THE SHIPMAN INQUIRY Chairman: Dame Janet Smith DBE Third Report Death Certification and the Investigation of Deaths by Coroners THE SHIPMAN INQUIRY Chairman: Dame Janet Smith DBE Third Report Death Certification and the Investigation of Deaths by Coroners Presented to Parliament by the Secretary of State for the Home Department and the Secretary of State for Health by Command of Her Majesty July 2003 Cm 5854 © Crown Copyright 2003 The text in this document may be reproduced free of charge in any format or media without requiring specific permission. This is subject to the material not being used in a derogatory manner or in a misleading context. The source of the material must be acknowledged as Crown copyright and the title of the document must be included when being reproduced as part of another publication or service. Any enquiries relating to the copyright in this document should be addressed to The Licensing Division, HMSO, St. Clements House, 2-16 Colegate, Norwich NR3 1BQ. Fax: 01603-723000 or e-mail: [email protected] THE SHIPMAN INQUIRY Chairman: Dame Janet Smith DBE The Shipman Inquiry, Gateway House, Piccadilly South, Manchester M60 7LP Tel: 0161 237 2435/6 Fax: 0161 237 2094 E-mail: [email protected] www.the-shipman-inquiry.org.uk Independent public inquiry into the issues arising from the case of Harold Shipman FOREWORD In the First Report of the Shipman Inquiry, I disclosed my finding that Shipman had killed at least 215 of his patients over a period of 24 years. It was clear that the current arrangements for death registration, cremation certification and coronial investigation in England and Wales had failed both to deter Shipman from killing his patients and to detect his crimes after they had been committed. The failure of the existing system prompted Parliament to set up the Shipman Inquiry, with Terms of Reference requiring me to examine the present arrangements and to make recommendations for changes that would protect patients in the future. The focus of the Inquiry has therefore been primarily on the protection of patients from the actions of a homicidal doctor. Yet, there are other important aims and objectives that must be served by a system of death investigation and certification besides the protection of patients, important though that is. The system must seek to protect the public from harm of other kinds and to expose the wrongdoing of others besides an occasional aberrant health professional. A sound system will advance medical science, through the better understanding of causes of death. It will assist in planning for the better use of the huge resources now expended on the National Health Service. It will serve the interests of private individuals by providing a proper understanding of the cause and circumstances of a death in which they have an interest. It will assist in the prevention of avoidable deaths and injuries in the future. My task has been to make recommendations for a system that will meet the needs and legitimate expectations of society. In the course of the Inquiry’s work, I invited views about how a new system might be devised. Many individuals and organisations responded to my invitation with interesting and constructive ideas for change. However, some respondents sought to persuade me not to propose any radical changes to the system just because one doctor had been able to evade the existing safeguards. I was urged to accept that the system was working reasonably well; a few minor changes was all that was needed. There would never, it was said, be another Shipman. It seems to me that there are two reasons why those arguments should not prevail. The first is that we do not know that Shipman is unique. We know that he has killed more people than any other serial killer yet identified, but we do not know how many other doctors have killed one or more patients. Some such killings have come to light; others may remain hidden. If Shipman was able to kill for almost 24 years before he was discovered, who can say with confidence that there are not other doctors, still unknown, who have killed in the past? Who can say that there will be none in the future? If there is a risk that a doctor might kill in the future and if, as is now clear, the present system would neither deter nor detect such conduct, surely the system must be changed. The second reason is that my investigations have satisfied me that the system is not working as well as it should. The evidence received by the Inquiry suggests that there is much dissatisfaction with the present arrangements. It is said that the existing system is fragmented, is not sufficiently professional, is applied to very variable standards in different parts of the country and does not meet the needs of the public, especially the bereaved. It is said that it does not satisfy the public interest in the discovery of the true causes of death in the population. It does not contribute, to the extent that it should, to the improvement of public health and safety. If these complaints are well founded, as I have found they are, then there are good reasons for radical change, quite apart from the need to ensure that, so far as possible, homicide does not go undetected. v The Shipman Inquiry In July 2001, while this Inquiry was working on Phase One, Mr Tom Luce was appointed to chair a Fundamental Review of Death Certification and the Coroner Services in England, Wales and Northern Ireland (the Coroners Review). His Terms of Reference overlapped, but were not coterminous with, those of the Shipman Inquiry. He was asked to co-operate with the Inquiry. That he has done and I am most grateful for the openness with which he shared the Review’s developing ideas with the Inquiry, by speaking at one of our seminars in January 2003 and by allowing me to read his Report in draft. I also wish to express my gratitude to those individuals who have attended to give evidence and to take part in the seminars. I must mention particularly those who came from overseas to participate in the seminar relating to systems of death investigation and certification in other jurisdictions. I thank, too, all those who wrote to the Inquiry giving their views about the present system and their ideas for change and improvement. Many individuals and organisations have provided witness statements, records, reports and other documentary material, thus enabling the Inquiry to assemble a huge amount of evidence. All have been generous with their time and effort, for which I am very grateful. I must also thank Counsel, Dr Aneez Esmail, Henry Palin and other members of the Inquiry team, who, as in Phase One, have worked with energy, determination and good humour and without whose support this Report could not have been written. This Inquiry was set up in the wake of a tragedy that shocked the world. It is my hope that some good may now come from those tragic events and that in the future we will have, in this country, systems of death investigation and certification that will bring real benefits in the fields of public health and safety and will meet the needs and expectations of private individuals, especially the bereaved. It is my earnest hope that the recommendations of this Report, together with those of the Coroners Review, will lead to radical change. Janet Smith June 2003 vi CONTENTS FOREWORD SUMMARY RECOMMENDATIONS CHAPTER ONE The Conduct of Phase Two, Stage Two of the Inquiry Terms of Reference 33 The Subject Matter 33 The Inquiry’s Approach 33 The Evidence 34 Before the Oral Hearings 45 The Oral Hearings 46 Submissions 47 The Seminars 47 The Structure of This Report 47 CHAPTER TWO Registration of Death, Medical Certification of the Cause of Death and the Coronial System: a Brief History Introduction 51 Registration of Death and Medical Certification of the Cause of Death 51 The Origins of the Coronial System 57 CHAPTER THREE The Origins of the Existing Cremation Certification System Introduction 63 The First Cremations 63 Statutory Recognition for Cremation 64 The Report of the Departmental Committee 1903 64 The Cremation Regulations 1903 67 The Period from 1904 to 1930 67 The Period from 1930 to 1950 68 The Report of the Interdepartmental Committee 70 The Period from 1950 to 1952 71 The Cremation Working Party 72 The Report of the Brodrick Committee 75 The Period from 1971 to 1977 82 The Period from 1978 to 1988 84 The Draft Cremation Regulations of 1989 90 The Period from 1990 to the Present 90 vii The Shipman Inquiry CHAPTER FOUR The Functions of the Police, Ambulance Services, General Practitioners and Deputising Doctors in the Immediate Aftermath of a Death in the Community Introduction 95 The Role of the Ambulance Service 95 Police Attendance at the Scene of a Death 97 Attendance of a Doctor When a Death Occurs Outside Normal Working Hours 101 The Need for Clarity 105 Further Involvement of the Police 105 Is Police Involvement in the Investigation of Deaths for the Coroner Appropriate? 108 Conclusions 111 CHAPTER FIVE Medical Certification of the Cause of Death The Existing System 113 The Purposes of the System 116 The Strengths and Weaknesses of the System 117 Reporting a Death to the Coroner 123 No Certificate of the Fact of Death 126 Shipman’s Manipulation of the System 127 Loss of Public Confidence due to Shipman 128 Conclusions 128 CHAPTER SIX Registration of Deaths The Registration Service 131 The Registration of a Death 132 The Duty of a Registrar to Report a Death to the Coroner 133 The Process of Registration 135 The Registrar’s Duty to Scrutinise