The fourth report of the inquiry into serial killer GP Harold Shipman today called for "a modernisation and rationalisation of the system of regulating controlled drugs".
In particular, inquiry chairman Dame Janet Smith recommended the creation of a nationally co-ordinated Controlled Drugs Inspectorate to replace the current "fragmented" system.
The Manchester-based inquiry found that Shipman was able to order vast amounts of diamorphine - pharmaceutical heroin - with ease.
He used the drug to murder at least 215 people in Hyde, Greater Manchester, between 1975 and 1998.
The GP was jailed for life for 15 counts of murder in 2000 and was found hanging in his cell at Wakefield Prison in January of this year.
The report found that between 1992 and 1998 alone, during which time he killed at least 143 people, the GP obtained 24,000mg of diamorphine illicitly.
His favoured practice was to order single 30mg ampoules of the drug - an unusual amount as it would be too much for a heart attack victim and too little for a cancer sufferer, the two most common users of diamorphine.
However, such a dose would be fatal for "morphine-naive" patients.
He ordered each 30mg dose under the name of a different patient, which should have aroused suspicion as normally the drug would be prescribed to a single patient in increasing amounts until their death.
Dame Janet criticised pharmacist Ghislaine Brant, who ran the pharmacy next to Shipman's practice, saying she had "lost her professional objectivity" when dealing with the trusted GP.
The report stated she had "plainly not applied her mind" when considering whether the dosage was appropriate for the patient, but Dame Janet conceded that Shipman had deliberately set about gaining the pharmacist's trust for his own ends.
The report also criticised the inexperience and poor training of Detective Constable Patrick Kelly, the police Chemist Inspection Officer (CIO), who carried out a routine check on the pharmacy records in July 1993.
It stated: "At the time DC Kelly was very inexperienced. He had been appointed as a CIO only three months before. His training had been inadequate.
"It comprised a few weeks apprenticeship with a CIO who worked only part-time in that role.
"Even so, by the time he examined this CDR (Controlled Drugs Register), DC Kelly had seen at least 150 CDRs and, in my judgment, he should have recognised that the consecutive entries in this one was very unusual."
Dame Janet added that while Greater Manchester Police was "responsible for the inadequacy of DC Kelly's training and supervision", it provided a better CIO service than many other police forces.
Even today, the report stated, some police forces have no CIO and some chief constables "do not consider that CIO work is a proper use of police resources".
In her foreword to Home Secretary David Blunkett, Dame Janet suggested it would be extremely difficult to prevent a repeat of Shipman's atrocities, but her recommendations would make it far less likely.
She said: "I have to report that there is no easy way to prevent a doctor who is determined to obtain illicit supplies of a controlled drug from doing so.
"Nor is there any foolproof way of detecting, after the event, that a doctor has diverted controlled drugs, to his or her own use."
Dame Janet's primary recommendation is a nationally-co-ordinated, but regionally-based, controlled drugs inspectorate similar to that already in place in Northern Ireland.
It should be made up of pharmacists, doctors and some investigators with law enforcement experience.
The inspectorate would have responsibility for the supervised destruction of surplus controlled drugs following a patient's death, as another of Shipman's methods was to collect and hoard such supplies.
Other recommendations included making it a criminal offence for doctors to prescribe drugs for themselves, as Shipman did when addicted to pethidine in the 1970s.
Dame Janet recommended that a special prescription form be introduced to enable closer monitoring of individual doctors.
In general terms, she recommended that GPs and pharmacists should be subject to closer scrutiny and keep better records of the drugs they dispense, but demanded that such controls do not overshadow patient care.
She said: "Doctors who wish to prescribe controlled drugs for the genuine needs of patients must not be unduly hindered from doing so.
"Pharmacists must not be overburdened with administrative requirements when dispensing controlled drugs.
"Plainly, it is important to prevent the abuse of controlled drugs but measures taken to achieve that end should not adversely affect the provision of health care."
Dame Janet stated in the report that such measures would have been unlikely to reveal the full extent of Shipman's activities, but if he had been investigated he "would probably have ceased killing for a time ... in that way, at least some lives would have been saved".Reuse content