The Shipman Inquiry Investigation - Case Study Example

Shipman inquiry Student’s Name University Affiliation 1.0 Introduction The Shipman Inquiry was an investigation, which was launched after the trial of a British doctor, named Harold Frederick Shipman who mysteriously transformed from a caring, family doctor into a serial killer. Shipman was arrested in 1998 and charged with 15 individual counts of murder. After obtaining proves that Shipman murdered approximately 250 people, he was ranked as the most creative serial killer in documented history (Whittle &Ritchie, 2000). The Shipman Inquiry, directed by Dame Janet Smith, was launched on 1 September 2000. The British government created the inquiry to investigate all deaths certified by Dr. Shipman. The inquiry released multi-staged reports. The sixth and final report was tabled in 2005. The inquiry was estimated to have cost 21 million pounds to consider 2,500 witness statements and analyze approximately 270,000 pages of witness evidence. Investigations indicated that Dr. Shipman had created a certain procedure, which was applied for more than two decades to kill approximately 250 patients (Dyer, 2002). Investigations revealed that Shipman’s operations as a serial killer might have begun in 1975 and ended in 1998. 2.0 What happened? Discovery of Dr. Shipman’s evil ways began when a local undertaker noted that his patients were dying at an alarmingly high rate. The undertaker, named Deborah Massey informed Dr. Linda Reynolds of the Brooke Surgery in Hyde of her concerns. Consequently, Dr. Linda Reynolds expressed the concerns to the Coroner of South Manchester District named John Pollard. The chief concern of Dr. Linda was the unusually high death rate recorded with Shipman’s patients. Ideally, she discovered a huge number of cremation forms, especially for elderly women that Dr. Shipman had countersigned. It was palpable that something was awry and the matter was mentioned to the police. Initially, the police abandoned the investigation for failure to find sufficient evidence. The doctor was finally arrested after killing three more people. Kathleen Grundy, a former mayor, was the last victim who was discovered dead at her home on 24th June, 1998. The last individual to visit her alive was Dr. Harold Shipman who later signed her death certificate. According to records, Dr. Shipman indicated “old age” as the chief cause of death. Questions emerged after Grundy’s daughter named Angela Woodruff and a lawyer by profession, received information from the solicitor, Brian Burgess that her mother’s will had been made. Because she was a lawyer, Woodruff had always handled her mother’s legal affairs. It was doubtful to find out that her mother had written another will. In addition, the doubtful will excluded all her children and left 386,000 pounds to Shipman (Kinnell, 2000). With the information, Woodruff was convinced that the document was a forgery. She also believed that Dr. Shipman might have murdered her mother with an aim of benefitting from the death. Woodruff alerted the police, leading to exhumation of Kathleen Grundy’s body for examination. A post-mortem indicated that Grundy died of morphine overdose, administered approximately three hours before her death. The time precisely coincided with the time Dr. Shipman visited her. The police immediately raided Shipman’s home when the information was discovered. The raid became instrumental in accessing additional evidence that proved that Dr. Harold Shipman was indeed a murderer. At his home, there were medical records, a unique collection of jewelry and an old typewriter believed to have been used to forge documents (Whittle &Ritchie, 2000). Expansion of investigations from the death in question was made possible by medical records discovered in Harold’s house. 3.0 How it happened? Investigations revealed that Shipman had created a strategy, which worked owing to the fact that he was a reputable doctor. He used unexpected afternoon home visits to murder his patients via lethal injection of morphine. After injecting the lethal drug, Shipman would then proceed to sign the victim’s death certificate and falsify medical records to cover up the illegality. Part of his plan involved advising families to cremate the bodies of their kin while maintaining that further enquiry of their deaths was unnecessary. Surprisingly, Shipman would stress that further investigation was not necessary even under circumstances where victims were thought to have died of causes previously unknown to their families (Sitpond, 2000). When questionable situations emerged, the doctor would expediently supply computerized medical records that corroborated with his pronounced cause of death. 4.0 Who was involved In all the crimes that were investigated, Dr. Shipman was the only person involved. Analyzed evidence indicated beyond reasonable doubt that Shipman was the only person guilty of the stated felonies. Dr. Linda Reynolds, a surgeon at the Brooke Surgery in Hyde, had been unaware of Shipman’s evil undertakings until she noted a suspicious increase in the number of deaths and cremation forms demanded by his patients. 5.0 Why did it go undetected for so long? Following an inquiry into the case, numerous reasons could have led to led to a lengthy wrongdoing before detection. To begin with, any right-minded citizen would have found it difficult to suspect Dr. Harold Shipman of such evils. The reason is that during his more than two-decade operation, Harold Shipman emerged to be a highly reputable GP from Hyde in the Greater Manchester. He was celebrated as a proficient and caring doctor. When the issue was first posted to the police, the matter was not received with due level of seriousness. David Sykes, the chief superintendent lacked necessary experience to oversee the case and guarantee early exposure before the matter got out of hand. Results from the second inquiry discovered that Detective Inspector David Smith, who was part of the police investigation, supplied falsehood to the internal police inquiry. The falsehood contributed to delayed discovery of Shipman’s evil activities. During the inquiry, Dame Janet Smith pointed out that if coroner John Pollard and the police had acted expediently, then some victims might have been saved (Smith, 2005). Information from the third inquiry showed that detection was also delayed because existing coroner system was fragmented and lacked adequate safeguards. Loopholes existing within the coroner system were exploited by Shipman to enable him perform criminal activities and escape undetected for a long time. Initial system was flawed because it enabled heightened number of deaths certified by Dr. Shipman to go unnoted (Pringle, 2000). 6.0 What recommendations were made? The last four reports of the Shipman inquiry were detailed and meticulous. The reports contained recommendations totaling 190. Some of the major recommendations are briefly stated below. Coroners need to be better trained to handle such instances The General Medical Council (GMC) should meet with legislators and see that annual reports are circulated. Standard procedures should be formulated for employment of staff to the GP surgeries. Issues raised by non-patients concerning GPs must be scrutinized just as direct patient complains. Agreeable guidelines for voicing concerns in every healthcare sector need to be put in place Professional staff to be used in investigating all patient complaints to ensure thoroughness and enhance patient-protection The department of health need to formulate a national system for supervising patients of GP The practice of use of class A drugs by doctors and pharmacists need to be controlled. The report recommended that medical practitioners should only be allowed to dispense controlled drugs under circumstances where need for them is obvious (Dyer, 2004). A 5-year revalidation was to be effected based on fitness to practice Online medical registers to show patients if doctors have been investigated of discipline Doctors with history of drug use closely monitored Centrally held disciplinary and criminal records of doctors 7.0 Has it happened anywhere else? In the past, many doctors had been prosecuted in Britain including David Moore, Dr. Thomas Lodwig in 1990, Dr. Leonard Arthur in 1981, and Dr. John Bodkin Adams in 1957. In the case of Dr. John Bodkin, police investigations showed that he killed close to 160 patients between 1946 and 1956 (Jesse, 1990). The doctor became wealthy after inheriting goods from elderly patients. Adams was found not guilty, because of flawed police investigations. In 1999, Moore was proven guilty of killing a patient. In an interview, Moore confessed that he had assisted close to 300 patients to die (Dyer, 2006). Another case was reported in Australia concerning Suresh Nair, Malaysian trained neurosurgeon. Suresh Nair was charged with murder, but later convicted of manslaughter. Reports indicated that he was a cocaine addict who had been previously refused to operate in a public hospital owing to “serious concerns” at work (Duff & Bowden, 2014). Nonetheless, there was negligence in the hiring process of the Nepean Private hospital that culminated into loss of lives. 8.0 What professionals were involved? The surgery staff, GPs, Coroners, and the police were the only professional groups involved in the case. 9.0 Who discovered the problem? Although suspicions surrounding the problem had been noted, it was only after Angela Woodruff voiced concern about her mother’s will that leading evidence was discovered. Immediately when Angela Woodruff registered suspicions regarding her mother’s case, she notified the police who noted that indeed there was a problem. Grundy, who was also a former mayor, was discovered dead at her home on 24th June 1998. Dr. Shipman was the only person who visited just before her death and he was responsible for signing her death certificate. In the death certificate, the doctor indicated old age as the cause of death. Problems emerged when Angela Woodruff, a lawyer by profession, received information from the solicitor that her mother had made another will where she gave Shipman 366,000 pounds and excluded all her children. As a legal practitioner, Angela was responsible for overseeing her mother’s legal issues. Thus, the existence of a second will indicated an instance of forgery. When police begun their investigation, Grundy’s body was exhumed and examined. Results indicated that her body contained traces of diamorphine, which was administered just before her death. The revelation led to a raid into Shipman’s house where more evidence to his evil acts was retrieved. Retrieved medical records became a platform for launching investigations into 15 cases. 10.0 Conclusion It is perplexing to note that cases of professional misconduct in health care sector are becoming a commonplace. Cases, such as those of Shipman, Moore, Bodkin, Suresh, and Neale where medical practitioners apply their skills to commit felonies pose a huge challenge. It is imperative that operational apparatuses be put in place to avert possible occurrence of such cases in the future. With the help of better policies and structures, it can be possible to encourage improvement of professional conduct within the medical sector to improve quality of services and safety of patients. All the recommendations listed under the Shipman Inquiry need to be implemented to ensure that loopholes existing in current systems are sealed. References Duff, E. & Bowden, T. (2014). Hospital missed warning on cocaine-addicted doctor Suresh Nair. Retrieved from: http://www.smh.com.au/nsw/hospital-missed- warning-on-cocaineaddicted-doctor-suresh-nair-20140823-107fu7.html Dyer, C. (2006). Past NHS medical controversies – BBC News. Retrieved from http://news.bbc.co.uk/2/hi/programmes/panorama/4852340.stm Dyer, C. (2004). Shipman inquiry recommends tighter rules on controlled drugs. BMJ, 329(7459), 188-188. Dyer, O. (2002). Shipman murdered more than 200 patients, inquiry finds. BMJ, 325(7357), 181a-181. Jesse, F. (1990). Murder for lust of killing. In: J. Goodman (ed.). Medical murders. London: Piatkus. Kinnell, H. (2000). Serial homicide by doctors: Shipman in perspective. BMJ 321 (7276), 1594–7. Sitpond, M. (2000). Addicted to murder. The true story of Dr Harold Shipman. London: Virgin. Smith, J. (2005). The Shipman Inquiry:. London: Stationery Office. Pringle, M. (2000). The Shipman inquiry: implications for the public’s trust in doctors. Brit. J. Gen. Pract: editorial. Whittle, B, Ritchie J. (2000). Prescription for murder. The true story of mass murderer Dr Harold Frederick Shipman. London: Warner. Read More