Doctor as murderer
Death certification needs tightening up, but it still might not have stopped Shipman
Harold Shipman, a general practitioner from
Greater Manchester, has been convicted of
murdering 15 of his patients. Inevitably, his
conviction raises serious concerns for clinicians,
patients, and society. How could such crimes go undetected? What lessons can be learnt and can similar
murders by doctors be prevented in future?
Serial killers in health care like Shipman and
Beverly Allitt are particularly shocking because they
damage the trust that exists between clinicians and
their patients. In 1993 Allitt, a nurse working on a
paediatric ward, was convicted of murdering four
children, attempting to murder three, and causing
grievous bodily harm to six.1
Like many singlehanded doctors, Harold Shipman
had over 3000 patients in his care. His patients seemed
to like him. Until the suspicions began to gather that
eventually led to his prosecution, few concerns were
raised about his clinical competence. Evidence
emerged that he had falsified the notes of some of his
patients, but this was not incompetent record keeping:
rather, it was done to conceal his crimes.
In 1976 Shipman was convicted of several offences
relating to the misuse of pethidine, and this conviction
was reported to the General Medical Council. Shipman
sought treatment and no further action was taken. This
conviction adds to all the other concerns raised,
although no evidence of recent drug misuse has been
presented. Moroever, it is important not to appear to
conclude that drug misusers turn into serial killers. Since
the 1970s new procedures have been put in place by the
GMC to deal with substance misuse, and other health
problems, though a further review may be warranted.
Shipman murdered his patients with injections of
diamorphine. Various regulations govern the prescription, storage, recording, and destruction of controlled
drugs by doctors and are there to prevent misuse. More
stringent regulations could deny patients and doctors
access to the drugs necessary to alleviate pain and suffering. Separate arrangements are in place to detect
unusual patterns of prescribing by NHS general practitioners (PACT - prescription analysis and costing
tool), but budgetary rather than clinical concerns usually trigger these. Morphine and diamorphine are not
expensive drugs.
Having murdered these patients, Shipman issued a
certificate of the cause of death, which in every case was
accepted by the registrar. Should his crimes have been
detected at this stage? Doctors attending patients during their last illnesses must issue a certificate giving the
cause of death to the best of their knowledge. The
information on death certificates is often not accurate,
especially when compared with information from
necropsy.2 3
Many patients die of chronic disease, and
characterising the immediate cause of death might
require investigations that seem meddlesome.2 An underlying acceptance of the limits of accuracy when
certifying the cause of death is one factor that allowed
Shipman to go undetected for so long.
None of the deaths with which Shipman was
charged was reported to the coroner. Coroners (or
procurators fiscal in Scotland) make their own rules on
the categories of death they require to have reported to
them, and the Registrar of Births, Marriages, and
Deaths is the only person with a legal duty to report
deaths to the coroner. The BMA has repeatedly argued
that although in practice doctors do report deaths
directly to the coroner, a statutory duty should be
placed on them to do so in specified circumstances and
that these circumstances should be defined and agreed
nationally. Similar duties should be imposed on nurses
and undertakers if they suspect that the death warrants
investigation.4
There are safeguards, to detect crime, when a body
is cremated, but their effectiveness is questionable. For
deaths not being investigated by the coroner,
permission to cremate must be applied for. The doctor
who issued the death certificate must complete a form
and a second doctor who has been registered for at
least five years must sign a confirmatory certificate.
Both doctors must see the body and the second doctor
must discuss the circumstances of the death with the
first. These forms are then inspected by crematorium
medical referees who must be satisfied that the cause of
death has been definitely ascertained.3
No specific training is required either for the second doctor or for
crematorium referees. Ironically the Brodrick Committee, which reported in 1971 on death certification
and the coronial system, recommended abolishing
these safeguards because it doubted their necessity.5
This move was opposed by the BMA.
It would be unnecessary and intrusive if all deaths
were to be investigated by a coroner. It is tempting to
think that Shipman may have been detected sooner if
all those who died at his hand had undergone
necropsy - indeed, Shipman made determined efforts
to avoid necropsies. Nevertheless, necropsies, though
likely to raise questions, may not have revealed the
cause of the deaths unless suspicion was high. In only
5% of hospital deaths can necropsy show findings that
are incontrovertibly incompatible with life.6
In the absence of suspicion, possibilities such as
insulin poisoning cannot be excluded without
complex toxicological analysis. Poisoning with potassium may go undetected without access to a blood
sample taken immediately after collapse. Even deaths
due to smothering are unlikely to be detected at
necropsy.6
When the bodies of Shipman's patients
were eventually exhumed, evidence of morphine was
found in some. Yet if a more robust system had been in
place, making necropsies more likely, Shipman might
simply have used means other than morphine to kill
his patients.
Some hospital clinical and pathology departments
hold regular audits of deaths. Similarly, many group
practices also conduct audits of recent deaths. In
primary care these are often triggered by staff stress
after a difficult illness or the death of a patient with
dependent relatives, suggesting how far removed is the
thinking behind these audits from the suspicion necessary for a forensic examination of a suspicious death. A
group practice of five doctors will have about 100
deaths a year, over half of them occurring in hospital
and most of the rest in nursing homes, hospices, or
residential homes. A singlehanded general practitioner
will expect to have less than five deaths annually in the
patient's home.
Systems for regular revalidation of all doctors have
been agreed, and systems of clinical governance are
being put in place across the NHS. Yet it is
questionable whether, had these systems been in place
at the time, Shipman would have been identified
sooner. Deficiencies have long been recognised in the
legal systems surrounding death.3,4,7
More rigorous procedures for certification and registration should at
least make detection more likely and investigation
more efficient and straightforward. Trust in doctors,
fundamental to an effective relationship with patients,
has been undermined by this case. The profession
must respond robustly to show that trust is well
founded.
Nevertheless, although lessons can be learnt and
procedures tightened up, no guarantees can be given
that any doctor, nurse, or other clinician could not if
sufficiently determined and perverse repeat Shipman's
crimes. In the investigation following the Allitt murders
the Clothier Committee concluded that "a determined
and secret criminal may defeat the best regulated
organisation in the pursuit of his or her purpose."1
It is difficult to envisage any set of laws or regulations that
will guarantee that the acts of a criminal as
experienced, knowledgeable, cool, and determined as
Shipman can be prevented in the future.
Bill O'Neill, science and research adviser, BMA, London WC2H 9JP
University of California San Diego Medical Center, San Diego, CA 92103.8676, USA
Email: psoc@aol.com
studentBMJ 2000;08:45-88 March ISSN 0966-6494
- Clothier C, MacDonald CA, Shaw DA. The Allitt inquiry: independent
inquiry relating to deaths and injuries on the children's ward at Grantham and
Kesteven General Hospital during the period February to April 1991. London:
HMSO, 1994.
- Black D, Everest MS, Acheson ED, Adelstein AM, Cameron HM,
Campbell ACP, et al. Medical aspects of death certification. A joint report
of the Royal College of Physicians and the Royal College of Pathologists.
J Royal Coll Physicians Lond 1982;16:206.18.
- Horner JS, Horner JW. Do doctors read forms? A one.year audit of medi.
cal certificates submitted to a crematorium. J R Soc Med 1998;91:371.6.
- British Medical Association. Deaths in the community. London: BMA, 1986.
- Home Office. Report of the committee on death certification and coroners.
London: HMSO, 1971.
- James DS, Leadbeatter S. Detecting homicide in hospital. J Roy Coll Physicians Lond 1997;31;296.8.
- Leadbeatter S, Knight B. Reporting deaths to coroners. BMJ 1993;306:1018.
