Tuesday, 24 March 2009

The Lessons of The Case of Dr Harold Shipman

Nurse 'gave patient suicide tip'. The allegations relate to deaths at the hospital in 1999. A Jersey nurse allegedly showed a young female patient how to commit suicide, according to a leaked police report. In another case the nurse allegedly asked an ill woman's son why he bothered visiting when she would be dead by the morning. The claims were first looked into 10 years ago but are now being reinvestigated by Jersey Police. The same male nurse is alleged to have been on duty when 13 patients died over two months in 1999. According to the leaked report the average death rate between 1998 and 1999 on the ward at Jersey General Hospital was 4.5 deaths per month. But in February 1999 there were eight deaths in four nights when the nurse was on duty, and a further five deaths in March also when the nurse, who cannot be named for legal reasons, was on shift. Increased dose - The police report at the time says that could have been explained by a bout of illness among frail patients, but could equally be down to foul play. But no action was taken on the report which has been recently leaked. The police investigation into the deaths is now being reviewed by the force.

It is ironic that this investigation took place in 1999, because of course that is when the police investigation into Doctor Harold Shipman began. That concluded on 31 January 2000, when he was convicted of killing 15 patients, and sentenced to life. The enquiry which followed made its conclusions known in 2003, and severely criticised the police force for its weaknesses at the time, as well as the coroner's office.

The two Greater Manchester Police detectives who investigated the doctor were inexperienced and unfit to handle the case, the inquiry found. As a result they missed many opportunities to bring Shipman's crimes to light. "If the police and the coroner had moved with reasonable expedition, the lives of Shipman's last three victims would probably have been saved," said Dame Janet Smith, the judge heading the inquiry.

There were clearly defects in the way police handled suspicious deaths in the Shipman investigation in 1999, and given that this is the same time frame that the suspicious deaths were occurring in Jersey, the natural question that raises itself is this: how good were the local force at these kinds of investigations? Would they have known the right way to proceed? Were police in general, both here and in the UK, adequately trained to handle investigations of "suspicious deaths"?

The initial police inquiry was triggered when another GP raised concerns Shipman might have been killing his patients. Two officers "found no cause for concern" and ended their inquiry after three weeks. The senior officer, Chief Superintendent David Sykes, was "unable to give effective leadership" but did not do anything about it, Dame Janet said. And the junior officer, Detective Inspector David Smith, was "out of his depth" and made "many mistakes" but did not ask for help and later lied to cover them up, she said.

The way the deaths were also investigated afterwards was also a matter of scrutiny, and they were passed off as "natural deaths" without a proper post-mortem. Senator Stuart Syvret leaked the report, but there is no mention of any requests for post-mortems or exhumations. Whether such forensic evidence was possible was unknown, but given the sudden increase in deaths, one wonders who was responsible for issuing death certificates, at the hospital, and whether they flagged up the unusual increase:

In March, 1999, five deaths occurred, all during the duty time or the next morning when MAROLIA would have been on night shift. Such fluctuations could easily be explained by a serious bout of flu affecting frail or already critically ill patients, but equally it could be due to foul play.

This was the Shipman enquiry's comments on "suspicious deaths":

She also called for "radical reform" of the way coroners work in England and Wales, after Shipman managed to evade their scrutiny by saying his victims had died of natural causes. In particular, Mr Smith missed the chance to order post-mortems on two suspected victims which would have led to a full investigation, she said.


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