Oxford Medical

The Shipman Inquiry was an independent public inquiry into the issues surrounding the case of Harold Shipman, led by Dame Janet Smith DBE. The inquiry began in 2001 following Shipman’s arrest in 1998 and trial in 2000. He was convicted of murdering 15 of his patients during his time as General Practitioner at Market Street, Hyde near Manchester. The inquiry subsequently established he probably committed 250 murders, possibly more, while he was GP in Hyde and Todmorden.The inquiry involved approximately 2,500 witness statements and 270,000 pages of evidence, and cost £21 million to complete. There were 6 reports in total with the First Report published on 19 July 2002 and the Final Report on 27 January 2005. The report runs to 5,000 pages and outlines the changes that need to be made in order to safeguard patients in the future.

The Shipman Inquiry covered 4 key areas:

1. The extent of Shipman’s unlawful actions
2. The actions of the professional bodies and organisations involved in the procedures that followed the deaths of Shipman’s patients
3. The performance of those organisations responsible for monitoring primary care and how controlled drugs are used
4. The measures needed to ensure patients are protected in the future

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 The report found that the systems in place to monitor the following, failed:

• Death registration
• Drug prescription
• Doctors

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 Recommendations made in the report include:

• Coroners need to be better trained
• The use of Class A drugs by doctors and pharmacists need to be better controlled. Several measures were suggested for this including that medical practitioners can only dispense controlled drugs when the need is obvious, and in cases when the purpose is unclear justification may be needed; and it should be made a criminal offence for a doctor to prescribe a controlled drug for himself
• Changes to how doctors are overseen need to be made. In particular, the General Medical Council (GMC) needs to do more to protect patients rather than simply “looking after its own”
• The GMC should be accountable to Parliament and publish an annual report
• Steps should be taken to improve how complaints are handled by GP surgeries
• All patient complaints should be investigated by professional staff and the goals should be to protect patients and be fair to doctors
• Concerns expressed about a GP by a non-patient should be dealt with in the same way as patient complaints and investigated accordingly
• Primary Care Trusts (PCTs) should have extended powers to enable them to issue warnings to GPs and impose financial penalties in cases of misconduct or for unsatisfactory clinical standards or professional performance
• The Department of Health (DH) should create a national system for monitoring GP patient mortality rates
• There should be standard procedures for recruiting staff to GP surgeries, including obtaining a reference from the doctor’s previous surgery or PCT
• Clearer guidelines should be available for raising concerns in the healthcare sector

A central database of every doctor working in the UK should be made available to NHS bodies and medical professional organisations, including information relating to the Criminal Records Bureau (CRB) and any disciplinary action records