ILLUMINATION
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ILLUMINATION

A Killer Among the Medical Profession

How medical practice has changed in the UK since Harold Shipman’s conviction

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Harold Shipman was an ordinary General Practitioner in the town of Hyde near Manchester. He worked from a shop front premises and was the only doctor there. He was well liked. Older patients felt he listened to them and were comfortable in his presence. Little did they know that they were at serious risk of being murdered.

He killed around 250 people.

No one will ever know the true count as his killing spree began at least 20 years before his behaviour was exposed. His method was to inject his victims with a high dose of diamorphine. Diamorphine is an opioid, generally used for pain relief in end stage cancer and is a powerful respiratory depressant. The victim would rapidly succumb to unconsciousness and then death.

The reality of the situation was that the victim (usually an elderly woman living alone) would have opened their door gladly to their trusted doctor. They would have sat quietly as he discussed their medical management and she would have consented freely to be given an injection.

At that time, computerised notes were not universal, and many doctors still kept handwritten files on patients. It was relatively easy to alter these notes, adding additional diagnoses, which it seems Dr Shipman did on occasion. Once he had certified the death, it appears he sometimes stole jewellery and on a number of occasions was know to have altered wills in his favor.

Was his motivation financial?

It doesn’t seem so as he lived a very ordinary lifestyle with his wife Primrose in am uninspiring house. Despite apparently having been in the house of several of his victims with him, Primrose consistently denied that there was any wrongdoing. They were not intellectual equals. They had met when she was seventeen and working as a window dresser in a shop. She never went to college. She reportedly adored him and they married in 1966 when she became pregnant. They went on to have 4 children together. Primrose was very reclusive, and he was certainly the dominating partner. She remained loyal to him throughout his trial, sitting silently and unobtrusively watching the proceedings every day.

When he was convicted of killing 15 people in 2000, he was sent to prison for life. In 2004, just before his 60th birthday, he hanged himself. It is said that this was a strategic move as he knew that his wife would receive some pension if he died before the age of sixty. She had been living in penury after his conviction as the house was repossessed and she had no income of her own. His suicide was a calculated move and a surprising admission of his care for his life partner.

We will never know his motivation as he refused to answer questions. Some theorized that it may have all started when he experienced the distress of seeing his mother die in pain from cancer and felt powerless to help her. That may of course have been his reason for pursuing a medical education.

At the time of his exposure, I was working as a General Practitioner in a group practice. Every doctor in the country was horrified with the revelations that appeared in the press. I remember listening to an interview with another doctor who worked near Dr Shipman. She had been approached by him to countersign cremation certificates, as was the practice then. Usually the two doctors would speak on the phone, discuss the circumstances of death and ascertain if there were any witnesses. Once satisfied with the response to standard questions, the second doctor would sign the papers and cremation could then go ahead. The doctor in the interview commented that she had thought there had been more than usual requests from Dr Shipman and she had flagged this up but nothing had been done. He was of course able to spread the requests among a number of doctors so the true death count was not apparent.

As more information became available, a pattern was observed. Each of the victims either died at his practice in a consulting room alone with him, or were found seated in their own home. In my limited experience of observing sudden death events, the patient would often be in bed, or lying in a crumpled heap on the floor, possibly having hit their head on furniture as they fell. In no instance would they have had the time and prescience to sit themselves comfortably in their favorite chair. Incongruously, when families were notified of the death, they took solace from the fact that their relative had appeared to die peacefully.

Harold Shipman singlehandedly shattered patient/doctor trust and there was a perceivable difference in consulting style which every doctor embraced whether knowingly or not after the event. More time was spent giving detailed explanations of interventions. Trust could not be assumed.

Paternalistic medicine died with Harold Shipman.

What changes have occurred as a result of this man’s crimes?

In January 2001 an enquiry was commenced and building on that, sweeping changes were made to regulatory practices relevant to many areas of medical practice. A comprehensive discussion can be found in this paper Learning from tragedy, keeping patients safe.

1. First steps.

The Government tightened up on reviewing GP qualifications and mandatory police checks. Ensured that every GP had an annual appraisal, and new powers were introduced allowing local management to investigate and suspend GPs. A five year revalidation process was proposed and implemented. If you are interested to know what that involves this document provides guidance. NHS England » 10 steps to revalidation. Any initial concerns about a practitioner were to be investigated by a designated doctor in a screening process.

2. Cremation rules and burial.

The previous system was deemed to be inadequate. However it did take a number of years before the new process was set up. In 2009 new forms were produced and a much more rigorous process of questioning the circumstances of death are now required. Both signing doctors have a duty to question the relatives. An appointed medical referee must view the certificates before cremation is allowed to go ahead. The referee may have full access to the medical notes if requested. Any discrepancies can be referred for a judicial review under the auspices of the Coroner’s Office. Details of the reforms can be found here An overview of the death certification reforms — GOV.UK (www.gov.uk)

3. Better monitoring of GP practices.

Comparison of mortality rates. Detailed analysis of prescribing practices. As a direct consequence of Harold Shipman, singlehanded practices are no longer advised, and those that are functioning can expect increased surveillance. Clinical Governance to be strengthened and developed and a rigorous process of reflecting on any failings with the purpose of instigating improvements and learning from any mistakes.

4. Controlled Drug Management.

It is clear that Dr Shipman managed to get around the existing regulations by collecting drugs for patients himself, keeping some, and using unused drugs from deceased patients which should have been returned for destruction. A register of doctors allowed to prescribe such drugs is now up and running. There is regular inspection of individual records by a controlled drug inspectorate. In my own practice, one practitioner was assigned to do monthly stock checks on all controlled drugs, checking individual registers and returning out of date products to the pharmacy.

5. Easier processes for patients and relatives to make inquiries and complaints.

Expressions of concern are now given the same weight as complaints and investigated fully.

6. Patient safety.

Putting the patient first and keeping a record of all significant incidences. Any clustering of events should thus be identified at an early stage. The concept that now patients are much more knowledgeable due to access to the Internet, has changed the tone of the doctor/patient consultation. Paternalism is outdated.

Significant changes have occurred in the NHS since Dr Shipman became a media celebrity. Failings were identified and systems put in place to prevent such events ever occurring again. His case was unique. How could such a well respected doctor have got away with such crimes for so long? The whole concept of a serial killer among the medical profession was so alien to everyone, including the police, that the reluctance to believe may have delayed concerns being taken seriously.

It is a sad indictment on the health service that it took a mass murderer to initiate well overdue reforms.

Are we in a better place now? Certainly there is more accountability and better standards are in place. Fitness to practice is no longer a one off right but a regularly reviewed state. Learning processes have been formalised and slotted into normal practice routine.

Dr Shipman was a wake-up call we wish we had never had to experience.

Can other countries confidently state that such an event could never happen there?

Previously published on Vocal.media

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Carol Price

Carol Price

I used to be something else, but now I can hold my head up and say I am a writer. Retired doctor. Passionate about empowering people. Editor of Illumination

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