A rogue doctor could still get away with murder despite a shake-up of the coroner's system designed to deter another serial killer like GP Harold Shipman, according to the judge who led the inquiry into his crimes.
The Shipman Inquiry concluded nearly five years ago that loopholes in the coroner's system had allowed the family doctor from Hyde, near Manchester, to cover his tracks by signing death certificates himself, avoiding the involvement of a coroner.
It found Shipman murdered at least 215 victims by giving lethal morphine injections, during a killing spree lasting from 1975 to 1998.
He was convicted in January 2000 of murdering 15 of his patients and jailed for life but died after being found hanging by his bedsheets in his cell at Wakefield Prison in 2004.
Dame Janet Smith, who chaired the inquiry, told the BBC she was concerned about the lack of progress in implementing her recommendations on tightening up the way deaths are recorded.
She said until the details of reforms to death certification are published, it is difficult to see how the system could prevent another "dishonest" and "malevolent" doctor getting away with murder.
"I really was shocked to find how totally our system of death certification is dependent upon the honesty and integrity of a single doctor."
She added: "Once you realise that you can have a dishonest doctor and a malevolent doctor, then it is obvious that under our system that doctor can get away with murder."
However, Justice Minister Bridget Prentice told the programme she was confident the "possibility of something as horrific as Shipman will have very, very little chance of happening again".
"There will be this need to have two doctors examining certificates, there will be the opportunity for families to query what's on the death certificate," she said.
"I think a number of aspects like that will make sure that we don't see another Shipman."
The Coroners and Justice Bill was published in January - nearly five years after the Shipman Inquiry ended.
Under the proposed reforms to the coroner's system, a second doctor will be required to review deaths which have not been referred to a coroner.
The Government also proposed changes to cremation procedures to allow families to inspect the medical forms of deceased relatives so they will be able to draw the medical referee's attention to any concerns about unexpected symptoms or discrepancies in the case.
The regulations were introduced as an interim measure and precede longer-term Department of Health plans to create the role of a Medical Examiner, who will deal with all deaths.
Could Shipman Happen Again? will be broadcast on BBC Radio 4 at 8pm.Reuse content