Independent report

The Shipman Inquiry third report: death certification and the investigation of deaths by coroners

This document contains the following information: The Shipman Inquiry third report: death certification and the investigation of deaths by coroners.

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The Shipman Inquiry third report: death certification and the investigation of deaths by coroners

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This document contains the following information: The Shipman Inquiry third report: death certification and the investigation of deaths by coroners.

This is the third report of the Shipman Inquiry, set up to investigate the circumstances surrounding the murders of over 200 patients by their GP, Dr. Harold Shipman. It examines the present arrangements for death registration, cremation certification and coroners’ investigations in England and Wales; and sets out recommendations for changes to protect patients from the concealment of homicide in the future, as well as to establish a sound system for promoting medical knowledge and aiding NHS resource planning. 48 recommendations are made including: the need for radical reform of the coronial system, with a new Coroner Service to be established as a executive non-departmental public body (ENDPB), governed by a Board responsible for policy formulation and strategic direction. The aim of the Service should be to provide an independent system of death investigation and certification accessible to the public, with procedures designed to provide a through and open investigation of suspicious deaths and to detect cases of homicide, medical error and neglect. Posts of medical and judicial coroners should be established as independent office-holders under the Crown, and trained investigators given an enhanced role in place of the coroner’s officer. The Service should be organised through a regional and district structure, based on the ten administrative regions in England and Wales. The death certification scheme should require the completion of two forms, with a statutory duty imposed upon the consultant doctor in cases of a death occurring in hospital or on the GP in case of a death occurring other than in hospital. There should also be a statutory duty on any ‘qualified’ or ‘responsible’ person to report any concerns relating to a death believed to amount to evidence of crime, malpractice or neglect.

This Command Paper was laid before Parliament by a Government Minister by Command of Her Majesty. Command Papers are considered by the Government to be of interest to Parliament but are not required to be presented by legislation.