The Pharmaceutical Journal
Vol 277 No 7407 p13-16
1 July 2006

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New CD regulations will not obstruct “another Shipman” who intends to kill

In this article, Cathal Gallagher argues that the Shipman Inquiry has failed to close the loopholes in the regulation of Controlled Drugs used by Shipman. Inherent in the work of doctors is a level of trust, he says, and it is still possible for GPs to divert CDs for nefarious purposes

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SUMMARY

It is now over 18 months since the fourth report of the Shipman Inquiry, examining the regulation of Controlled Drugs in the community, was published. It sought to address how, over the course of 20 years, Shipman acquired the large quantities of diamorphine that he used to kill over 200 patients. Despite the regulatory controls in place, Shipman’s diversion of diamorphine went undetected. When it eventually came to light, it was not because his unlawful acquisition of the drug had been detected, but because he had come under suspicion of murdering Kathleen Grundy. The report made apparent that the regulatory framework governing the use of CDs had not operated as it should. The purpose of regulation, according to the report, is to ensure accountability for the use of CDs so as to avoid their diversion to improper use, and to detect such diversion if it occurs. Regulation had, obviously, failed in this case. The terms of reference of the inquiry required Dame Janet Smith to “examine the actions of those involved in the operation of these arrangements and to recommend changes that would lead to the better protection of patients in future”.

Now that legislators have had a chance to digest the contents of, and act upon, the recommendations of the Shipman Inquiry, it is timely to discuss, with particular reference to the fourth report, the key changes recommended and the extent to which the recommendations have passed into current law on CDs. Furthermore, an analysis of how effective the changes will be in achieving the principal objective of the inquiry — to protect patients in the future from “another Shipman” — is now warranted.

To gauge accurately the effectiveness of the Shipman Inquiry, it will be necessary to identify the key recommendations of the inquiry, and assess whether each of these recommendations complies with the principal objective of the inquiry, namely, “to establish what changes to current systems should be made in order to safeguard patients [from a recurrence of these events] in the future”.2 If the recommendations are not consistent with the primary remit of the inquiry, it will be useful to identify any other mischiefs that they correct, and whether these provide any benefit for patients or health care professionals. To establish if a change of the regulations relating to CDs will help prevent “another Shipman”, a good starting point is to examine the illegal activities, most specifically those relating to the diversion of CDs, carried out by the original offender.