Learning from tragedy, keeping patients safe - Overview of ...

Learning from tragedy, keeping patients safe

Overview of the Government's action programme in response to the recommendations of the Shipman Inquiry

Presented to Parliament by the Home Secretary and the Secretary of State for Health by Command of Her Majesty

February 2007

Cm 7014

London: the Stationery Office

?13.50

? Crown Copyright 2007

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Contents

Foreword

3

Chapter 1: Introduction

5

Harold Shipman

5

Early action

6

Setting up the Shipman Inquiry

6

The inquiry's reports

6

Chapter 2: Main themes of the inquiry's reports

8

The 1998 police investigation

8

Death certification and the coroners' system

8

Use of routine monitoring data

9

Responding to complaints and concerns

10

The controlled drugs audit trail

11

Regulation of doctors

11

Chapter 3: Developments in the NHS since Shipman's day

13

Clinical governance

13

Patient safety ? An organisation with a memory

14

Handling performance issues and the National Clinical Assessment Service

15

Towards a "patient-led NHS"

15

Regulation of healthcare organisations

16

Summary

16

Chapter 4: The Government's action programme

17

Police investigation of cases involving health professionals

17

Reform of the coroners' system

18

Improvements in the process for death certification

19

Safer management of controlled drugs

20

Clinical governance and the identification of potential performance issues

22

A new approach to complaints and concerns

23

Local handling of identified performance issues

24

Reform of professional regulation

25

Making a reality of revalidation

26

Chapter 5: Taking the action forward

28

References

29

List of abbreviations

32

Annexes:

A. The "three inquiries": Ayling, Neale, and Kerr and Haslam

33

B. Further details on the Government's action programme

35

LEARNING FROM TRAGEDY, KEEPING PATIENTS SAFE 3

Foreword from the Secretary of State for Health, the Minister of State for Policing, Security and Community Safety, and the Minister of State for Constitutional Affairs

There can be few people in the United Kingdom who are unaware of Harold Shipman, a respected GP from Hyde in Greater Manchester who, over a period of 20 or more years, was responsible for the murder of around 250 of his patients. In the years since Shipman was convicted, two questions are continuously debated. Firstly, what made an apparently caring, competent doctor turn to murder on such a horrific scale? And secondly, why did nobody in authority realise what was going on?

The Shipman Inquiry was set up in January 2001, following Shipman's conviction the previous year for the murder of 15 of his patients. The Inquiry was tasked with investigating the extent of Shipman's unlawful activities, enquiring into the activities of the statutory authorities and other organisations involved, and making recommendations on the steps needed to protect patients for the future.

The Inquiry published a total of six reports. The first and last addressed the extent of Shipman's criminal activities, as a general practitioner (First Report) and in the early part of his career as a junior hospital doctor (Sixth Report). The other reports considered the various processes and systems which failed to detect his activities at an earlier stage ? the 1998 investigation by the Greater Manchester Police (Second Report), death certification and the coroner system (Third Report), the systems for ensuring the safe and appropriate use of controlled drugs (Fourth report), and the arrangements for monitoring and disciplining GPs including arrangements for whistleblowing and handling complaints in the NHS (Fifth Report).

We owe an immense debt of gratitude to Dame Janet Smith and her team for their meticulous analysis of the weaknesses in existing systems which Shipman was able to exploit for his criminal purposes, and for the skill with which her recommendations balance the need to safeguard the normal processes of patient care and the need to protect the public from professional abuse.

As the Shipman Inquiry acknowledged, the NHS today is in many ways very different from the NHS in which Shipman practised. Among many other changes, there is a far greater acceptance of the view that the quality and safety of patient care is not just the responsibility of individual doctors, nurses and other health professionals ? important though that is ? but a shared responsibility of all healthcare organisations. New structures and processes have been put in place to ensure the quality of care, to focus healthcare organisations on continuous quality improvement, and to ensure that seriously deficient clinical performance is rapidly identified and dealt with. In this new climate, it seems unlikely that the activities of a Shipman would have gone unrecognised for long.

It is also vital to keep a sense of proportion. The overwhelming majority of health professionals are committed to providing the best care they can to their patients. We need to celebrate their commitment, support their efforts, and provide them with the means to seek even further improvement in the quality of the care they provide. It would be a tragedy if, in trying to protect

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