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Shipman report: System failed patients

Dame Janet Smith
Dame Janet said only Shipman would know the true murder figure

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LONDON, England -- Dame Janet Smith has criticised the lack of medical and legal controls that allowed British doctor Dr. Harold Shipman to kill at least 215 of his patients.

In her 2,000-page report Dame Janet, a high court judge who headed the public inquiry, said the systems that should have safeguarded his patients had failed.

Shipman, a GP in Manchester, northwest England, was convicted for the deaths of 15 elderly women patients in 2000, but the inquiry revealed that at least 215 patients, mainly women, were murdered. (Full Story)

A further 45 were "suspicious," the report found.

The consequences had tragic consequences on the families of those who were murdered, but also on the community which became shocked and shaken in its previously unquestioning faith in the medical profession.

"No-one reading this report can fail to be shocked by the enormity of the crimes committed by Shipman," Dame Janet, who investigated the killings, said in her report on Friday.

"His activities have brought tragedy upon them and also upon the communities in which he practiced." (Families' Devastation)

The High Court judge added in her interim report: "It is deeply disturbing that Shipman's killing of his patients did not arouse suspicion for so many years.

"The systems which should have safeguarded his patients against his misconduct, or at least detected misconduct when it occurred, failed to operate satisfactorily."

Dame Janet said Shipman was able to hide behind the respectable veneer of his profession. It ensured that very few relatives felt "any real sense of disquiet" about the circumstances of the victims' deaths. (Suburban Slayer)

"Those who did harbour private suspicions felt unable to report their concerns," she said.

Shipman was able to defy the system
Shipman was able to defy the system

"Deeply shocking though it is, the bare statement that Shipman has killed over 200 patients does not fully reflect the enormity of his crimes.

"As a general practitioner, Shipman was trusted implicitly by his patients and their families. He betrayed their trust in a way and to an extent I believe is unparalleled in history," she said in her report.

His motive for the killings did not become any clearer, Dame Janet reported. Shipman himself has never admitted his guilt or given any reason for the murders.

Dame Janet ruled out financial gain or sexual depravity as motives, adding only Shipman would know the reason and the real numbers involved.

She added the bearded doctor was highly dominant and addictive, but his true psyche remains a mystery.

"During the visit he would kill the patient. Afterwards he behaved in a variety of ways and had a variety of explanations for what had happened," Smith said.

"The way in which Shipman could kill, face the relatives and walk away unsuspected would be dismissed as fanciful if described in a work of fiction."

Dame Janet said the second phase of her report would consider how to ensure that unexpected or unexplained deaths were reported and that their causes were properly investigated.

"By the end of the inquiry, I hope to be able to make recommendations which will seek not only to ensure that a doctor like Shipman would never again be able to evade detection for so long, but also to provide systems which the public will understand and in which they will have well-founded confidence," she said.

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