No guarantee another Shipman couldn’t happen again

Fifteen years after Shipman was jailed, the Royal College of Pathologists has called for the introduction without further delay of a system of independent medical examiners who can issue death certificates.

Following the Shipman trial, an inquiry found that a primary reason he had not been caught sooner was the inadequate system for certifiying the cause of death.

The system must be changed Dame Janet Smith, 2003

Many of Shipman’s elderly victims were cremated. Often he signed the death certificate, and got one of several GPs from another practise to provide a second signature. None of them noticed anything wrong about the frequent deaths, many of which happened while Shipman was present or shortly after his departure.

Dame Janet Smith, who led the investigations into what went wrong, noted in 2003 “if there is a risk that a doctor might kill in the future and if, as is now clear, the present system would neither detect nor deter such conduct, surely the system must be changed.”

‘Incomprehensible’

Proposals for a new system of independent medical examiners were drawn up.

As envisaged by the 2009 Coroners and Justice Act, the medical examiner would provide scrutiny of all deaths not referred to a coroner, working with families to answer questions and address concerns. Medical examiners will consider all deaths, not just those where a body is to be cremated.

The 2009 law put Primary Care Trusts (PCTs) in charge of the medical examiner system. But PCTs were abolished in the recent NHS reconfiguration, leaving the reforms adrift, despite the 2013 Francis report into the Mid-Staffs scandal also recommending their introduction.

There’s no guarantee that wrongdoing could come to light Helen Shaw, Inquest

Dr Suzy Lishman, president of the Royal College of Pathologists said “it is incomprehensible that the recommended changes have not been implemented.”

Helen Shaw of the charity Inquest, told Channel 4 News that the lack of will in government to bring in the new system was “appalling”, adding “without the system as envisaged, there’s no guarantee that wrongdoing could come to light”.

Early detection

Dr Alan Fletcher, who became the first medical examiner in England and Wales in 2008 when a pilot scheme was established in Sheffield, told the Francis Inquiry that his work had resulted in fewer cases being needlessly referred to the coroner, and that “whilst the system may never prevent the actions of a healthcare professional acting with murderous intent, it should enable detection at an earlier stage”

However despite the five pilot studies, the planned timetable for reform is now well behind schedule, and some suspect the government of dragging its feet.

Dr Lishman told Channel 4 News “there is a misconception that measures put in place to improve patient safety mean that medical examiners aren’t necessary. This is not true.” She added that more medical examiners would improve the accuracy of statistics about the cause of death, allowing trends to be spotted sooner, making the allocation of NHS resources more targeted.

In a statement the Department of Health told Channel 4 News: “We are committed to reforming the system of death certification.

“We now have working models of the medical examiner service in Sheffield and Gloucester and will be working to review how they fit with other developments on patient safety. The reforms will proceed in light of that review”

In Sheffield Dr Fletcher told Channel 4 News that he believed the reforms were long overdue for nationwide roll-out, adding that the current state of affairs in most of the country meant “sometimes inaccurate medical certification, sometimes inconsistent coroner referral and a system that does not consistently ask for the views of the bereaved.”