The Shipman Inquiry was tasked in investigating the events of the unlawful killings of around 250 patients by their doctor Harold Shipman (Home Secretary and the Secretary of State for Health, 2007). A well-deserved question to ask was what current practices allowed for a doctor to hide such severe malpractice and murder such an alarming number of patients without detection? (Baker, 2004). The discussion of necessary recommendations for governmental reform would go on to aid in ultimately preventing similar unlawful events from occurring (Baker, 2005). By the impact of the crimes and the perusal of the recommendations made by the inquiry, the health care system has undergone substantial change in comparison to the time that Shipman practiced (Home Secretary and the Secretary of State for Health, 2007). Beyond learning lessons in protecting patients from cases such as this within the health care system, the report approached restructuring the coroner’s system, strengthening the death investigation and registration system, and encouraging greater communication amongst “coroners, treating physicians, and families” (Young, 2004). Through broadening the role of the coroner, a movement towards obtaining these goals could be made. The Shipman Inquiry ultimately created a better understanding for the need of reforming, restructuring, and broadening the coroner’s system in a number of different aspects. Though government response and subsequent reform was unlikely to exactly follow the recommendations reviewed by the inquiry (Forrest, 2003), these recommendations would go on to majorly influence the coroner’s system, death certification, and death investigation systems in England and Wales including changes made under the Coroner’s Justice Act of 2009 (Pitman, 2012), as reform was essential to correct a system that had allowed Shipman to conceal and conduct his malpractice (Forrest, 2003). It is essential to question that the practices and laws in place are protecting the safety and health of patients and that monitoring these practices is crucial to assure a patient’s wellbeing (Baker, 2004).
In beginning to discuss the recommendations made by the inquiry and in review of the coroner’s system in England and Wales surrounding the era of the Shipman killings, public unawareness over the benefit of coroners in terms of an “independent investigator of potential health care issues” (Young, 2004) was a fundamental problem to be addressed. By recommendations towards broadening the role of the coroner (Young, 2004) a transformation of the coroner’s system into somewhat of a monitoring system could be established to review medical records and death certification from healthcare practitioners. This could also help in improving the understanding that when a concern is raised about a death or death investigation a coroner could be addressed to investigate (Young, 2004), both for the medical practitioners and the bereaved. This awareness would have possibly changed the perception of the bereaved families of Harold Shipman’s patients and the general public towards his actions (Young, 2004), considering they would have understood that their concerns could have been raised to a coroner (Young, 2004). Broadening the role of a coroner in death investigations, and their incorporation in the health care system also benefits a stronger understanding of why, when, and how a death occurred, provides “valuable recommendations” (Young, 2004), and ultimately helps to understand how laws and government response can adapt to prevent similar incidents. With these recommendations taken in to place at the time Shipman was able to conceal his crimes, there would have been greater monitoring in practice that would have most likely prevented his actions. Changes towards creating a monitoring system through the power of the coroner were recommended in the inquiry to aid in reviewing death investigations and examinations conducted by medical practitioners and allow an independent investigation. Reforms to the system in this sense could help in the “early detections of aberrant behavior” (Baker et al., 2003) from medical practitioners. The inquiry also urged a fundamental cross-checking of information from the treating practitioner of the deceased to prevent a dishonest doctor such as Shipman, or any medical practitioner who aim to conceal errors or neglect (Department of Health, 2016). Additionally, the report emphasized strengthening communication amongst coroners and treating physicians (Young, 2004). This included a discussion of previous lack in efficiency by doctors in circumstances of deciding if reporting information to a coroner was to be conducted, and when the decision to do so was made, the lack in quality of information that was being reported (Department of Health, 2016). Systematic reform was strongly urged by the inquiry, and through the engagement with the recommendations proposed, the government was able to act upon a change in the healthcare system, death investigation systems, and throughout the coroner’s system.
By reviewing the recommendations proposed by the Shipman inquiry, there appears to be an overarching theme of improving consistency, efficiency, protection, support, and transparency. Certain laws and government reactions were conducted to accommodate finding a solution to those issues. Early actions made by the government following the inquiry included introduction of checks on qualifications, history, and criminal record checks of all candidates applying for GP positions, mandating that GPs “cooperate with assessment by the National Clinical Assessment Service” (Home Secretary and the Secretary of State for Health, 2007), and new powers that would allow for suspension or removal of practitioners by Primary Care Trusts (PCTs) (Home Secretary and the Secretary of State for Health, 2007), though this was changed to the power of local authorities in 2012 under the Social Care Act, to strengthen independent review (Department of Health, 2016). Under previous requirements, as during the time Harold Shipman practiced, during the final illness of a patient, their doctor would be responsible for completing the medical certificate of the cause of death (Home Secretary and the Secretary of State for Health, 2007). This provided many open opportunities to hide malpractice or error, and in the case of Harold Shipman, allowed for a doctor to be responsible for a death, and successfully hide their crime (Home Secretary and the Secretary of State for Health, 2007). The Shipman inquiry prompted major reforms to the death certification system alongside a government response and “led to the design and piloting of a new rigorous and unified system of certification” (Department of Health, 2016). The first largely progressive and fundamental change following the crimes by Dr. Shipman was the new procedures for death certification to include a two-step process (Dyer, 2004). In the new system after a death occurs, a medical professional will verify the death, following certification from the treating doctor including the cause of death, which will then be followed by a medical examiner, whose role will be discussed later, that will investigate any information from the bereaved and seek authority for cremation or burial (Dyer, 2004). This new system and course of action ultimately aided in solving some of the concerns raised by the Shipman Inquiry such as issues of communication with the bereaved, efficiency of the system in protecting patients, and transparency in the actions of healthcare practitioners so malpractice is difficult to hide or conceal. Along with satisfying the recommendations of the inquiry, these actions would help in “restoring public confidence and building a better system of death investigation” (Home Office, 2004).
In the legal system, the role of the coroner in death investigation is cardinal (Milroy and Whitwell, 2003). The Coroner’s Justice Act of 2009 pursued protection of patients from incidents similar to the actions of Shipman, by improving efficiency to the coroner’s system. Reforms to death certification and the subsequent establishment of the act received substantial support from all parties in parliament (Department of Health, 2016). The act states that any death that is not referred to or investigated by a coroner will be investigated through the independent system of a medical examiner (Department of Health, 2016). The independent review from a medical examiner can provide valuable medical input along with both a medical and judicial approach to the investigation of unnatural deaths (Forrest, 2003). The medical examiner would be able to enforce powers of scrutiny towards the medical records completed by practitioners, and cross check any suspicious information when the cause of death cannot be determined or there is a suspicion of unnatural death (Department of Health, 2016). Medical examiners would also be in charge of interviewing and investigating possible leads of concern by family members, a query that would go on to be named the Shipman question and to conduct a subsequent examination of the deceased (Department of Health, 2016). Interviewing and incorporating the family throughout the investigation by the medical examiner also helps to improve the concern the inquiry approached over communication with the bereaved, as it is evident in regard to an investigation of the death of their loved ones, family and loved ones of a patient “deserve more certainty” (Forrest, 2003).
Another major reform established by the Coroner’s Justice Act was appointed the role of Chief Coroner (Pitman, 2012). By appointing a leader amongst the coroner’s system, the establishment of the role of Chief Coroner put someone responsible for maintaining consistency, training, efficiency, and accountability (Pitman, 2012). The Chief Coroner can appoint coroners to proceed or commence an investigation on an unnatural death, which they are then responsible for monitoring (Ministry of Justice, 2014). In a movement to restore public trust and confidence in the “death certification process” (Secretary of State for the Home Department, 2003), the Chief Coroner produces an annual report to provide information on “key issues facing the coroner system” (Secretary of State for the Home Department, 2003). This report provides the benefit of allowing public awareness on the role of the coroner, and issues prevalent in the coroner’s system, along with examining the coroners’ reports to establish responses and information to prevent deaths (Secretary of State for the Home Department, 2003). Creating a greater system of monitoring and review by the broadening the role of the coroner along with establishing the role of Chief Coroner not only aids in determining the factors involved in deaths to maintain protection against unlawful killings, but also offers important information for “criminal trials and other medico-legal purposes” (Young, 2004).
In conclusion, the impact of the Shipman inquiry and the discussion surrounding the unlawful killings of some 250 patients (Home Secretary and the Secretary of State for Health, 2007), lead far beyond assuring patient protection and security in the healthcare system (Baker, 2004), but transformed the coroner’s system into a more efficient, consistent and transparent structure. From changes in communication with the bereaved and public awareness of the coroner’s role in investigating suspicious or unnatural deaths (Young, 2004), to the two-step process of death registration and certification (Dyer, 2006), and the reforms conducted under the Coroner’s Justice Act of 2009 by appointing the role of Chief Coroner (Pitman, 2012), the Shipman inquiry has fundamentally reformed the coroner’s and death certification system in England and Wales.