The Shipman Inquiry

Shipman 4 - Implications for Pharmacy: Controlled Drugs

Presentation to theBritish Pharmaceutical Conference

2005By

Mandie LavinDirector of Fitness to Practise and Legal Affairs

and Kay Roberts

Expert Witness to the Shipman Inquiry

General background to the Shipman case

Harold Frederick Shipman

• Initially worked at Pontefract General Infirmary 1970 - 74

• Worked as a GP in Todmorden 1974 - 76• Was convicted in 1976 of dishonestly

obtaining drugs, forgery of National Health Service prescriptions and unlawful possession of pethidine (asked for another 74 TIC’s)

• GMC took no action on the convictions and the Home Office imposed no restrictions on his practice

• Moved to a group practice in Hyde in 1977, and in 1992 then set up as a single-handed GP, also in Hyde

Shipman - The GP

• Throughout career Shipman enjoyed high level of respect

• Extremely popular GP with patients particularly elderly

• Well regarded by FHSA/HA -innovative and advanced - “very up to date on all latest information and advice”

• Active in local medical politics and enthusiastic member of local branch of Small Practices Association

• Reportedly perceived quite simply as the best doctor in Hyde

Police investigations

• March 1998 - a local General Practitioner reported concerns to the Coroner about the excess number of deaths among Shipman's patients

• Initial police investigation did not uncover the truth behind Shipman’s activity

Police investigations

• Arrested in September 1998 – on suspicion of forging a Will

• A body was exhumed and the truth of the deaths began to emerge

• Suspended from practice, charged with 14 further murders

• Convicted at Preston Crown Court on 31 January 2000 and sentenced to 15 terms of life imprisonment

• Subsequently GMC erased Shipman’s name from Medical Register and DPP announced that no further criminal proceedings would be taken

The Inquiries

• February 2000 - the Secretary of State for Health announced an independent private Inquiry

• Public pressure led to a call for a Judicial Review into the decision that the Inquiry was to be held in private

• September 2000 - the Secretary of State for Health announced a Public Inquiry. Dame Janet Smith DBE was invited to become Chairman

“The Shipman Inquiry”

• Phase 1– The Inquiry considered how many patients

Shipman killed, the means employed and the period over which the killings took place

• Phase 2– Stage 1: The Police Investigation of March

1998– Stage 2: Death and Cremation Certification– Stage 3: Regulation of Controlled Drugs– Stage 4: Regulation of General Practitioners

The Inquiry’s Findings

• FIRST REPORTDeath Disguised

– published 19 July 2002

The Inquiry's First Report considered how many patients Shipman killed, the means employed and the period over which the killings took place

• This Report concluded that Shipman killed 215 patients, 171 women and 44 men between 1975 and 1998

The Inquiry’s Findings

• SECOND REPORTThe Police Investigation of March 1998

– published 14 July 2003

The Inquiry's Second Report examined the conduct of the police investigation into Shipman that took place in March 1998 and failed to uncover his crimes

The Inquiry’s Findings

• THIRD REPORTDeath Certification and the Investigation of Deaths by Coroners

– published 14 July 2003

The Inquiry's Third Report considered the present system for death and cremation certification and for the investigation of deaths by coroners, together with the conduct of those who had operated those systems in the aftermath of the deaths of Shipman's victims

The Inquiry’s Findings

• FOURTH REPORTThe Regulation of Controlled Drugs in the Community– published 15 July 2004

The Inquiry’s Fourth Report considered the systems for the management and regulation of controlled drugs, together with the conduct of those who operated those systems

The Inquiry’s Findings

• FIFTH REPORTSafeguarding Patients: Lessons from the Past - Proposals for the Future

published 9 December 2004

The Inquiry’s Fifth Report considered the handling of complaints against general practitioners (GPs), the raising of concerns about GPs, General Medical Council procedures and its proposal for revalidation of doctors

The Inquiry’s Findings

• SIXTH REPORTThe Final Report

Published 27th January 2005

The Inquiry’s Sixth Report considered how many patients Shipman killed during his career as a junior doctor at Pontefract General Infirmary between 1970 and 1974. The Inquiry also considered a small number of cases from Shipman's time in Hyde, which the Inquiry became aware of after the publication of the First Report

“The Regulation of Controlled Drugs in the Community”

Inspection Arrangements

• Co-ordinate existing governance arrangements

• All healthcare professionals subject to monitoring and inspection

• NHS and private healthcare organisations to nominate ‘Accountable Officer’ to oversee the safe effective use and management of CDs

Inspection Arrangements

• PCOs to carry out yearly clinical governance review of each contractor based on

• analysis of data e.g. prescribing/supply chain• reports from routine visits• statements from organisation• random sampling

• Healthcare Commission to assess adequacy of arrangements of private & voluntary healthcare providers and care homes

Inspection Arrangements

• Statutory duty of collaboration between Inspection bodies and healthcare organisations

• Development of core inspection standards• External scrutiny by Healthcare Commission• Proposed that RPSGB inspect CDs in

community pharmacies

Report Recommendations

• Only doctors in active clinical practice will have the right to prescribe

• CD prescriptions to have only 28 day validity.• Technical breaches of CD regulations should not be

a bar to dispensing• Private CD prescriptions standardised and

monitored in the same way as NHS prescriptions.• The prescriber to be identified

Implementation

• Some legislative changes in place by March 2006 – electronic registers and CD scripts– standardised private prescription forms and GP

requisition forms for CDs– ability to amend technical defects – record name and ID of persons collecting Sch 2

CDs

Implementation

• Remaining legislative changes approx 2007– mandatory use of electronic CD registers– information from CD registers sent to

central repository– mandatory running balances– time prescription issued and dispensed

to be recorded

Questions?