Shipman Inquiry: Second and Third Reports (Hansard, 14 July 2003)

§ Baroness Scotland of Asthal

This morning, the Home Secretary and the Secretary of State for Health are publishing and laying before Parliament the Shipman inquiry's second and third reports:The Police Investigation of March 1998, and Death Certification and the Investigation of Deaths by Coroners. These follow the publication, last year. of the first report, Death Disguised, which established the extent of Harold Shipman's activities. The inquiry's 83WA final reports, on controlled drugs, and disciplinary systems and complaints, are expected next year.

We would like to thank Dame Janet Smith for the considerable work, and care and attention that have obviously gone into the preparation of these reports. We also wish to reiterate our sympathy to the relatives and friends of Shipman's victims. For their sake and in the wider interest of the community, it is essential that lessons are learned from these dreadful events.

The second report covers the investigation conducted by the Greater Manchester Police in March and April 1998; five months before Harold Shipman was arrested. It makes it clear that, while the inquiry does not blame police management systems, the conduct of those officers involved in this specific investigation fell below the standard which the community is entitled to expect of public servants in their position. There was a subsequent internal inquiry by Greater Manchester Police into the failure of the March 1998 investigation. In the words of Dame Janet this inquiry was "quite inadequate".

We take the judgment of the Shipman inquiry on the Greater Manchester Police extremely seriously. For the initial investigation to have failed is severe enough, but for the subsequent investigation into its handling to have been so flawed requires the most urgent and strenuous efforts to ensure that such an event could never recur. It is for Greater Manchester Police to investigate but we await its report, and will expect rapid and effective action as well as lessons to be learnt by other forces in response.

We have asked our officials to work closely with the Greater Manchester Police to establish what can usefully be drawn from the report and to offer appropriate support and advice. We will help Greater Manchester Police to move forward. Through the Home Office Police Standards Unit and Her Majesty's Inspectorate of Constabulary we are already working with the force to deliver performance improvements for the benefit of those living and working in the force area.

It will also be for Greater Manchester Police to decide what action may be appropriate in relation to any individual police officer. The Home Secretary has written to the Chief Constable to ask to be kept informed of how the criticism against individuals in the force is being addressed.

The report recommends that guidance should be issued to those detective officers who have to undertake investigations into allegations of wrongdoing by health professionals. Work on this is already under way. The Association of Chief Police Officers and the Department of Health, with the advice of the Health and Safety Executive, are jointly developing a memorandum of understanding. This sets out the roles and responsibilities of both organisations when a serious incident takes place or is suspected of occurring, and principles for effective liaison when criminal investigations may be needed 84WA into such incidents involving NHS patients. The memorandum will also refer to other guidance on incidents of this type; for example, guidance to police senior investigating officers, which the report identified as being developed.

The third report found systemic shortcomings within the cremation arrangements and coroner system. The report of the Fundamental Review of Coroner Services and Death Certification, published on 4 June, identified similar inadequacies, although the solutions proposed are slightly different.

As we announced when the earlier report was published, in order to assist the Government to develop a coherent long-term strategy for the future of our death investigation processes, we have asked the chair of the fundamental review, Mr Tom Luce, to conduct some further work to link the review's recommendations to the findings of the Shipman inquiry. This will enable us to formulate a comprehensive programme of reform later this year, taking into account both sets of observations and recommendations.

Dame Janet makes two recommendations for short-term improvement: that cremation certification procedures should be strengthened and that practices in coroners' offices should be improved. As a matter of urgency, our officials are discussing these proposals with the relevant agencies as part of our existing programme to take forward interim measures to improve these services. We shall ensure that guidance to deliver more robust procedures and practices is issued as soon as possible.

The Financial Secretary to the Treasury last week published a consultation document on modernisation of the civil registration service, including death certification. Like the Fundamental Review of Coroner Services and Death Certification, this also presents an opportunity for comprehensive reform, this time specifically of the registration service and its interaction with related services.