Two detectives who carried out a failed investigation into Harold Shipman were inexperienced and not fit for the case, the inquiry into his crimes ruled today.
If a "properly directed investigation" had taken place, the lives of his last three victims "would probably have been saved", inquiry chairman Dame Janet Smith said.
The investigation, in March 1998, was triggered after a fellow GP raised concerns that Shipman might have been killing his patients. It found no cause for concern.
Chief Superintendent David Sykes failed to realise he was too inexperienced to supervise the case and that Detective Inspector David Smith was "out of his depth".
Mr Smith then lied to both a number of internal investigations and to the Shipman Inquiry in a bid to deflect criticism from himself.
He was inexperienced and not accustomed to working alone and failed to understand the issues surrounding the case.
If the police, together with coroner John Pollard, had acted more quickly, the deaths of three Shipman patients would "probably" have been prevented, Dame Janet said.
Mr Smith's investigation in March 1998 found no cause for concern and Shipman went on to kill a further three women before finally being caught five months later.
Dame Janet's comments came as the Shipman Inquiry's second and third reports were published by Home Secretary David Blunkett.
In its first report, published last year, the inquiry ruled that Shipman, now 57, had killed at least 215 of his patients over 23 years, during which he was a family GP in Todmorden, West Yorkshire, and later Hyde, Greater Manchester.
Since then, the inquiry has looked into the discreet investigation carried out by Greater Manchester Police following concerns raised by another GP, Dr Linda Reynolds.
She told the police she thought Shipman may have been killing his female patients using some sort of drug.
But Mr Smith did not understand the issues raised and failed to ask a number of important questions.
When he then consulted the medical adviser to the health authority, Dr Alan Banks, he was wrongly reassured that there was nothing unusual about a number of deaths he had looked into.
His advice effectively concluded Mr Smith's investigation.
Today, Dame Janet concluded that Mr Smith should never have been appointed to the investigation.
His superior, Chief Superintendent David Sykes, then "failed to recognise that Det Insp Smith was out of his depth" and "failed to discuss the issues ... in any detail".
If he had done so, Mr Sykes "would have realised the extent of Det Insp Smith's lack of understanding", Dame Janet said.
He had made "many mistakes", including failing to ask important questions of Dr Reynolds and not checking whether Shipman had any previous convictions.
Shipman had been convicted in the 1970s for drug offences and acting dishonestly.
Many of his mistakes were due to his lack of experience, but Mr Smith still continued his inquiry "pretending that he knew what he was doing".
He never sought help and as a result, "never understood the issues, never had a plan of action, had no one to help him analyse the information he received, had no one to make suggestions as to the information he should seek ... and was allowed to close the investigation before it was complete", Dame Janet added.
Even when it was decided to close Mr Smith's investigation, there was no "detailed discussion of the evidence" with Mr Sykes. Mr Smith submitted no written report.
Although not primarily responsible for the failure of the inquiry, "his inaction contributed directly to the adverse result", the report concluded.Reuse content