Shipman inquiry urges British coroner system reform

The third report looked into the issue of death certification and the investigation of deaths by coroners.

In her recommendations, Dame Janet said: “The coronial system should be retained, but in a form entirely different from at present.

“There must be radical reform and a complete break from the past, as to organisation, philosophy, sense of purpose and mode of operation.”

Dame Janet concluded that there was “virtually no training for coroners“.

Many, especially part-time coroners, operate in isolation with little contact with colleagues, which creates a “considerable variability of practice and standards in different coroner’s districts“.

The report said that Shipman, through the issuing of death certificates stating natural causes, was able to evade the coronial system altogether.

“A way must be found to ensure that all deaths receive a degree of scrutiny and investigation appropriate to their facts and circumstances,” said Dame Janet.

“The coroner or member of the coroner’s staff takes what the doctor says completely on trust. In general, no attempt will be made to verify the accuracy of the information given by the doctor from any other source.

“Information provided by the person reporting the death should be cross-checked with a member of the deceased’s family or some other person with recent knowledge of the deceased. If appropriate, other inquiries should be made.”

Dame Janet said a new role needed to be made to investigate non-suspicious deaths.

“What is needed is a person specifically trained to investigate non-suspicious deaths,” she said.

Britain's coroners officers should have the support of a team of investigators, who should be specially trained, the report said.

Dame Janet's comments came as the Shipman Inquiry's second and third reports were published by Britain's Home Secretary David Blunkett.

In its first report, published last year, the inquiry ruled that Shipman, now 57, had killed at least 215 of his patients over 23 years, during which he was a family GP in Todmorden, West Yorkshire, and later Hyde, Greater Manchester.

Since then, the inquiry has looked into the discreet investigation carried out by Greater Manchester Police following concerns raised by another GP, Dr Linda Reynolds.

She told the police she thought Shipman may have been killing his female patients using some sort of drug.

But Mr Smith did not understand the issues raised and failed to ask a number of important questions.

When he then consulted the medical adviser to the health authority, Dr Alan Banks, he was wrongly reassured that there was nothing unusual about a number of deaths he had looked into.

His advice effectively concluded Mr Smith’s investigation.

Today, Dame Janet concluded that Mr Smith should never have been appointed to the investigation.

His superior, Chief Superintendent David Sykes, then “failed to recognise that Det Insp Smith was out of his depth” and “failed to discuss the issues ... in any detail“.

If he had done so, Mr Sykes “would have realised the extent of Det Insp Smith’s lack of understanding“, Dame Janet said.

He had made “many mistakes“, including failing to ask important questions of Dr Reynolds and not checking whether Shipman had any previous convictions.

Shipman had been convicted in the 1970s for drug offences and acting dishonestly.

Many of his mistakes were due to his lack of experience, but Mr Smith still continued his inquiry “pretending that he knew what he was doing“.

He never sought help and as a result, “never understood the issues, never had a plan of action, had no one to help him analyse the information he received, had no one to make suggestions as to the information he should seek ... and was allowed to close the investigation before it was complete“, Dame Janet added.

Even when it was decided to close Mr Smith’s investigation, there was no “detailed discussion of the evidence” with Mr Sykes. Mr Smith submitted no written report.

Although not primarily responsible for the failure of the inquiry, “his inaction contributed directly to the adverse result“, the report concluded.

Once Shipman was arrested later that year, Mr Smith sought to attribute his failures to the faults of others, the report found.

He lied to an internal police inquiry and continued lying throughout the Shipman Inquiry, Dame Janet said.

Only last year did Greater Manchester Police (GMP) carry out a thorough internal inquiry into Mr Smith’s investigation and finally admit it had been “seriously flawed“.

Dame Janet said: “I am driven to the conclusion that, had it not been for the Shipman Inquiry, the GMP would never have made any more thorough inquiry into the matter.”

After Shipman's trial, which concluded in January 2000, an internal inquiry was carried out into Detective Inspector Smith's investigation, headed by Detective Superintendent Peter Ellis.

Because Det Insp Smith had not been required to submit a report in writing, it was not realised at that point that his investigation had been deeply flawed.

It was therefore not until 2002 that a further inquiry headed by Detective Chief Superintendent Peter Stelfox was carried out, the results of which were broadly similar to Dame Janet’s conclusions.

Speaking after the publication of the report today, Dame Janet said: “I must and do feel sympathy for those few who have been found responsible for the failure of this investigation.

“They must live with that responsibility for the rest of their lives.

“Although their situation was of their own making, it should be recognised that it is their misfortune ever to be caught up in the consequences of Shipman’s criminality.

“There must be many others who would also have failed if put in the position in which these men found themselves.”

She added: “My final word must be for the families of Shipman’s last three victims. For them, these hearings and the reading of this report will have be profoundly distressing.

“Once again, I can only offer them my deepest sympathy.”

Asked whether she considered Mr Ellis’ inquiry a “whitewash” she said: “I do not think it was intended as a whitewash or a cover-up but it certainly failed to get to the bottom of what had happened and to appreciate the seriousness of the failure of the earlier investigation.”

She added that Det Insp Smith had struggled with the “credibility gap” and had failed to accept that the allegations being made against the GP may have been true.

She said: “Nonetheless, the investigation did fail for the reasons I have explained. It seems to me that the main failure was a systems failure and that the wrong people were in charge of it.”