and was unable, said Dame Janet, to “open his mind to the possibility that the allegation might be true and, as a result, did not undertake his examination of the records as objectively as he should.”