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 …