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Shipman inquiry: GPs' fatal errors are going undetected

Fatal GP errors are going undetected because too few patient deaths are reported to coroners, claims the chair of the Shipman inquiry.

In her third report, published last week, Dame Janet Smith recommended a new independent coroner's service that would be encouraged to 'think dirty' and scrutinise the circumstances surrounding every death before certifying a cause (see box).

Coroners would also have the power to seize documents and drugs from practices under investigation.

The plans were described as a 'step backwards' by the RCGP, which said they undermined the Government's 'blame-free culture' for learning from adverse incidents.

Dame Janet said the number of deaths resulting from medical errors was under-reported because it was left up to GPs or relatives to refer cases to the coroner.

'It appears that many doctors consider it would be wrong for the coroner to examine the possibility that medical error might have contributed to a death,' she said.

She insisted doctors who made mistakes should be treated in the same way as negligent drivers or employers whose workplace was unsafe.

She added: 'We do not know that Shipman is unique. We know he has killed more people than any other serial killer but we do not know how many other doctors have killed one or more patients.'

Dr Maureen Baker, honorary secretary of the RCGP, said: 'The profession is signed up to learning from adverse incidents. I'm concerned with the focus on an individual as opposed to a system. There will be a tendency for people not to be open.'

Dr John Grenville, GP

expert witness to the Shipman inquiry, also expressed doubts over the proposed overhaul of death certification. 'I think there's a major difference between a case where things didn't go as well as they might have done and where a major error was made,' said Dr Grenville, secretary of Derby-shire LMC.

Shipman inquiry recommendations for

overhaul of death certification

 · A new coroner's office would be notified of all deaths with investigator examining two standard forms:

·form 1 to be completed by health professional, recording the facts surrounding the death, including who was present.

·form 2 to be completed by doctor who last treated patient, attaching relevant sections of patient notes. If patient had not been treated recently, form will be filled out by patient's GP. Doctor completing form 2 can give

a professional opinion of the cause of death.

 · Coroner's investigator checks facts on forms with relatives or carers to ensure no inconsistencies.

 · Family given opportunity to raise concerns. Family can see form 1 but not necessarily form 2 as it may contain confidential information. If no concerns raised, investigator certifies cause of death, usually the cause given by the form 2 doctor.

 · If the form 2 doctor uncertain of cause of death, or if family or other person expresses concern, death referred for further investigation by medical coroner.

Six GPs are criticised over signing form C

Dr Rajesh Patel is one of six GPs criticised in the Shipman inquiry report for the way they signed form Cs.

Dame Janet said the six GPs' actions were 'mitigated' though not excused by the 'generally low standard of form C completion prevailing throughout the profession'.

Dr Patel was criticised for just one form he signed concerning the death of Marjorie Waller.

Dame Janet said Dr Patel could not have paid attention to what Shipman had put on form B. Dr Shipman wrote that Mrs Waller had died of bronchopneumonia preceded by a collapse but that neighbours had found her dead on the bed ­ an account that did not make sense.

Dr Peter Bennett was also criticised for signing a form despite glaring inconsistencies.

Dr Susan Booth, Dr Jeremy Dirckze, Dr Stephen Farrar and Dr Alastair MacGillivray were all criticised for not noticing patterns of unusual features concerning the deaths on the forms they signed.

All six GPs worked in Hyde, Greater Manchester.

Out-of-hours concerns

Delays by out-of-hours GPs in attending deaths were highlighted as a serious problem in the latest Shipman report.

Dame Janet called for a national policy setting out the responsibilities of GPs and the police for dealing with the immediate aftermath of a death in the community.

She highlighted wide variations in procedures and said she was particularly concerned about the delays in attendance by out-of-hours doctors, having looked at evidence from 16 out-of-hours organisations.

'It appears there is often delay in attendance by a deputising doctor who might, understandably, give priority to the urgent needs of the living,' she said. 'As a result the police are called out to an increasing number of deaths in which there is no suspicion of criminal involvement.'

The inquiry heard that in 10-15 per cent of cases a police surgeon was called because of difficulties in getting a deputising doctor to attend.

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