The Shipman Inquiry

First Report
Death Disguised

Considered how many patients Shipman killed, the means employed and the period over which the killings took place. July 19, 2002.

Second Report
The Police Investigation of March 1998

Examined the conduct of the police investigation into Shipman that took place in March 1998 and failed to uncover his crimes. July 14, 2003.

Third Report
Death Certification and the Investigation of Deaths by Coroners

Considered the present system for death and cremation certification and for the investigation of deaths by coroners, together with the conduct of those who had operated those systems in the aftermath of the deaths of Shipman's victims. She has made recommendations for
change based on her findings. July 14, 2003.

Fourth Report
The Regulation of Controlled Drugs in the Community

Considered the systems for the management and regulation of controlled drugs, together with the conduct of those who operated those systems. She has made recommendations for
change based upon her findings. July 15, 2004.

Fifth Report
Safeguarding Patients: Lessons from the Past - Proposals for the Future

Considered the handling of complaints against general practitioners (GPs), the raising of concerns about GPs, General Medical Council procedures and its proposal for revalidation
of doctors. She has made recommendations for change based upon her findings.
December 9, 2004.

Sixth Report
Shipman: The Final Report

Considered how many patients Shipman killed during his career as a junior doctor at Pontefract General Infirmary between 1970 and 1974. She also considered a small number of cases from Shipman's time in Hyde, which the Inquiry became aware of after the publication of the First Report. She also considered the claims by a former inmate at HMP Preston regarding alleged claims by Shipman about the number of patients he had killed. January 27, 2005.

The Shipman Inquiry was the report produced by a British governmental investigation into the activities of general practitioner and serial killer Harold Shipman. Shipman was caught in 1998 and the inquiry commenced after his trial in 2000. It released its findings in various stages, with its sixth and final report being released on 27 January 2005. It was chaired by Dame Janet Smith DBE.

While Shipman was convicted of 15 murders, the inquiry established that he probably committed 250 in total, though the true number could be more. The Inquiry took approximately 2,500 witness statements and analysed approximately 270,000 pages of evidence. In total the six reports ran to 5,000 pages and the investigation cost £21 million.

Remit and make up of inquiry

On 1 February 2000, the Secretary of State for Health, Alan Milburn, announced that an independent private inquiry would take place into Shipman's activities. It would decide what "changes to current systems should be made in order to safeguard patients in the future". Its findings would be made public, though it would be held in private. It was to be chaired by Lord Laming of Tewin.

It began work on 10 March and was to produce a report by September 2000. Many families of the victims along with certain sections of the British media called for a Judicial Review in the High Court. It found in their favour and recommended that the Inquiry be held in public. The Secretary of State for Health agreed and in September 2000, announced that the Inquiry would be held under the terms of the Tribunals of Inquiry (Evidence) Act 1921. This was then ratified by both Houses of Parliament in January 2001. Lord Laming was replaced by Dame Janet. Dame Janet initially hoped to finish her inquiries by "Spring of 2003". The Inquiry was held in the Town Hall in Manchester with proceedings relayed by closed circuit television to the public library in Hyde, where Shipman had lived, in order for the town's inhabitants to follow it more easily.

There were four main areas investigated:

1. The extent of Shipman's unlawful activities

2. The actions of the statutory bodies and other organisations concerned in the procedures and investigations which followed the deaths of Shipman's patients

3. The performance of the statutory bodies and other organisations with responsibility for monitoring primary care provision and the use of controlled drugs

4. What steps should be taken to protect patients in the future

Findings

The Inquiry found "major flaws in the systems that govern death registration, the prescription of drugs and the monitoring of doctors." In all, including the 15 deaths Shipman was convicted of, it concluded that Shipman had killed 250 patients, starting in 1971 while he was working in Pontefract General Infirmary. Though the majority of his victims were elderly, there was a "quite serious suspicion" that he had killed one patient aged four.

The report rejected claims by a prisoner, John Harkin, who knew Shipman while he was in Preston prison, that Shipman had confessed to 508 deaths. In Dame Janet's view, no "reliance [could] be placed on Mr Harkin's account."

Recommendations

The Inquiry made a number of recommendations for the reform of various British systems. It called for coroners to be better trained and underlined that better controls on the use of schedule 2, 3 and 4 drugs by doctors and pharmacists were needed.

It also recommended that fundamental changes be implemented in the way that doctors are overseen. Specifically, it said, the General Medical Council "was an organisation designed to look after the interests of doctors, not patients".

Post-inquiry situation

In 2008, a University of Dundee investigation found that even if the monitoring of patients' deaths was introduced as the Inquiry suggested, it would provide "such poor evidence that it would take 30 deaths to detect a murderous trend" because since 2004 in Britain, "patients have been registered with practices, not individual doctors, so the data on each GP is lacking".

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