Have we heeded the lessons from Shipman?BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c5711 (Published 18 October 2010) Cite this as: BMJ 2010;341:c5711
Harold “Fred” Shipman was a popular general practitioner (GP) who practised for more than 20 years in Hyde, Greater Manchester. To his patients, there seemed nothing to mark him out from other family doctors in the town. People trust doctors and they trusted him. It took more than two decades to unmask him as the United Kingdom’s most prolific serial killer.
In January 2000 he was convicted of murdering 15 of his patients. A four year inquiry chaired by the appeal court judge Dame Janet Smith concluded that the death toll was probably more than 200 between 1971 and 1998. Mostly elderly women but nowhere near death, they were killed in their homes or in his surgery with a large shot of diamorphine. “None of your victims,” Mr Justice Forbes told him when he sentenced him to life imprisonment, “realised that yours was not a healing touch. None of them knew that in truth you had brought her death, death which was disguised as the caring attention of a good doctor.”
Like his patients, the system trusted Dr Shipman. He signed the death certificates himself so there was no need to refer the case to the coroner. Fellow GPs to whom he gave a plausible account of the death countersigned the cremation certificates without making their own inquiries. The medical referee who was supposed to scrutinise the forms simply checked that they were filled in properly. The coroner was finally alerted by another GP after an undertaker commented that Dr Shipman’s death rates seemed abnormally high, but a botched and unnecessarily protracted police investigation allowed three more patients to be murdered.
Nearly 10 years have passed since Dame Janet began her inquiry, spurred by the declaration of the then health secretary Alan Milburn that the government wanted to learn how to improve the systems—and quickly. As well as two reports detailing the extent of Dr Shipman’s killings and delivering her verdict on the botched police investigation, she issued three reports between June 2003 and December 2004 calling for reform of the system: on death certification and coroners; on regulation of controlled drugs in the community; and on safeguarding patients, which included regulation of the medical profession and revalidation or periodic checks on doctors’ competence.1
Was the four years’ work by the inquiry team and £21m (€24m; $33m) of public money that it consumed worth while? Dame Janet’s verdict when she spoke at Gresham College in London last month2: “I think, on balance, yes—but it will be a close run thing.”
She believes it was certainly worth undertaking the first part of her investigation: to try to work out how many patients Dr Shipman killed and to look in detail at how he worked. But it has proved a challenge to achieve far reaching changes to the system that allowed it to happen. And while the likelihood of a rogue GP setting out to murder his patients is admittedly small, her investigation uncovered a catalogue of shortcomings in the systems for investigating deaths and regulating doctors.
Lack of action
Many of her key reforms have still not been implemented or have been watered down. Two of the most important—an independent adjudicator to decide doctors’ fitness to practise and reform of the archaic coroners’ system—have been enshrined in legislation and almost made it to the finishing line. But with a change of government in May and swingeing spending cuts to tackle the UK’s huge budget deficit, they were put on hold.
Her fourth report, on the regulation of controlled of drugs, was implemented relatively quickly, but only in part, and Dame Janet now doubts whether that section of her inquiry was worth while. She looked only at preventing health professionals from obtaining drugs illicitly and now thinks a broader based investigation might have prevented the death of David Gray, who was mistakenly injected with 100 mg of morphine by Daniel Ubani, an out of hours locum doctor from Germany.
Government proposals for implementation of some of her other recommendations proved too wishy washy and had to go back to the drawing board. Others fell foul of events; when the then home secretary David Blunkett stepped down after an affair with a married woman, his position paper on the coroners’ reforms—which would have gone some way to meet Dame Janet’s wish list and that of a separate Home Office review panel which reached similar conclusions—was abandoned.
When it was picked up again, more than two years later, the parcel had been passed from the Home Office to the Department for Constitutional Affairs (now the Ministry of Justice), which produced a diluted version of the reforms in the Coroners and Justice Bill. Dame Janet told the Commons constitutional affairs committee, which was examining the bill in 2006, that it “would go no way at all towards remedying the defects that failed to detect or deter Shipman.” Even if the bill went through, she warned, “there could still be a Shipman out there killing patients.”
The bill was passed and became an act, providing for a new position of chief coroner, along with improvements to the death certification system. The Department of Health says a second public consultation on the death certification reforms, and draft regulations, are planned for spring 2011, with implementation to begin in April 2012.
But the new justice secretary, Kenneth Clarke, ordered a review of the “scope and timing” of implementation of the coroners reforms as part of the government’s spending review. A Cabinet Office document leaked to the media last month showed the Office of the Chief Coroner as one of several bodies that the government might abandon. Dame Janet told the Gresham College audience, “I regret to say that I am not confident that the act will be implemented at all.”
Her proposal was for a national coroners service. The chief coroner’s office would have provided national leadership and standards but would still be funded by local authorities. “What effect would a chief coroner have on local authority funding?” asked Andre Rebello, coroner for Liverpool and honorary secretary of the Coroners’ Society, which also wanted a national service. Even if the act became law, without a national service and centralised funding, the current postcode lottery would continue, he said. But as it has turned out, there will not even be a chief coroner. On 14 October justice minister Jonathan Djanogly announced, “We have decided that in the current economic climate we cannot go ahead with plans to implement national leadership from a chief coroner, an appeals system, or a medical adviser.”
Prospects for regulatory reform
Dame Janet’s fifth report, on regulation, was critical of the UK doctors’ regulator, the General Medical Council, for “looking after its own,” although it cleared the GMC of failing to deal properly with Dr Shipman when it let him return to practice after a conviction for obtaining pethidine by deception for his own use in 1976. One of her key recommendations was that the GMC, which she found had “fundamental flaws” and perpetuated a doctors’ culture of mutual self-interest at the expense of patients, should lose the right to be both prosecutor and judge in disciplinary cases.
The Labour government agreed and set up the Office of the Health Professions Adjudicator (OHPA). A chairman and chief executive were appointed, and the new body was set to begin work next April. But the arrival of the new Conservative/Liberal Democrat coalition government changed the agenda. In a consultation which closed on 11 October, the government said its preferred option was to repeal the legislation setting up the office and leave the role with the GMC.
Instead of the new body, which was intended eventually to cover all the health professions and be funded by the regulators, the government wanted to “strengthen the independence of the GMC’s adjudicatory body.” The GMC now proposes to set up a new disciplinary tribunal, which could be created as a statutory body to enhance its independence.
Dame Janet is far from convinced that OHPA should be axed. “If it were not for the fact that I know that the GMC itself now recognises the need for real independence of adjudication, I would be in total despair. I do acknowledge that public expenditure must be cut, but it appears most unfortunate if the start-up costs cannot be met as the long term advantages both in terms of cost and quality of provision are overwhelming,” she told the audience at Gresham College.
Walter Merricks, who was appointed to chair OHPA in November 2009, agrees. “A huge amount of time and effort, in parliament and elsewhere, has gone into legislating and planning for the implementation of Dame Janet’s recommendation. If ministers’ primary concern is the cost to public funds of setting up OHPA, we have put forward a method of doing so at minimal cost.”
OHPA suggests that it should be retained but in a “lite” form with no need for separate accommodation and with minimal staff seconded from the GMC, which would not need fresh legislation. Its role would be limited to appointing, training, and appraising the judicial members of the GMC’s disciplinary tribunal, and having responsibility for the tribunal’s judicial functions and procedural rules to ensure its effective operation.
Mr Merricks adds, “If ministers are concerned to reduce the number of statutory bodies, legislating for a doctors’ disciplinary tribunal, their current proposal, will merely substitute one body for another. If separate legislation is eventually needed for tribunals for each of the other health professions, that would be a far worse result, both in terms of the number of bodies and consistency of process and outcomes, than a single adjudication office to cover all.”
The GMC has made several reforms to its disciplinary processes since the Shipman inquiry. But revalidation is still not a reality nearly six years after the fifth report proposed it. The original ideas for implementation were “pointless” and had to be beefed up, Dame Janet said, and the present government was “not encouraging progress.” But “a real determination within the GMC and the medical royal colleges to work out something valuable and effective” led her to think “they will get there in the end.”
Niall Dickson, the GMC’s chief executive, acknowledges that revalidation has taken a long time to implement but says the council is determined to see it delivered. “Revalidation has been a long time in coming—some would say too long—but we believe it will soon become a reality for every doctor in the UK. There is real commitment to make it happen and a shared view that the model must be relatively simple and straightforward. We are working closely with the health departments in the four parts of the UK, and with employers and doctors to bring this about.
“The consultation we have just completed has demonstrated that there is support for the principle. Creating a system to ensure that all doctors are competent and fit to practise is the right thing to do. The task now is to make sure the model is right. We will amend and simplify to achieve that. It will not be perfect when it starts but over time it will be refined and improved.”
Dr Shipman was his own final victim: he hanged himself in January 2004 in his cell at Wakefield prison. His legacy was to show up the flaws in a system which let him get away with murder for more than two decades. How far and when those flaws will be remedied are still open questions.
Cite this as: BMJ 2010;341:c5711
Competing interests: The author has completed the unified competing interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.