The Pharmaceutical Journal
Vol 269 No 7208 p124
27 July 2002

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Shipman inquiry to go on to examine CD controls

The next phase of the public inquiry into how Harold Shipman was able to murder so many of his patients undetected will report on how systems for monitoring Controlled Drugs can be improved.

No timetable for the CD investigation has been published, but it will not be until much later this year.

In her first report, Dame Janet Smith, the judge conducting the inquiry, says that the legal controls over CDs clearly failed to work because they allowed Shipman to obtain large quantities of diamorphine and use it to kill 215 of his patients. She says that it was only his clumsy forging of the will of the last person he murdered that led to his discovery.

The second part of the inquiry is to consider why the CD controls failed and what measures should be taken to strengthen and improve them.

Shipman was a former pethidine addict with convictions for drugs offences in 1976. Following that, he guaranteed not to carry CDs ever again in his practice as a doctor, so he was not obliged to keep a CD register.

This did not stop him obtaining and stockpiling opiates by a variety of means, including prescribing them for patients and collecting them personally after having forged patients' signatures, claiming exemption from prescription charges. This gave pharmacists the impression that the patients concerned had actually seen the prescriptions. Sometimes patients received injections of small amounts of the drugs prescribed, sometimes they were murdered with them and sometimes Shipman kept the drugs. On occasion, he falsified patients' records by recording the administration of morphine to patients when CD registers from pharmacies in the surrounding area that might have dispensed the drugs showed that no prescriptions had been recorded in those patients' names.

Death disguised, the Shipman inquiry, first report, is available on the internet