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THE SHIPMAN INQUIRY - BULLETIN NO.3 - November 2002

Following the publication of Dame Janet Smith's report into how many patients she believed Shipman had murdered, Phase Two of the Shipman Inquiry has now commenced.

Phase Two which started in May 2002 is looking into the systems which enabled Shipman to quite literally get away with murder over such a long period of time. Stage 2 of Phase 2 started in October and is considering the issues surrounding death and cremation certification.

Dame Janet Smith has announced that she intends to prepare her second report, on all issues arising from Stage 1 of Phase 2 which covered the police investigation of March 1998 and Stage 2 by early spring/late summer 2003.

Proceedings so far

Caroline Swift QC, Leading Counsel to the Inquiry, opened Stage 2 by stating that the existing systems for death and cremation certification are intended to protect the public against the concealment of homicide. Yet, those very systems permitted 215 killings, over 22 years, to continue undetected.

Miss Swift took two cases to illustrate how Shipman was able to conceal the fact that he had killed by exploiting the existing systems in order to escape detection. The Coroner's office, police, certifying doctor, Registrar, secondary doctor, medical referee and funeral director were all bodies which played a part in the events following the unlawful killing of the two ladies mentioned above, yet, it took suspicions raised over a forged will, not the death itself, to kick-start the investigation which led to Shipman's eventual arrest.

Richard Lissack QC, Leading Counsel to the Tameside Families Support Group whom we represent, opened on behalf of many of the relatives by stating that "it is a sobering thought that the systems in place at the time that Harold Shipman murdered remain in place today effectively unchanged."

Mr Lissack queried how Shipman was able to certify the cause of death as "old age" in numerous cases, without being questioned further. He also queried how Shipman was able to complete the Form B cremation certificate with answers now known to be so obviously false, again without question or scrutiny. Mr Lissack went on to the issue of the Form C secondary doctor and raised questions regarding its purpose. He also outlined general issues regarding the need for a complete overhaul of the role of the Registrar and Coroner.

Mr Lissack concluded by asking the Government to take full advantage of the future recommendations of Dame Janet Smith, to ensure that reforms are put in place, for the sake of our clients and the general public.

Relatives views

Several relatives were invited by the Inquiry to expand on suggestions for change which they had touched on in previous witness statements. The overall feeling which came out from 2 days of evidence from relatives was that there should be a much more open outlook by all concerned when somebody dies. The secrecy behind the cremation forms, for example, should not exist. They would welcome a system in which relatives are asked for further information following a death in order to prevent a doctor lying to all the relevant bodies and consequently not raising any suspicion.

Out of the 12 relatives who gave evidence at the outset of this stage, all of them, either implicitly or expressly, confirmed that they would find it helpful if there was a single point of contact as a "one-stop shop" for the handling of all aspects of families' requirements following bereavement.

Medical Referees

The Inquiry also heard evidence from 2 Medical Referees from areas outside Dukinfield. It emerged from the course of these hearings, that Medical Referees receive no training at all in relation to the role. It also emerged that guidance received from the Home Office in 1988, reported that it was acceptable to have conflicting times on these forms, on the basis that they were confusing and relatives often gave differing timings to those of the GP.

With regards "Old Age" being stated as a cause of death, it was noted that the whole system is based on trust.

Both witnesses expressed the view that there should be no procedural differences between cremations and burials. Medical records should be made available and relatives should be spoken to. It was also suggested that one 'Medical Examiner' could play an investigative role, and fulfil the role of both the Form C doctor and the Medical Referee.

The Inquiry also heard from the previous Medical Referee at Dukinfield Crematorium who had authorised 111 cremations of Shipman's victims and accepted that the present system of cremation certification had failed. They explained that the purpose of the role as Medical Referee was to ensure that everything was in order and that there was no reason why the body should not be cremated.

Dame Janet suggested that there were many unanswered questions when looking through the forms which had been authorised by the former Dukinfield Medical Referee. The Medical Referee presumed that such questions would have been raised by the Form C doctor, to which Shipman should have provided a satisfactory explanation.

Form C Doctors

The Inquiry heard several days of evidence from doctors who had signed Form C's, where Shipman had signed the Form B, over a number of years.

It became evident that GPs do not receive any formal training in the completion of Forms B and C. The following points were made by the GPs asked to give evidence:- 'Form C is a rubber-stamping exercise and of no value in verifying the cause of death' 'natural causes should not be used as a cause of death' 'the Form C procedure should be changed- it should be investigative and should certainly involve the viewing of medical records'

A number of the GPs mentioned that they paid almost no attention to the details on Form B but rather listened to Shipman's explanation of events.

Further Evidence

The Registrars have recently given evidence, and the Coronial system is now under scrutiny.

Dame Janet Smiths findings from Phase 1 - started 20 June 2001 and ended 10 December 2001.

PHASE 2 OF THE INQUIRY (ongoing at present)

If you believe that you might have a legal claim relating to Shipman Bulletin 3, please complete the online enquiry form or call 0870 024 0558. Your enquiry will be forwarded to a solicitor who specialises in Shipman Bulletin 3.

If you have any comments in relation to Shipman Bulletin 3, please use the online discussion forum.