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Friday, 5 January, 2001, 13:50 GMT
Shipman: calls for change
Richard Baker
Professor Richard Baker: angered by discoveries
The major report into the killings of Harold Shipman has called for changes to make sure such a situation could never be repeated.

Professor Richard Baker, the statistics expert from Leicester University who compiled the document, confessed to the BBC that what he had uncovered had angered him greatly.

His recommendations, which demand far stricter monitoring of GPs, were "personal", he said.

Beefed up GP monitoring

"A lack of accountability that is not acceptable"

Shipman did not undergo at any point of his career the kind of review of his clinical performance which might have uncovered his killing spree.

He was not a member of the Royal College of General Practitioners, further limiting the opportunity for detection.

Professor Baker wants routine monitoring of GPs to include an examination of their death rates - and a review of the amounts of controlled drugs such as diamorphine they are prescribing.

Death rate records

"Health services must accept responsiblity for protecting patients from such individuals"

In order to make these checks, there needs to be an overarching system for keeping track of death rates.

None exists, says Professor Baker.

He calls for a practical system to be put in place, which allows the authorities to check not only how many deaths have taken place in a particular area, but also which doctors have signed the death certificate for each.

Additional information such as place of death, the length of their terminal illness and even who was present at death should be recorded, he said.

Death certification procedures

"Shipman himself offered a clue as to how the system could be improved"

The practice of requiring a second doctor to confirm the circumstances of death prior to cremation is of little value, says Professor Baker.

The present system is little more than a formality.

He wants causes of death fully corroborated from clinical records or other health professionals, as well as relatives and carers.

More information should be recorded on forms authorising burial or cremation.

GPs own records

"Shipman's records were extremely poor"

The record-keeping at his surgery in Hyde hampered the investigation, claims the report.

His entries on both computer and paper were inadequate.

In addition, while health authorities hold records of deceased patients for a short time, many have a policy of returning them afterwards to the GP.

Professor Baker recommends that this should be reviewed in the light of the Shipman case, and also that the quality of computer records should form part of the government's plans to inspect GPs clinical skills.

Controlled drugs

"Shipman did not maintain a controlled drugs register. It is unacceptable that this state of affairs should have gone unnoticed and unchallenged."

There is now confusion about who is responsible for keeping a check on doctors' use of controlled drugs such as diamorphine, which Shipman used to kill his victims.

A system should be introduced, says Professor Baker.

In addition, the failure of pharmacies or doctors to record batch numbers of drugs made it hard to find out which patient received which drug.

Batch numbers should be recorded in clinical records, he recommends.

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05 Jan 01 | Health
Shipman 'may have killed 236'
05 Jan 01 | Health
A nightmare for more families
28 Dec 00 | Health
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