The FailureFailure
The person who certifies a death can also hide it
The short answer
How did Harold Shipman's killings go undetected?
Harold Shipman certified the causes of death of patients he had killed. The Shipman Inquiry found that being able to certify them without objection from anyone let him pass off the killings as natural deaths. It found that a coroner investigated only two of the deaths, and that certification detected none of the 215 killings it had identified by 2003.1
Timeline · The Failure
Twenty-one years from report to law
- The line
- Event
- The catch
- A wait
Notation
- The line
- Time, left to right. Down the screen on a phone.
- Event
- A fact on the record.
- Missed chance
- The system had him and let him go.
- The catch
- The error that ended it, knocked out of line.
- Open case
- No one charged.
- A wait
- Time passes and nothing moves.
Data table
| Year | Event | Notation |
|---|---|---|
| 1998 | forged will reported | The catch |
| 2003 | Third Report | Event |
| 2009 | Coroners and Justice Act | Event |
| 2024 | statutory system | Event |
| 2003–2024 | 21 years to law in force | A wait |
How was Harold Shipman caught?
Winifred Mellor, Joan Melia and Kathleen Grundy were killed by their doctor, Harold Shipman, in 1998, after a police investigation into him had closed.12 That investigation began in March 1998, when a doctor at a practice opposite his surgery told the coroner of her concerns about the number of his patients who were dying.12 The coroner asked the police to investigate, and the investigation closed on April 17, 1998, after the detective who conducted it concluded that the concerns had no substance.12
According to the Inquiry’s Second Report, Mrs. Grundy was found dead on June 24, 1998, and her daughter later told police she suspected that a will in her mother’s name had been forged.2 Under the will, Shipman was the sole beneficiary.2 Her body was exhumed and morphine was found, and he was arrested that September.12
On January 31, 2000, he was convicted of murdering 15 patients and of forging the will.23 A public inquiry chaired by Dame Janet Smith then examined the full extent of his crimes.318 Its First Report, in July 2002, found that he had killed at least 215 patients.2311 Its Sixth and final Report, published on January 27, 2005, concluded that he killed about 250 patients between 1971 and 1998 and positively identified 218 of them.3411
Why did no one in authority question his certificates?
Since 1926, the Shipman Inquiry found, the law in England and Wales had required a doctor who attended the patient, or a coroner, to certify the cause of death before burial or cremation. Once a doctor had certified, there was no check on the truth or accuracy of the statement and no audit of deaths not reported to a coroner.1
The Inquiry found the procedure virtually unchanged for over 75 years.1 Its most serious weakness was that it depended on the integrity and judgment of a single medical practitioner.1 Nobody in authority had the power or knowledge to question a certificate Shipman issued, and a burial needed no further check.118
Many of Shipman’s patients died suddenly, in circumstances in which no honest doctor would have claimed to know the cause of death.1 Shipman, who had killed them, certified the cause himself, avoided a report to the coroner and so avoided any official inquiry.1 For Kathleen Grundy, he certified old age.1 In the six months before the police investigation of March 1998, the Second Report found, he had certified 31 deaths.2
Cremation carried additional safeguards: a second doctor completed a confirmatory certificate, and a medical referee examined the forms.118 In the vast majority of cases, the second doctors who signed for Shipman questioned no one independent of him about the death.1 They trusted him as a respected colleague.1 The Inquiry found that the procedure, as operated, served no useful purpose as a deterrent to Shipman or as a means of detecting what he did.1
What changed in England and Wales, and when?
A statutory medical examiner system came into force in England and Wales on September 9, 2024. The reforms require every death to be reviewed by a medical examiner, a senior doctor not involved in the patient’s care, or investigated by a coroner. The Welsh Government says the Shipman Inquiry first proposed the system in 2003.568
The Third Report, published in July 2003, concluded that certification of the cause of death by a single doctor was no longer acceptable.1718 It said a doctor’s statement of the cause of death should be scrutinized by someone with a medical qualification, or with special training in medical matters and ready access to expert medical advice.1
The primary legislation is the Coroners and Justice Act 2009.6 A medical examiner system began on a non-statutory basis in 2019.56 The Medical Certificate of Cause of Death Regulations 2024, which extend to England and Wales, came into force on September 9, 2024, with separate medical examiner regulations for England and for Wales.8915
After many of the killings, the Inquiry found, relatives were not consulted during certification or given any specific opportunity to discuss the death.1 Under the reforms, medical examiners give bereaved people an opportunity to ask questions and raise concerns with someone not involved in the care.6 From the Third Report to the law in force took 21 years.78
Why did hospitals keep hiring Charles Cullen?
In New Jersey, the murder of the Rev. Florian Gall led to the arrest of a nurse, Charles Cullen, in December 2003.121417 Cullen pleaded guilty to 29 murders, 22 of them in New Jersey, and was sentenced there in March 2006 to consecutive life terms.1017
He had worked for 16 years at 10 hospitals and nursing homes in New Jersey and Pennsylvania.1017 He had never been disciplined in New Jersey, so his record appeared clean.1317 He kept finding work, in part because hospitals did not share their suspicions for fear of being sued.1017
New Jersey’s Health Care Professional Responsibility and Reporting Enhancement Act, P.L.2005, c.83, was approved on May 3, 2005.1416 It requires a health care facility to notify the state Division of Consumer Affairs when, for impairment, or for incompetence or misconduct that relates adversely to patient care or safety, it discharges a professional or suspends or revokes the professional’s privileges.1617 Asked by another facility, it must truthfully report a former employee’s job performance in patient care and the reason the employee left.16 The acting governor’s signing release said the need for these safeguards became apparent after Cullen moved from job to job despite a questionable employment record.14
The rule
The only witness filed the paperwork. England and Wales now require an independent review of every death.
Questions
Did Harold Shipman sign his victims’ death certificates?
- Yes. The Shipman Inquiry found that his ability to certify the cause of death of the patients he had killed, without objection from anyone, enabled him to pass off the killings as natural deaths. It found that only two of his victims’ deaths were investigated by a coroner.1
How many patients did Harold Shipman kill?
- The Shipman Inquiry’s Sixth and final Report, published on January 27, 2005, concluded that he killed about 250 patients between 1971 and 1998 and positively identified 218 of them. He was convicted on January 31, 2000, of murdering 15 patients and of forging a will.2311
What is a medical examiner in England and Wales?
- A senior doctor who provides independent scrutiny of causes of death and was not involved in caring for the patient. Since September 9, 2024, that scrutiny has been a legal requirement before the registration of every death that a coroner does not investigate.68
When did medical examiner scrutiny become a legal requirement?
- On September 9, 2024, when regulations made under the Coroners and Justice Act 2009 came into force in England and Wales: the Medical Certificate of Cause of Death Regulations 2024 and separate medical examiner regulations for England and for Wales. A non-statutory system had operated since 2019.68915
What law followed the Charles Cullen case in New Jersey?
- The Health Care Professional Responsibility and Reporting Enhancement Act, P.L.2005, c.83, approved on May 3, 2005. It requires health care facilities to notify the state Division of Consumer Affairs when they discharge or restrict a professional for incompetence or misconduct affecting patient care, and to answer other facilities’ inquiries truthfully.1416
The record
Sources
The Shipman Inquiry (Chairman: Dame Janet Smith DBE), Third Report, “Death Certification and the Investigation of Deaths by Coroners,” Cm 5854 (July 2003), official copy on gov.uk: Foreword; Summary paras 12 to 14, 19, 26, 40 and 50; paras 3.123, 5.63, 5.64, 12.32, 15.9 and 19.1 to 19.4. Supports: how death and cremation certification worked, how Shipman used it, and the Inquiry’s conclusions.
The Shipman Inquiry (Chairman: Dame Janet Smith DBE), Second Report, “The Police Investigation of March 1998,” Cm 5853 (July 2003), official copy on gov.uk: Summary paras 1 to 4 and 13; paras 1.1 to 1.3. Supports: the March 1998 police investigation and its closure, the three patients killed after it, the forged will, the exhumation and arrest, the conviction, the count of 215 and the 31 certified deaths.
The National Archives (UK), catalogue description of series JA 10, “Independent Inquiry into the issues arising from the case of Dr Harold Shipman (The Shipman Inquiry): Official Archived Website,” administrative background. Supports: the conviction on Jan 31, 2000; the Inquiry’s chair and terms of reference; the First Report (Jul 19, 2002); the Sixth Report (Jan 27, 2005) and its figures of about 250 and 218.
The Irish Times, “Shipman killed 15 as a student doctor - report” (Press Association report, Jan 27, 2005), quoting the Sixth Report. Supports: the final estimate of about 250 patients killed between 1971 and 1998.
Mark Drakeford MS, Cabinet Secretary for Health and Social Care, “Written Statement: Coming into Force of the Death Certification and Medical Examiner Reforms” (Welsh Government, Sep 9, 2024). Supports: the reforms came into force that day; a non-statutory service in Wales since 2019; the Shipman Inquiry first proposed the system in 2003.
Department of Health and Social Care, “An overview of the death certification reforms” (gov.uk guidance, updated Aug 14, 2024). Supports: an independent review of every death by a medical examiner or a coroner; the medical examiner’s role; the Coroners and Justice Act 2009; the non-statutory start in 2019; regulations in force on Sep 9, 2024.
gov.uk, “The Shipman Inquiry third report: death certification and the investigation of deaths by coroners,” publication page, Cm 5854. Supports: the publication date, Jul 14, 2003.
The Medical Certificate of Cause of Death Regulations 2024, S.I. 2024/492, regulation 1 (legislation.gov.uk, as made; made Apr 11, 2024). Supports: commencement on Sep 9, 2024, and extent to England and Wales.
The Medical Examiners (England) Regulations 2024, S.I. 2024/493, regulation 1 (legislation.gov.uk, as made; made Apr 11, 2024). Supports: commencement on Sep 9, 2024, for medical examiners appointed by English NHS bodies.
Associated Press, “Nurse who killed 29 sentenced to 11 life terms” (NBC News, Mar 2, 2006). Supports: the New Jersey pleas and the March 2006 sentencing, the 16-year career at 10 hospitals and nursing homes, and hospitals’ failure to share their suspicions.
The Shipman Inquiry (Chairman: Dame Janet Smith DBE), Sixth Report, “Shipman: The Final Report” (Jan 27, 2005), complete text without appendices as published on the Inquiry’s website, archived copy of Jan 12, 2006: paras 7.2 and 7.78. Supports: about 250 patients killed between 1971 and 1998, 218 positively identified; the First Report’s finding of at least 215.
Associated Press, “Ex-nurse pleads guilty to 13 patient deaths” (NBC News, Apr 29, 2004). Supports: his arrest on Dec 12, 2003, and his work at nine hospitals and one nursing home over 16 years.
CBS News, with the Associated Press, “Nurse Pleads Guilty To 13 Killings” (page dated Nov 17, 2004, reporting his first pleas, entered on Thursday, Apr 29, 2004). Supports: New Jersey’s Division of Consumer Affairs had no record of complaints or disciplinary action against him.
New Jersey State Law Library, Legislative History Checklist for L. 2005, c. 83, N.J.S.A. 45:1-33 (“Health Care Professional Responsibility and Reporting Enhancement Act”), bill S1804, with the bill text and the acting governor’s signing release of May 3, 2005. Supports: the date of approval; the release tying the law to the Cullen case and recording his arrest on the charge of murdering the Rev. Florian Gall.
The Medical Examiners (Wales) Regulations 2024, W.S.I. 2024/505 (W. 81), regulation 1 (legislation.gov.uk, as made; made Apr 12, 2024). Supports: commencement in Wales on Sep 9, 2024.
New Jersey Legislature, P.L.2005, c.83 (Senate bill 1804), “Health Care Professional Responsibility and Reporting Enhancement Act,” chaptered law text, approved May 3, 2005: sections 1, 2 and 15. Supports: the law’s name and date, the duty to notify the Division of Consumer Affairs, and the duty to answer other facilities truthfully.
Nick Vadala, “The true story of Charles Cullen” (The Philadelphia Inquirer, Oct 27, 2022; headline shortened). Supports: the pleas to 29 murders, 22 in New Jersey; the 16-year career at 10 hospitals and nursing homes; the clean record; hospitals’ fear of lawsuits; the arrest after the murder of the Rev. Florian Gall; the March 2006 sentencing; the reporting law.
Home Secretary and Secretary of State for Health, “Learning from tragedy, keeping patients safe: Overview of the Government’s action programme in response to the recommendations of the Shipman Inquiry,” Cm 7014 (February 2007), official copy on gov.uk: Foreword and paras 1.7 to 1.9, 2.5 and 2.6. Supports: no further check on the certificate before a burial; the two doctors and the medical referee for a cremation; the Inquiry’s remit, chair and conclusion; the count of around 250.
Educational analysis. Adjudicated cases only. Victims named with respect.