The Shipman Inquiry

Tribunals of Inquiry (Evidence) Act 1921

House of Commons 23 January 2001

6.41 pm

The Minister of State, Department of Health (Mr. John Hutton): I beg to move, That it is expedient that a Tribunal be established under the Tribunals of Inquiry (Evidence) Act 1921, for inquiring into a matter of definite public importance, that is to say, the matters arising from the deaths of patients of Harold Shipman, with the following terms of reference--

(a) after receiving the existing evidence and hearing such further evidence as necessary, to consider the extent of Harold Shipman's unlawful activities;

(b) to enquire into the actions of the statutory bodies, authorities, other organisations and responsible individuals concerned in the procedures and investigations which followed the deaths of those of Harold Shipman's patients who died in unlawful or suspicious circumstances;

(c) by reference to the case of Harold Shipman to enquire into the performance of the functions of those statutory bodies, authorities, other organisations and individuals with responsibility for monitoring primary care provision and the use of controlled drugs; and

(d) following those enquiries, to recommend what steps, if any, should be taken to protect patients in the future, and to report its findings to the Secretary of State for the Home Department and to the Secretary of State for Health.

Harold Shipman, who practised as a GP in Hyde, Greater Manchester, was found guilty on 31 January last year at Preston Crown court of 15 charges of murder, and one of forging the will of one of his patients. The clinical audit of Shipman's practice, which was published on 5 January, has revealed that he may be responsible for many more deaths.

Shipman's victims placed their trust in him as their local GP. He abused his position of trust callously and determinedly. It is beyond belief that a doctor could act in that way. Shipman was a cold, calculated, evil killer. His crimes have shocked the country and caused enormous grief and suffering to hundreds of people. However, we should not lose sight of the fact that the overwhelming majority of GPs in this country do a brilliant job for their patients. We must not allow Shipman's crimes to threaten the essential relationship between doctors and their patients.

From the outset, we wanted to make sure we learned the lessons of the case as quickly and effectively as possible so that we could take all the necessary measures to protect patients. That is why my right hon. Friend the Secretary of State announced on1 February last year that an inquiry was to be set up under the National Health Service Act 1977. It was to have taken evidence in private, but would have published its conclusions and recommendations in full.

The decision to take evidence in private was, as the House knows, successfully challenged through a judicial review brought by families of the victims and by sections of the media. They wished the inquiry to be held in public. In upholding the request for a judicial review, the court asked my right hon. Friend to review his original decision. Consequently, we decided that the new inquiry should be held in public, and we consulted the families about the form it should take. The strong view of the victims' families was that the Tribunals of Inquiry (Evidence) Act 1921 provided for the most suitable form of public inquiry.

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On 21 September, my right hon. Friend announced that there would be a public inquiry under the 1921 Act into the issues surrounding the crimes committed by Harold Shipman. The tribunal will be wide ranging and cover different responsibilities, including those that fall outside the health service's remit. Tribunals under the 1921 Act generally hold all or most of their meetings in public and have all the powers of the High Court in respect of calling witnesses and the production of documents. They may take evidence on oath and they provide absolute privilege in respect of defamation. The inquiry will be comprehensive and inclusive. It will enable the victims' relatives in particular to play their full part in the inquiry.

Mr. Douglas Hogg (Sleaford and North Hykeham): The Minister referred to the victims' families, who are very important. Is it intended to grant the families the opportunity to be legally represented so that they can participate in the inquiry and ask questions through their counsel in the cross-examination of relevant witnesses?

Mr. Hutton: I understand that the chairman of the tribunal has ultimate responsibility for determining such matters. However, it is the usual practice in inquiries under the 1921 Act for witnesses to be legally represented. [Interruption.] I understand that the question arises in relation to people who wish to give evidence before the tribunal.

Mr. Hogg: Of course that is partly correct. However, will members of families who have a genuine interest in the outcome of the inquiry because their relatives may have been killed by Dr. Shipman, but who do not have evidence to give, have an opportunity to instruct counsel so they can ask relevant questions of witnesses?

Mr. Hutton: I cannot add much more to the answer that I attempted to give to the right hon. and learned Gentleman.

Mr. Hogg: Will the Minister write to me?

Mr. Hutton: I am happy to write to the right hon. and learned Gentleman with more details if he would find that helpful. However, the question is whether those people wish to give evidence before the tribunal. If so, their entitlement to legal representation is essentially a matter for the chairman of the tribunal. As I said earlier, it is the usual practice in such inquiries for such legal representation to be permitted.

Mr. David Winnick (Walsall, North): I wonder whether my hon. Friend can assist me. I accept that it is not within his brief, but it has been reported in the press that Shipman was responsible for many other murders. That is being investigated. Would setting up the tribunal preclude charging Shipman with those murders? I appreciate that he has already received a life sentence. That is an important question, not least for the victims of that terrible man's crimes.

Mr. Hutton: No, setting up an inquiry will not preclude taking criminal action. Following the publication

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of Professor Baker's review of the clinical audit of Dr. Shipman's practice, Greater Manchester police have established a new incident room at Ashton-under-Lyne police station. They are conducting further inquiries and examining the evidence that might support any further prosecutions. As my hon. Friend knows, any decision to bring such a prosecution is ultimately the responsibility of the appropriate prosecuting authority--in this case, the Crown Prosecution Service.

Mr. Gerald Bermingham (St. Helens, South): Does my hon. Friend agree that the Director of Public Prosecutions has already said that there will be no prosecution in respect of the second batch because of the question of getting a fair trial? It seems logical that the DPP will reach the same conclusion about the 64 cases that Manchester police are now investigating.

Mr. Hutton: Hon. Members will understand that I do not want to pre-empt such decisions. There are on-going inquiries, for which the police are responsible, into the suspicious deaths of some of Dr. Shipman's patients. It would not be sensible to try to second-guess the decisions of appropriate prosecuting authorities.

Dr. Liam Fox (Woodspring): On a point of information, will the Minister tell us how far back the audit of Dr. Shipman's records goes?

Mr. Hutton: I understand that Professor Baker's review considered all the evidence from Dr. Shipman's practice from the beginning of his time as a GP. I believe that the clinical audit covers 20 years.

My right hon. Friend the Secretary of State announced the terms of reference and the chairman of the inquiry on 3 January. Subject to the House's agreement and that of another place, the terms of reference for the inquiry have been set out in the motion. First, after receiving the existing evidence and hearing such further evidence as necessary, the inquiry will consider the extent of Harold Shipman's unlawful activities.

Secondly, the inquiry will examine the actions of the statutory bodies, authorities, other organisations and responsible individuals concerned in the procedures and investigations that followed the deaths of those of Harold Shipman's patients who died in unlawful or suspicious circumstances.

Thirdly, by reference to the case of Harold Shipman, it will inquire into the performance of the functions of those statutory bodies, authorities, other organisations and individuals with responsibility for monitoring primary care provision and the use of controlled drugs.

Finally, following those investigations, the inquiry will recommend what, if any, steps should be taken to protect patients in future, and report to the Home Secretary and to the Secretary of State for Health.

The inquiry will be chaired by Dame Janet Smith, who has been a High Court judge since 1992. She was presiding judge of the north-eastern circuit between 1995 and 1998, and a judge of the employment appeals tribunal since 1994. She is extremely well qualified for the job.

I would like to acknowledge the strong contribution made by my right hon. Friend the Member for Stalybridge and Hyde (Mr. Pendry) in getting an inquiry set up into these terrible crimes. He has been in regular contact with

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my right hon. Friend the Secretary of State for Health about the case and has, in particular, been tireless in his support for the relatives of the many victims of Harold Shipman. Unfortunately, my right hon. Friend cannot be here tonight as he is recovering from an illness that he developed at Christmas.

The House will know that the Government and the medical profession are already taking action to modernise regulatory structures and to deal with poor performance wherever it occurs. During the summer, we consulted fully on proposals that included regulating deputy and assistant doctors through health authority supplementary lists and regulating doctors within personal medical services by means of a separate list system. Those proposals also included requiring all doctors in general practice to declare any criminal convictions and any adverse General Medical Council findings. That work forms the basis of the proposals in the Health and Social Care Bill now before Parliament.

By setting up primary care groups and primary care trusts, which provide more locally focused management structures for general practice, we have restricted the opportunities for doctors to act inappropriately. In addition, the Health and Social Care Bill will introduce important new powers to strengthen the links between GPs, health authorities and primary care trusts. Underpinning those provisions will be greater information sharing, to support appraisal and mandatory clinical audit.

Personal medical services contracts agreed for the third-wave pilots from April 2001 will require doctors to participate in at least three clinical audit programmes each year, and to allow 30 hours for continued professional development per year per doctor. My officials in the Department of Health are in discussion with the British Medical Association about how to apply the same standards to all general practitioners.

From April this year, all GPs will be required to participate in annual appraisal. The purpose of the appraisal will be developmental, but it will also identify poor performance wherever it exists. That is important in order to protect patients. In August last year, we took powers to allow the GMC to impose interim suspensions on doctors when necessary, including in conduct, health and performance cases. Additionally, the minimum period of erasure from the medical register is now five years, ensuring that when a doctor is struck off, he should not expect to return except in the most exceptional circumstances. The GMC must also notify a doctor's employer if it is considering his fitness to practise.

In November, we took the necessary legal powers to set up the National Clinical Assessment Authority. The authority will become operational in the first half of this year and is at the centre of the Government's co-ordinated approach to better protection for patients and better support for doctors. It will provide a central point of contact for the NHS when concerns arise about a doctor's performance.

NHS employers and health authorities will be able to refer a doctor to the NCAA if concerns about his or her performance cannot be resolved locally. The authority will carry out rapid objective assessments and make recommendations to NHS hospitals and health authorities so that they can take appropriate action. That could involve further training, support, or, if problems were intractable, dismissal or referral to the GMC.

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The Home Secretary is overseeing a review of the procedures involved in the certification of deaths and the authorisation of burials and cremation. The Office for National Statistics, the Department of Health and the Welsh Assembly are all involved in this work. The results of the review will be fed into the inquiry.

Right hon. and hon. Members may be interested to know that the location of the inquiry will be in central Manchester. We have secured newly refurbished offices next to Piccadilly railway station for the use of the chair and secretariat, and Manchester town hall will be used for the witness hearings.

The inquiry will also set up a closed circuit television link to Hyde town hall, so that the witness hearings can be televised there on large TV monitors. That should enable the people of Hyde to keep in touch with the proceedings, should they wish to do so, without having to travel into central Manchester.

We owe it to the families and friends of those murdered by Harold Shipman to implement whatever steps are necessary to prevent a repetition of such terrible crimes. Shipman broke the trust of his patients in the most appalling way. However, he should not be allowed to break the trust that exists between family doctors and their patients. The measures that I have described today are intended to strengthen that bond of trust. They express the Government's determination to apply the lessons of the Shipman case to ensure that patients in future have the full and proper protection that they deserve.

6.55 pm

Dr. Liam Fox (Woodspring): I am grateful to the Minister for coming to the House and for giving his comments. However, as the Secretary of State gave the original statement to the House, and as it was his decision that resulted in the High Court review and the U-turn by the Government, it would have been only proper for him to come to the House himself to give the explanation of subsequent events. I say that with no disrespect to the Minister.

Even after a lapse of time, the immense wickedness of Harold Shipman is still hard to imagine. The tabloid terms that we have seen so often, such as "multiple killer" and "serial killer", still understate the full horror of what has happened. The way in which Harold Shipman abused his professional trust and the bond that he had with his patients is particularly vile and difficult to understand. That trust was given by patients who literally, and mistakenly, put their lives in his hands. The anguish of the relatives is difficult for any hon. Members to imagine. As a doctor, I cannot conceive of a bond built on trust being abused in such an unspeakable manner. We must also remember, however, that it was Harold Shipman who was found guilty, and not the medical profession. I am grateful for the tone of the Minister's comments because, in cases of this kind, the specific is extrapolated to the general far too often. We must remember that the vast majority of our doctors are dedicated and hard-working, and we need to protect their reputation when considering any aspects of the case relating to Harold Shipman. All we ask is that all possible measures be put in place to prevent such a case happening again.

The Minister detailed the terms of reference for the inquiry. The extent of the crimes is, as he said, still in doubt. It is unknown exactly how many victims of this

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man there were, or over how long a period the crimes took place. I imagine that that will be extremely difficult to ascertain from the medical records, and that much work will need to be done. That process will be very time consuming, and any chance of a short inquiry will, therefore, be remote. There will be much supposition and doubt about Harold Shipman's previous clinical practice, which is why there is a need for full disclosure in the case, not only to maintain public confidence but to give all due comfort to the relatives of his victims. Questions as to who might have known what was going on or who might have been able to stop the events early before more patients became victims will be crucial for the inquiry.

The inquiry must also examine the role that the statutory authorities should play, the role that they did play, and the role of any responsible individuals who should have known what to look for, or who may have seen but not wanted to know, the pattern that was emerging. We need to know what all this will mean for future practice. We need to know the implications of peer review and audit, not least in the case of single-handed practitioners. How will we ensure that those who practise on their own will be audited by their peers in a way that ensures that all the same safeguards are applied to them as are applied to those in group practices?

I am sure that all hon. Members would acknowledge the sterling work carried out by the many single-handed doctors in this country, and we do not seek to denigrate what they do. However, we must ensure that, although they work individually on a contractual basis, they do not work in isolation on a clinical basis. That is one of the most important questions for the inquiry to consider.

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Mr. Hogg: Does my hon. Friend agree that the best way to try to determine the extent of Dr. Shipman's crimes is to ascertain that from him? He has little reason not to make a full disclosure because he is not to be further prosecuted. Does my hon. Friend also agree that one way forward might be for the inquiry--and, indeed, the prosecution authorities--to give an undertaking that Shipman will not be further prosecuted and to try to get him, on the back of such an undertaking, to make full disclosure?

Dr. Fox: We have already had the assurance that there will be no further prosecution should further evidence be found. Although I should like to think that such co-operation would be valid in the investigation, I must say to my right hon. and learned Friend that I would not necessarily regard someone who has murdered many of his patients as being of suitable character to be a witness. I would not want to place too much reliance on such a person, which is why we must hold an external inquiry--a full audit of all Shipman's records. All possible means must be used to try to ascertain the truth. Talking to Harold Shipman may be a useful pointer, but I am sure that my right hon. and learned Friend agrees that we should in no way rely on that to get to the bottom of what may be an extraordinarily widespread and sordid series of events.

We need to know how revalidation and the Government's annual appraisal proposals--and, indeed, subsequent reform of the General Medical Council-

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might affect these and subsequent cases. Such issues must be considered not individually, but as part of a whole. We must ensure that action is taken quickly and decisively at all levels in respect of early warning, early action and firm final action, not only to deal comprehensively with such cases but to ensure that those who are not guilty are cleared as quickly as possible and able to continue their careers.

Mr. Winnick: To return to the point made by the right hon. and learned Member for Sleaford and North Hykeham (Mr. Hogg), if it emerged that Shipman was responsible for other deaths for which he had not been charged and convicted, how would those left behind feel? Shipman might have murdered their loved ones, but no action would be taken in court. Surely they would feel that the person in question had got away with such crimes. There is a point at issue here; perhaps the hon. Gentleman will address it.

Dr. Fox: I sympathise with that point, but it has already been made clear by the relevant authorities that there will be no further prosecutions. That is a matter not for the House but for the independent prosecuting authorities, although I acknowledge the hon. Gentleman's reflection of how the relatives would feel.

We must work out how the Government's proposed National Clinical Assessment Authority would affect subsequent cases. Indeed, there has been confusion over statements from Downing Street and the Department of Health as to whether the NCAA would guard against such cases. My view is that the Minister put the case rather better than No. 10 that such a measure would not have stopped a Harold Shipman-type case. It is being put in place to ensure that those who practise incompetently rather than criminally are discovered more quickly. The Opposition welcome supplementary lists, which are long overdue, as they will bring the regulation of part-timers and locums into line with that which full-time doctors must undergo. As for the impact on primary care as set out in the terms of reference, there is an interesting point in respect of the disclosure of previous offences. Of course it must be right that people should have to disclose their disciplinary conduct record, but it must also be sensible to include a double lock under which an employing authority has a duty to check the disciplinary background of anyone it was to take into its employ to ensure that there was no blemish. Simply asking for self-disclosure from those with a disciplinary blemish on their record is not sufficient and the public will want a stronger mechanism. We must also ensure that should such a mechanism be put in place, we have sufficient law to police it as that would greatly underpin public confidence in such cases.

We must consider how controlled drugs are used and, in particular, what happens when patients die with controlled drugs in their homes. How should such drugs be disposed of and what are the rights and duties of doctors? All those points require clarification and I hope that the inquiry will consider them in detail. Many of us with experience of such matters well understand the problems that doctors face and the pressures on relatives in terms of removing medicines and clearing up a house. That can cause great distress, so the clearer the regulations, the better the situation is likely to be for all involved.

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We look forward to the inquiry closely considering the coroners service. Many questions have been raised about its role in the Shipman case. Why was the pattern missed if it was so widespread and occurred over such a long period? What record-keeping mechanism would expose such a pattern? What review mechanisms were in place? What new review mechanisms are needed? Is the coroners service suitably regulated? If so, how is it to be policed? All those are important questions, but perhaps something even more important needs to be done.

A general practitioner who is not the doctor of the patient in question is called to sign part 2 of a cremation certificate for a colleague. The patient's own doctor cannot sign. I know from experience that certificates can often be signed in haste, perhaps to help relatives at a distressing time or to expedite funeral arrangements. The chances of missing a pattern increase when signing such certificates is spread among a number of doctors, so there must be a strong argument for a single person in a district to have the job of signing part 2.

If one person had the specific job of checking medical records and signing part 2, it would become evident to that individual if a pattern was emerging among doctors in the area, and the pattern would be easier to detect. Whatever the results of the inquiry, I hope that the Government will consider such a legislative move, which represents a simple way of putting in place a safeguard that does not currently exist. Although it is all too easy for such patterns to be missed for many of the right reasons, they can also be missed for many of the wrong reasons. We welcome a public inquiry. The scale of the crimes makes holding an inquiry in private unthinkable, and I know that that is the view of the relatives of the Shipman victims. The Secretary of State initially said:

The report of the inquiry will be made public.--[Official Report, 1 February 2000; Vol. 343, c. 908.]

That was clearly not enough. The families and relatives of the victims must be able to raise the issues that are important to them, as my right hon. and learned Friend the Member for Sleaford and North Hykeham (Mr. Hogg) said in his interventions.

Setting up large television screens is a long way from the Government's original plans. The families of the Shipman victims, a substantial element of our national newspapers and the national media and I gave written evidence, forcing the Government into a U-turn. There will be a public inquiry, but that is not what the Government wanted. I am grateful to the Minister for his explanation, but, in all justice, the Secretary of State should have had the courage to come to the House to explain why he did not want a public inquiry and why the High Court forced him into this action. Through the House, he should give an explanation to the relatives of the victims of Harold Shipman.

7.09 pm

Ms Chris McCafferty (Calder Valley): At the risk of sounding patronising, I thank my right hon. Friend the Secretary of State for having the wisdom and the stature to recognise that his original decision was not correct. As someone who has campaigned to ensure that Harold Shipman's time as a general practitioner in Todmorden in my constituency of Calder Valley is considered as part of any inquiry or investigation, I have always been open

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about my view that the only way to establish the truth is to hold a full, open public inquiry considering all the aspects of the Shipman case. We owe it to the many unknown and suspected victims of Shipman, and their families, to do all we can to ensure that we uncover the truth about his activities, and to establish safeguards to ensure that such things never happen again. Will my right hon. Friend the Secretary of State ensure that time scales and procedures governing submissions of evidence are widely publicised in Todmorden, where suspicious deaths are being investigated by West Yorkshire police? My constituents are very grateful to my right hon. Friend for ensuring that Todmorden was included in Professor Baker's clinical audit, for looking carefully at the professor's conclusions about Shipman's activities during his time as a GP in Todmorden, and for being mature enough to change his mind and propose a full and open public inquiry. I welcome the motion, and hope that all Members will support it.

7.11 pm

Dr. Peter Brand (Isle of Wight): Being a doctor can be an extremely lonely occupation at times. Medicine is not clear-cut; there are many grey areas. It is not surprising that some doctors, especially those in single-handed general practice--and, indeed, single- specialty hospital doctors--can find it extraordinarily difficult. It is well known that many doctors in such circumstances tend to move in two directions: they lose their confidence and take to alcohol or drugs; or they think they are infallible and start to behave strangely.

Shipman did not just behave strangely; he behaved wickedly, and quite exceptionally. I certainly hope that it is exceptional for someone to be as murderous as that. I also hope, however, that the inquiry will consider some of the wider issues that may cause people to behave as Shipman behaved, and to take account of some of the risks carried by all of us when we fail to support professionals whom we imbue with a great deal of responsibility.

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Dr. Fox: Just so that the hon. Gentleman is not misinterpreted, let me say this. I hope he is not suggesting in any way that the pressures of any practice would cause people to murder their patients when he says that we must consider the causes. In my view, there are no "causes" when someone cold-bloodedly murders his own patients.

Dr. Brand: I am grateful for that intervention, because it allows me to clarify my view. As I have said earlier, Shipman dealt with his sense of infallibility--or, perhaps, insecurity; we do not know what motivated him--in a uniquely wicked, murderous way.

I hope that the inquiry will, in a sense, be in two parts: one part considering Shipman and how he managed to get away with his wicked and evil deeds; and the other considering the support and regulatory mechanisms that we need in order to assure the general public that the privileged relationship between doctor and patient is not abused, albeit in a lesser way, by other practitioners. Shipman is unique, but I do not believe that he is the only medical practitioner--or nurse, or indeed vicar--who, having found that he is professionally isolated, has started to behave oddly.

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Mr. Nicholas Winterton (Macclesfield): Notwithstanding his response to my hon. Friend the Member for Woodspring (Dr. Fox), is not the hon. Gentleman just a little concerned that his remarks may be seen as making an excuse for what has occurred? Does he not fear that the families of the 300 people who have been murdered might misunderstand what the hon. Gentleman--who is a respected doctor--is telling the House?

Dr. Brand: The hon. Gentleman ascribes to me a motivation that does not relate to what I said. There is no excuse for a Shipman: that was unique wickedness, on an enormous scale. The point I am trying to make is that the circumstances in which Shipman practised allowed him to put himself in a position in which he could commit multiple despicable murders. I suspect that if Shipman had been a member of a support group involving other GPs--a Balint group, a royal college group or a BMA group--and had discussed his cases, it would have become clear at an early stage that he was a very odd man with very odd values. That is one of the ways in which professional peer review works.

I welcome the Government's move towards clinical governance and audit and examination of professional practice, but that in itself will not pick up uniquely murderous wicked people. This returns me to the point made by the hon. Member for Macclesfield (Mr. Winterton). It will pick up the incompetent--but if we encourage people working in isolation to be part of a structure in which they share experiences, it may well be possible for it to pick up totally aberrant behaviour.

I do not want to be mistaken for one who thinks that the country is full of doctors who behave in the same way as Shipman. I think, however, that we are short of mechanisms to audit, and also to protect the community at large. I feel that, notwithstanding some of the Government's welcome measures, we have a great deal further to go.

The hon. Member for Woodspring (Dr. Fox) mentioned the discredited "ash cash" arrangement, whereby, basically, a doctor countersigns the reputation of a colleague without actually doing much in the way of work. It happens day in, day out. The fact that the coroner does not necessarily liaise with the registrar for births, marriages and deaths is nonsensical. Most cremations go through the registrar, and the coroner deals only with what is abnormal, suspicious or uncertain. It would obviously make sense if a single organisation dealt with all deaths: that would enable suspicious or uncertain deaths to be fed through the system to establish whether patterns emerged.

We must view the matter not just within tight local- authority boundaries. After all, not just the constituents of the right hon. Member for Stalybridge and Hyde (Mr. Pendry) were affected; my hon. Friend the Member for Hazel Grove (Mr. Stunell) has constituents who have been bereaved through Shipman's wicked actions. The technology is, I believe, available to enable us to link information so that we see abhorrent patterns of behaviour.

Mrs. Ann Winterton (Congleton): The hon. Gentleman says that closer liaisons could take place at the end of life to check that the number of deaths were not caused by, for instance, murder. As a practising doctor, can he tell me why Dr. Shipman was able to obtain so many prescriptions for diamorphine? Why was that never

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picked up throughout his practice, given the number of times we have been told that doctors must not over-prescribe, that their prescribing is checked, that there are limited lists, and so forth? In fact, there seemed to be no brake on the prescribing pattern of this particular GP.

Dr. Brand: I shall touch on that, but I wish to return to the point that I was making. Patterns of deaths are important, not only within general practice but within hospital practice. It is helpful for people who audit these issues to look at death patterns in long-stay wards or wards specialising in the care of elderly people to see whether a pattern emerges. I share the concerns of the hon. Member for Congleton (Mrs. Winterton) about some of the practices involving long-stay beds or the way in which some older people are treated, or not treated, in hospital. We should see whether we can pick up and learn from the patterns.

Many issues were hinted at in the early reports into the Shipman affair. The issuing of prescriptions to Shipman for controlled drugs was quite astonishing. Industrial quantities of diamorphine were dispensed for no good clinical reason. I am not sure what the drugs inspectorate or the policeman who is supposed to be in charge of drug registers was doing; someone comes to see us every year--or every two, three or four years, depending on how busy they are--to see what we are doing with the drugs we buy. Likewise, pharmacies should be inspected to see what is happening with their dangerous drugs registers.

Clearly, this case should have been picked up. Shipman was stupid; we keep hearing what a clever man he was, but he got vast quantities of drugs from a small number of pharmacies. It is extraordinary that that was not picked up. It is extraordinary also that the clever pharmacist who tried to blow the whistle was not listened to by the coroner because the coroner did not feel that it was his responsibility.

Dr. Fox: Does the hon. Gentleman accept that the problem was not with the prescription, but with the hoarding of heroin from dead patients, and that the disposal of controlled drugs should be a central element of the inquiry?

Dr. Brand: There were two problems: first, inappropriate quantities were given to Dr. Shipman; and, secondly, he neither destroyed the drugs--the proper thing to do--nor entered them in his own drug register as having been received. It is essential that drugs are trackable between the manufacturer and the patient. In this case, the system clearly failed.

I am sure that many issues will come out in the inquiry, which will be handled sensitively. We owe that to the large number of patients and relatives who were affected. However, I hope that in the broad remit that has been given to the inquiry, time will be taken not only to look at how we avoid a Shipman, but at the wider issues. We should look at how the statutory authorities can work together to avoid similar, if not as disastrous, occurrences of repeated incompetence and inappropriate behaviour that may well be dangerous. These patterns can be picked up and I hope that the inquiry will involve a wide range of organisations. It is not good enough to say that this is a matter for the GMC and the employing authority. It is a matter for the different nations of the United Kingdom and for the

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international scene. There are lots of little strands floating around, following the reports on Neale, Leadbetter and other poor practitioners who got away with it for far too long. I hope that the inquiry will draw all of that together and that we will have an opportunity to discuss the recommendations in this House.

7.24 pm

Sir Nicholas Lyell (North-East Bedfordshire): I am glad that the Secretary of State has decided, on further reflection, to order a full public inquiry under the Tribunal of Inquiries (Evidence) Act. I am sure that that is the right decision. I am sure also that there will be great confidence in Dame Janet Smith, the High Court judge chosen to conduct the inquiry. She is highly respected and has a great deal of relevant experience.

When the Secretary of State came to the House earlier about the Shipman case, I was worried that the General Medical Council seemed to be being made something of a whipping boy. Although the GMC is undergoing changes, I find it difficult to appreciate how it would necessarily have been expected to spot a Shipman. The behaviour of Harold Shipman was extraordinary and far outside what, happily, we have expected during our lives. It was so utterly inconsistent with what we rightly expect, and get, from GPs that the ordinary disciplinary controls of the GMC would not have been appropriate. That is one of the issues that Dame Janet will consider. I should be surprised if the GMC--under almost any structure--would necessarily have found and stopped Harold Shipman. I should be interested to see what opinion the judge comes to on that.

I endorse what the Minister and my hon. Friend the Member for Woodspring (Dr. Fox) have said: Dr. Shipman was found guilty of these terrible multiple murders, not the medical profession. GPs generally provide an excellent service to the public and are having to do so under enormous pressure. I do not blame the present Government any more than previous Governments, but we know that greater numbers of hospital doctors and GPs are needed. We know that doctors work under great pressure and it is important that Governments of all complexions give them proper support.

The Minister referred to the NCAA. Although appraisal and audit may have some relevance to identifying a future Shipman, I would not want it to be thought that that was the NCAA's primary purpose. It is important that, while we should monitor GPs more closely than we have in the past, the monitoring should not become excessively burdensome. It should be constructive and designed, like most professional programmes these days, to enhance standards, rather than be overt policing of the activities of those concerned. The monitoring certainly should pick up aberrant behaviour and the personal appraisals should provide opportunities to spot possible danger, but they should always be constructive.

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Mr. Nicholas Winterton: Will my right hon. and learned Friend refer to what the hon. Member for Isle of Wight (Dr. Brand) said about how Dr. Harold Shipman was able to obtain such large quantities of diamorphine and to retain in storage such large amounts of the drug? My right hon. and learned Friend said, rightly, that Dr. Harold Shipman, not the medical profession, is to

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blame. However, the system is clearly to blame for allowing this man to store and use such huge quantities of that drug without question.

Sir Nicholas Lyell: My hon. Friend is entirely right, and I was just coming to that portion of my short speech.

Dr. Fox: Does my right hon. and learned Friend agree that a mechanism such as the NCAA is likely to pick up poorly performing doctors or those whose skills need to be upgraded, but that someone who purposefully kills his patients and hides the evidence is hardly likely to be picked up by such an audit?

Sir Nicholas Lyell: Yes, I agree entirely. I have not studied the Shipman case more than any other careful reader of the newspapers, but it comes through that Dr. Shipman presented himself to the world as a skilled and caring general practitioner, and I suspect that he might well have been able to bamboozle the NCAA, get quite a good chit--a high mark--as a GP, and keep his criminal misdeeds hidden.

The inquiry will want to question a range of authorities. The authorities responsible for the issuing, management and control of dangerous and lethal drugs such as diamorphine will be high on the list. The inquiry will examine the role of the employing authority in the case, and that of NHS management generally. It will consider the role of primary care groups under the new dispensations. It will certainly investigate the role of the coroner and the relevance of the register of deaths. It will look into the role of the police to some extent, although I am not suggesting that it would have been easy or even possible for the police to have discovered anything in advance. Those authorities are all intended to work together, and we would hope that they could pick up such aberrant behaviour rather earlier. I do not know how long Dr. Shipman had been murdering people--nobody does--but it seems to have been many years. We need to end up with systems that, while not blocking the good work of medical practitioners, give a greater opportunity for the misuse of drugs, and for serial killing, to be brought to light comparatively early.

I am concerned about the length of inquiries. The Scott inquiry was deliberately not conducted under the 1921 Act, on the basis that that might cause it to become overlong. After it had lasted for three and a half years, people--perhaps including Lord Justice Scott--may have felt that that might not have been as much of a problem as had been feared.

We have recently had, or are having, three immensely long inquiries: the Scott inquiry; the very skilful BSE inquiry under Lord Phillips; and, currently, the careful and difficult, but none the less immensely long, Bloody Sunday inquiry. I very much hope that the Shipman inquiry chairman does not think--I am sure that she will not--that great length is a necessary feature of all public inquiries. Obviously, the inquiry must have a full opportunity to consider carefully what has gone on, but if public confidence in public inquiries is to be fully restored, it is to be hoped that it will be able to proceed at a reasonable pace, to report in a not overlengthy amount of time and, above all, to provide a report of reasonable length, so that ordinary members of the public and the press can read a decent summary.

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I suggest that the report should not be over 150 pages long, with extra matter in appendices, so that the results do not moulder on shelves but are understood by the country at large and acted on by those who are responsible for trying to put things right.

7.34 pm

Mr. Douglas Hogg (Sleaford and North Hykeham): It is a pleasure to follow my right hon. and learned Friend the Member for North-East Bedfordshire (Sir N. Lyell), who made several points that I had intended to make. I have some experience of these matters, in that I represented Grantham when Beverley Allitt was working at Grantham hospital and killed several young patients there. Understandably, that caused immense distress in Grantham and triggered the same kind of anxiety that we see in the Shipman case. I welcome the Secretary of State's decision to hold a public inquiry. That was greatly desired by the families affected by the Beverley Allitt killings, and I regret that it did not take place, although I understood the reasons. In such grave cases, a public inquiry is absolutely essential. I welcome the fact that the Secretary of State changed his original decision. I agree entirely with my right hon. and learned Friend's points about having a relatively brief inquiry. He and I were both involved in the Scott inquiry, and I was involved yet more in the BSE inquiry. Both those inquiries were immensely long. With all respect to those who presided over them, I do not think that the length of the inquiries, or indeed the reports, added greatly to our knowledge. We need a sharply focused inquiry that is as brief as we can make it.

My right hon. and learned Friend made an important point about the nature of the ultimate report. It must be readable by the ordinary citizen. I do not know Dame Janet Smith, but I know that she is held in high respect on the north-eastern circuit and elsewhere, and I am sure that she will bear these points in mind.

Dr. Fox: Does my right hon. and learned Friend agree that the efficiency and speed of the inquiry must be balanced against the wishes of the relatives, who must at all times be assured that all matters have been appropriately considered, given the scope of the crimes involved?

Mr. Hogg: Indeed. There will be families of victims, or of possible victims, who do not want to give evidence, because they have none in the technical sense to give, but who none the less may feel that their relatives were murdered. It is desirable for the families to be represented at the hearings, so that, through their representatives, they can ask questions of witnesses, allowing avenues of concern to the families to be explored, even if they do not immediately occur to counsel for other parties. I hope that the Minister will seriously consider making public funds available for that representation.

I strongly hope--I believe that this will happen--that those whose competence and performance are likely to be called into question will also be represented and have the opportunity to ask questions. Many people's professional

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reputation will be on the line. The report may be highly critical of individuals, and it is proper for those individuals to have their interests properly safeguarded.

My right hon. and learned Friend spoke about the difficulties in spotting crimes of this kind. Such crimes are so exceptional that they do not immediately occur to anyone who is investigating deaths occurring either in GPs' surgeries or in hospitals. One of the problems with the Beverley Allitt case was that it did not occur to people early enough that a nurse could be doing such things. It is understandable that such a thought did not occur.

Similarly, it would not occur to most ordinary people--including coroners--that a GP could be murdering his or her patients. Therefore, one should be slow to criticise those who did not early on in that series of events think of murder.

It is important that we try to establish systems that throw up abnormal patterns of conduct or of fatality, so that those who take an overarching view--whether the coroner or those who sign the part 2 certificates--can tell from data that have already been accumulated that something out of the ordinary is occurring. I hope that Dame Janet Smith will address that matter.

The hon. Member for St. Helens, South (Mr. Bermingham) is entirely right to say that Dr. Shipman will not be prosecuted for any other offences. There are at least two reasons for that: first, because it has already been said on behalf of the prosecuting authority that he will not be prosecuted further, therefore he cannot be prosecuted; and, secondly, because the degree of the publicity that has been given to the cases means he could not get "a fair trial". I would strongly urge the prosecuting authorities not to attempt a further prosecution, which could certainly not go forward. However, there is a consequence that is worth considering. My considerable experience of criminals garnered from practising at the criminal Bar and defending many criminals suggests that, sometimes, there comes a time when they are willing to talk because they have nothing left to lose. It might be worth considering the possibility of intensively questioning Dr. Shipman again. He has nothing more to lose. He is one person who might be able to tell the relatives what happened, and one should not exclude the possibility that he might be willing to do so. He is a whole-life case--he will be in prison all his days; that is certain. Although he is clearly not a man on whose words one could place any weight, he might be able to illuminate some matters that are of interest and importance to the inquiry and the families. I anticipate many claims arising from the murders being made to the Criminal Injuries Compensation Board. Some of them may be fairly substantial, especially those involving the dependents of those who have been murdered, and some may be very large. I hope that officials at the Department of Health and the Home Office--I do not see a Home Office Minister present, but I am sure that the Under-Secretary of State for Health will draw my remarks to the attention of the Home Office--will consult the CICB on how best and most expeditiously to consider the claims that will emerge, which will be of considerable importance to individual dependents. I shall leave the Under-Secretary of State with that thought-- [Hon. Members: "The Minister of State"]. I apologise to the Minister of State, Department of Health, the hon. Member for Barrow and Furness (Mr. Hutton). I did not intend to slight him.

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To sum up, it is important that there is to be a public inquiry. I welcome the fact that the Secretary of State has changed his mind in that respect.

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7.43 pm

Mr. Hutton: First, I should like to express my appreciation to all those who have spoken in this short debate for having lent their support to the motion. I am sure that everyone shares my sense that it is the strong will of the House that the inquiry be established and allowed to get on with its work as soon as possible. The House will know that that is conditional on the other place approving a similar motion, but I am sure that that will happen soon, enabling the inquiry to start. I shall respond briefly to one of two of the points made in the debate.

I shall certainly draw to the attention of the inquiry secretariat the remarks of my hon. Friend the Member for Calder Valley (Ms McCafferty), especially those relating to access to the tribunal. The hon. Members for Woodspring (Dr. Fox), for Congleton (Mrs. Winterton) and others have expressed their concern about the use of controlled drugs by Dr. Shipman. I am sure that they are aware that that matter is specifically included in the terms of reference for the inquiry that we are establishing today. We expect Dame Janet Smith to give careful consideration to that aspect of the case, which has given rise to the concern voiced in the House tonight and elsewhere.

The right hon. and learned Member for North-East Bedfordshire (Sir N. Lyell) expressed concern about the work of the NCAA. I assure him that it will not work as a police force. However, as many right hon. and hon. Members will know from their constituency work, when concerns have arisen in the past about questionable or poor performance by GPs, there has been a lack of clarity about where to take those concerns and who is responsible for dealing with them. We think that the NCAA will provide a useful focal point for dealing quickly and effectively with such concerns, which does not happen at present.

On a point of information, concerns were expressed early on about the work of Dr. Shipman. One of the things we want the NCAA to do far more systematically than has been done in the past is put in place a proper set of procedures whereby such concerns can be addressed promptly , and effectively and, if necessary, GPs can be provided with more effective support, which is an important part of the process. When serious concerns arise, we should act quickly and effectively, but that has not happened.

Dr. Fox: Does the Minister agree that, regardless of the measures adopted, the more exceptional the case--to use the word of my right hon. and learned Friend the Member for Sleaford and North Hykeham (Mr. Hogg)--the less likely it is to be picked up by any authority, especially if the case involves, not incompetence, but wilful harm to

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patients? Should we not be careful to avoid raising expectations that we can prevent another very wicked man from committing similar murders?

Mr. Hutton: I agree in part. However, we think that the NCAA provides the best possible chance of our being able to intervene more effectively in such cases in future. That is what we want to achieve and we have been clear about setting out our objectives for the NCAA.

Mrs. Ann Winterton: Would that authority, had it been established, have been able to respond to relatives who after reading newspaper reports suspected that something had gone wrong with the treatment of a family member and were concerned, but did not know where to turn and, because they had such great respect for doctors, were inclined to think that they were only imagining a problem? Does the Minister think that ordinary patients and their relatives will be able to approach the new authority if they suspect that the care that they or their relatives are receiving is not as they would want it to be?

Mr. Hutton: Yes, that is precisely what we think. We are also trying to establish other mechanisms to ensure that patients' voices are effectively heard at all levels of the national health service. That is what the independent statutory patients forums will allow us to achieve. I tried to deal with the concern expressed in an intervention by the right hon. and learned Member for Sleaford and North Hykeham (Mr. Hogg) about legal representation in the tribunal. However, I shall write to him about that matter and draw his remarks about criminal injuries compensation claims to the attention of my right hon. and hon. Friends at the Home Office. We have had a short, but very useful debate. As I said, I am grateful to all those who have spoken. It is clear that the House strongly supports the motion and I am grateful for that support.

Question put and agreed to.

Resolved,

That it is expedient that a Tribunal be established under the Tribunals of Inquiry (Evidence) Act 1921, for inquiring into a matter of definite public importance, that is to say, the matters arising from the deaths of patients of Harold Shipman, with the following terms of reference--

(a) after receiving the existing evidence and hearing such further evidence as necessary, to consider the extent of Harold Shipman's unlawful activities;