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THE SHIPMAN INQUIRY

A public judicial inquiry began in February 2001, under the chairmanship of Dame Janet Smith DBE, a High Court Judge (but recently promoted to the Court of Appeal), into issues arising out of the conviction in January 2000 of Dr Harold Shipman for the murders of some of his patients. This inquiry has a very detailed (and regularly updated) website. The Inquiry must be distinguished from the Home Office's Fundamental Review of Death Certification and Coroner Services, which is quite separate, and whose Report was published on 3 June 2003.

Phase 2 of the Inquiry dealt (in Stage 2) with death and cremation certification, including the role of the coroner. A discussion paper was issued in 2002, which sought responses by 25 November 2002. A number of coroners gave evidence to this Phase. The Report of this part of the Inquiry (the Inquiry's "Third Report") was finally published on 14 July 2003.

The Third Report has much in common with the Report of the Home Office's Fundamental Review, mentioned above, but is also radically different in many respects. And, unlike the latter, the former does not cover stillbirths and neonatal deaths, bodies from overseas, bodies removed out of England, or Northern Ireland, because these matters did not arise in relation to Shipman. Moreover the Third Report deals only briefly with the scope and conduct of inquests, as the deaths of very few of Shipman's victims were even reported to the coroner.

In summary form the Third Report recommends the following proposals for change, amongst others:

• the coronial system should be retained, but radically reformed
• the reformed coroner service should provide an independent, cohesive system of death investigation and certification for every death, natural and unnatural
• there should be two types of coroners, exercising different functions, called "medical coroners" and "judicial coroners"
• the coroner service should be an Executive Non-Departmental Public Body, associated with, but independent of, the new Department of Constitutional Affairs and the Department of Health (or its Welsh equivalent), governed by a Board including a Chief Judical Coroner, a Chief Medical Coroner and a Chief Coroner's Investigator
• the coroner service should have the benefit of an Advisory Council to provide policy advice, the Council's members being representatives of various governement departments (not just the DCA and the DoH) and other relevant organisations (including professional ones)
• the coroner service should have a regional and district structure, with a regional medical coroner, a regional investigator and at least one judicial coroner for each region, and every region being divided into districts, each of which would have a medical coroner, one or more deputies, an investigative team, and an administrative staff
• death certification would involve a double process: Form 1 to report the fact and circumstances of death, and Form 2 to give a medical history of the deceased (both forms being capable of completion by the same doctor)
• the Forms would in every case - natural and unnatural - go to the coroner service for consideration whether further investigation was necessary
• further investigation might involve any or all of: consideration by the medical coroner, examination of records, interviewing of witnesses, examination of the scene, external examination of the body, an autopsy, and (in those cases which justified it) a public inquest hearing conducted by the judicial coroner.

The British Medical Association has issued a press statement welcoming the Report. The Coroners' Society has also issued a press statement, explaining that a detailed comment would be premature, but also that it had some concerns about whether the proposals would deliver the hoped-for benefits, and about the need for commitment to adequate resources.

There are also unofficial websites dealing with the Shipman case, such as that produced by the Manchester Evening News.

The transcript of the entire trial is available on the Shipman Inquiry website. Elsewhere on this site are the directions given by the trial judge to the jury on their separating (ie going home at the end of the day to their own homes rather than to an hotel) after the judge had given his summing up.

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Last modified:  Monday, 09-Aug-2004 08:53:20 BST by: Malcolm Bishop