A hospital consultant admitted yesterday that he did not make the most basic checks during a post-mortem examination of a victim of the serial killer Harold Shipman.
Dr David Bee failed to discuss Renate Overton's case with other doctors, examine her clinical history or consider why she might have fallen into a coma under Dr Shipman's care, he told the professional conduct committee of the General Medical Council (GMC).
He concluded she had died of natural causes, although she had been rendered unconscious by an overdose of diamorphine from Shipman in Hyde, Greater Manchester, in April, 1995.
Mrs Overton, 47, who was among Shipman's youngest victims, died after 14 months in a persistent vegetative state. The case of Mrs Overton and two others were the only ones referred to a coroner. Shipman usually avoided such scrutiny by getting a cremation certificate signed quickly after he had killed his victim.
Dr Bee, 71, from Stockport, was months from retirement when he performed the autopsy. Traces of the diamorphine would have long since have left the body when he examined it. But the GMC, sitting in Manchester, was told he could have investigated the reason Shipman gave for administering it. The post-mortem examination was the "last opportunity" for an inquest.
Dr Bee, who was a consultant in morbid anatomy at Tameside Hospital, is accused of serious professional misconduct and faces being struck off. He admitted six charges but not a seventh: that he failed to consider the results of a histological examination. The Shipman Inquiry has already criticised Dr Bee's work as "deeply flawed".
Shipman certainly seemed to feel the authorities might be on to him after his attempt to kill Mrs Overton went wrong, a rare event during the 23 years in which he is thought to have killed at least 215 patients.
He did not kill again for three months after the episode, a sign that he felt "extremely vulnerable", Dame Janet Smith, who chairs the Shipman Inquiry, said. "If his apparent negligence were investigated, there must have been a danger that his ... more sinister intentions would have been uncovered," she added.
The inquiry was told that a reluctance to challenge the word of Shipman, then a respected GP, meant other hospital staff did not report concerns about Mrs Overton. The former nurse, was asthmatic and should have never been given the dose that caused a respiratory arrest. The inquiry returned a verdict of unlawful killing.
Shipman was jailed for life in 2000 on 15 counts of murder. He hanged himself Wakefield Prison in January this year. Six Hyde GPs who signed cremation forms for Shipman will also face the GMC. Dr Bee's hearing is scheduled to last until Friday.