The Shipman Inquiry: Was it worth it? [Part 3] by Lady Justice Janet Smith

TL;DR

Doctor identifies major flaws in death certification and coroners' investigations, leading to the need for reform.

Transcript

i then embarked on the examination of our systems of death certification and coroner's investigation i found that every time a patient died shipman always signed the death certificate himself thereby avoiding the need for any referral to the coroner he simply bypassed the coroner's system altogether where the body was going to be cremated and the c... Read More

Key Insights

• ❓ Dr. Shipman exploited flaws in the death certification and coroners' investigation systems.
• 🧑‍🏭 Previous committees and reviews made similar recommendations for reform, but they were not immediately acted upon.
• 😀 The Foreigners and Justice Act of 2009 was a step towards implementing the recommendations, although it faced challenges in preparation for secondary legislation.
• 🇨🇫 A public inquiry may not always be the most effective and cost-efficient method for examining system shortcomings, as alternative approaches like review panels can offer more comprehensive examinations.
• 🙈 The subject matter of the inquiry can often skew the focus of the investigation, as seen in the emphasis on Shipman's actions rather than a general examination of system flaws.

Questions & Answers

Q: Why did Dr. Shipman sign the death certificates himself, bypassing the coroner's system?

Dr. Shipman's decision to sign the death certificates himself allowed him to avoid scrutiny from the coroner and facilitated the cremation process without further investigation into the cause of death.

Q: How did the flawed system allow the second doctor to simply accept the treating doctor's account without questioning it?

The system allowed the second doctor to forego inquiries into the cause of death as long as the treating doctor's account appeared plausible, leading to a lack of oversight and potential misconduct going unnoticed.

Q: What were the recommendations put forward by the various committees and review panels?

The recommendations included reforming systems of death certification and cremation, as well as improving the quality of practice in these areas to prevent abuse and ensure proper scrutiny.

Q: Why were the recommendations slow to be implemented?

Despite apparent approval and gratitude for the recommendations, the implementation process was slow, with changes in government and financial concerns delaying progress.

Summary & Key Takeaways

• A doctor discovered that a notorious patient, Shipman, bypassed the coroner's system by signing death certificates himself, which led to unscrutinized cremation certificates.

• The second doctor responsible for counter-signing these certificates did not inquire further into the cause of death, resulting in a flawed system.

• Previous committees and reviews had made recommendations for reform, but they were not implemented until years later with the passage of the Foreigners and Justice Act in 2009.