Showing posts with label Suspicious deaths. Show all posts
Showing posts with label Suspicious deaths. Show all posts

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.

Links

Saturday, 21 March 2009

Breaking the Lawyers Code

http://www.channelonline.tv/channelonline/DisplayArticle.asp?ID=401851

Hospital 'murders' allegation review: The case of a nurse suspected of killing patients at Jersey's General Hospital is being reviewed. Allegations made a decade ago led to a police investigation, but it was later dropped on legal advice. Now Senator Stuart Syvret has published a police report from the time on his blog. This morning Jersey police said case files are now being reviewed and that key people who had been involved will be spoken to. Detective Chief Inspector Chris Minty says the police want to establish if there is any new evidence which would justify further investigation. And police are also looking at whether publication of the report breaks the island's data protection law.

What is interesting from an outside point of view is that - on the evidence of Stuart Syvret's blog - a convincing array of evidence was being assembled, but he is missing one part - what was the "legal advice" which caused the case to be dropped? Perhaps if this is now made public by the authorities themselves, it will become clear whether it was justified or not. As we have seen more publically with Lenny Harper, and the 11th hour failure to allow charges by a centenier "on legal advice", the same "legal advice" is not made clear; it is a "black box" into which evidence goes, the Attorney -General and lawyers deliberate, and the end result is given, but none of the process of reasoning by which anyone could follow to see how they reached their conclusions. As a result, there is no way of knowing how sound that reasoning is, and other independent lawyers (perhaps acting for victims) have no way of knowing what it is.

It is rather like a conjuring trick, when the magician puts something into a sealed box, waves a wand, and hey presto, it has vanished. The excellent TV series "Breaking the Magicians Code" brought the means out into the open, and made the methods of the tricks transparent. It would be nice if "legal advice" could be more transparent as well, and less like a conjuring trick, in which everyone looking on is kept in the dark as to how it is done. Is this justice "seen to be done"?

As far as "breaking the Data Protection Law" is concerned, surely there is a public interest concern, in particular:

This is the entry on the Nursing and Midwifery Register:
Practitioner Details
Name: Mr XXX XXX
Expiry date: 31 Aug 2009
Register Entry Start Date
Registered Nurse - Adult 16 Jul 1997
Registered Nurse - Adult (Level 2) 05 Jan 1983
Recordable Qualifications Start Date
No Recordable Qualifications registered.
Geographical Location
Channel Islands

As has been noted, this man is still registered to work as a nurse. He could have access to drugs and be near the ill and the sick. Given the evidence that while he may or may not have been responsible for deaths, he has certainly claimed to suffer from "gulf war syndrome", should he really still be able to be potentially looking after vulnerable patients. Is it not in the public interest, and for his own sake, that he is no longer permitted to practice as a nurse? Might it not be like letting someone who has started suffering from epileptic fits carry on driving an HGV vehicle?