List of Issues
Phase 1 - Cases
Phase 2
Generic Evidence
Questions and Answers
Technical Assistance
List of Issues

The Inquiry was divided into two separate phases. The following is a list of the issues which were covered in each phase.

Phase 1

The Inquiry will consider how many patients Shipman killed, the means employed and the period over which the killings took place.

Phase 2

  • Stage 1

    The Police Investigation of March 1998

  • Stage 2

    Death and Cremation Certification
    The roles of the informant, medical practitioners, medical referees, the registrar and coroner. Custom and practice generally and in Hyde. Should funeral directors have a role? The forms used. Should they be changed? Good practice. The practices followed in the Shipman cases.

    Reporting and investigation of sudden deaths. The roles of the police, paramedics and coroner. Good practice. The practices followed in the Shipman cases.

    Proposals for change.

  • Stage 3

    Controlled Drugs
    The procedures for prescribing, dispensing (to include provision on signed orders), collecting, delivering, storing and disposing of controlled drugs and the monitoring of those procedures by the Home Office and the police. What did such monitoring reveal about Shipman?

    Proposals for change.

  • Stage 4

    Monitoring and Disciplinary Systems and Complaints
    Whistle-blowing. The opportunity available to those in positions of responsibility (including medical colleagues, nurses, health visitors, practice staff, pharmacists, funeral directors, sheltered housing staff and staff of nursing and residential homes) to report concerns or suspicions about the conduct of a medical practitioner. Good practice. What reports of concern were made about Shipman and how were they dealt with? What further reports ought to have been made?

    The systems for monitoring or analysing mortality rates. What did such systems reveal about Shipman?

    Disciplinary rules for general medical practitioners and the operation of the disciplinary processes operated within the NHS and by the General Medical Council. Powers of suspension. What happened in the case of Shipman?

    The system for recording information about medical practitioners' qualifications and past history (including criminal convictions) and communicating such information to those who may be considering appointing or employing them. What information is recorded arising from errors and complaints? What information was conveyed about Shipman?

    The system for monitoring the performance of general medical practitioners, with particular reference to those in single person practice, record keeping and prescribing. The role of patients and their complaints in the monitoring of a GP's practice. The role of practice staff in reporting on the performance of a GP. The role of the former Regional Medical Officer. How was Shipman's work monitored and with what result? Accountability of GPs and Health Authorities.

    Proposals for change.
An additional report was published into Shipman's activities whilst he was a hospital doctor at Pontefract General Infirmary.

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Published by The Shipman Inquiry
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