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Reviews / 2005

Statutory inquiryPublishedPrimary careEngland

The Shipman Inquiry

Dame Janet Smith · work from 2001 · published 2005

What this was

Statutory inquiry into the murders committed by GP Harold Shipman and into how death certification, controlled drugs and professional oversight failed to stop him. The inquiry reported in stages, with the final report in 2005.

Why it sits in the hub

Revalidation, controlled-drug accountable officers, and the medical examiner system all trace back here. Thirlwall's recommendations on medical examiners and deliberate harm sit on that unfinished work.

Findings

  1. Finding 1

    A GP was able to kill patients over many years without death certification or prescribing data raising an effective alarm.

    Data and early warningMedicines and devicesRegulation and oversight

  2. Finding 2

    Professional self-regulation did not protect patients from a trusted clinician.

    Culture and conductRegulation and oversight

Recommendations in this hub

Paraphrase of the public recommendations, not the official text.

  1. 1Partly doneGovernment

    Reform death certification so that deaths are scrutinised by someone independent of the doctor.

    Statutory medical examiners were introduced in England years later, and Thirlwall asked for a further review of that system in 2027.

    Learning from harmRegulation and oversight
  2. 2AcceptedGovernment and NHS

    Tighten the governance of controlled drugs.

    Medicines and devices
  3. 3AcceptedProfessional regulators

    Revalidate doctors so that a licence to practise is not held for life without check.

    Revalidation began in 2012.

    Regulation and oversightSafe staffing