The last three of Harold Shipman's victims would probably have lived but for an incompetent police inquiry by a badly supervised inspector who was "out of his depth", according to a report published yesterday by Dame Janet Smith, the chairman of the Shipman inquiry.
One of the two detectives blamed for a series of blunders lied to cover up his many mistakes, the report said. The officer, who faces disciplinary action, failed to make basic inquiries, such as discovering that Shipman had a criminal record for drug offences. The report follows an investigation of the original police inquiry that cleared Shipman of any wrongdoing and a separate report into the coroner system, which was found to be deeply flawed and in need of reform.
Shipman was convicted in January 2000 of murdering 15 of his patients, but is thought to have killed at least 215. His last three victims Winifred Mellor and Joan Melia, both 73, and Kathleen Grundy, 81 might have been saved if a proper investigation had taken place, Dame Janet concluded.
Yesterday's report also raises the possibility that Shipman could have been exposed as a killer as early as 1985 perhaps saving 100 lives but for the combined failings of a coroner, a pathologist and doctors, who missed vital clues pointing to the GP's guilt.
But Dame Janet's most outspoken attack is against officers from the Greater Manchester Police who ran a series of botched inquiries. The first, which began in March 1998, followed a complaint by a fellow doctor in Manchester who was concerned at the high fatality rate among Shipman's patients.
Detective Inspector David Smith, who organised the investigation, did not fully understand the issues, made no record of his inquiries, failed to check Shipman's past convictions and did not pursue the fact that post-mortem examinations could have been performed on two victims killed by Shipman shortly before his investigation began. If the autopsies had taken place they would probably have shown that morphine was being used to kill patients.
In her 165-page report, Dame Janet said: "[DI Smith] was wrong to continue with his investigation, pretending that he knew what he was doing when, as he admitted in evidence, he did not know 'where to go'." The 46-year-old officer, who has been with the Manchester force for 27 years, is currently on holiday. He is to face a disciplinary tribunal.
His supervising officer, Chief Superintendent David Sykes, who retired three months ago at the age of 50, failed to offer much help or discuss the case in detail, and allowed his subordinate to decide to close the investigation, the inquiry found.
"Once the investigation was under way, [Ch Supt Sykes] failed to realise that DI Smith was out of his depth," said the report, adding that: "[DI Smith's] decision to retain responsibility was not merely a poor decision within the band of decisions open to him; it was fundamentally wrong."
Dame Janet was also critical of a doctor who was consulted during the investigation. Dr Alan Banks was asked to review the cases of 15 of Shipman's dead patients, but he failed to notice anything suspicious, including the unusual fact that 14 of the victims were women.
DI Smith concluded that there was no substance to the concerns raised about Shipman and ended his investigation on 17 April 1998. After that time, Shipman killed three more patients before his arrest on 7 September 1998.
DI Smith later tried to play down the seriousness of the original allegations, and lied to deflect criticism.
"He consistently sought to attribute its failure to the fault of others. He told lies in those accounts and repeated some of those lies in statements made to this inquiry," Dame Janet said.
Two subsequent internal police inquiries declined to criticise DI Smith's investigation, saying it was "appropriate at the time", and not until last year did Greater Manchester Police finally admit that the investigation was "seriously flawed".
Dame Janet concluded that Greater Manchester Police only ran the 2002 inquiry because of the evidence emerging at the Shipman public inquiry.
Danny Mellor, the son of one of Shipman's last victims, Winifred Mellor, said: "Today's reports have just confirmed what we all knew it was an appallingly incompetent police investigation."
A police spokeswoman said the force has apologised to the families of the last three victims. She added: "We have already made a number of changes to our working practices as a result of our own reviews of the investigation."
In a separate report on the system of certifying deaths and cremations in England and Wales, Dame Janet said the coroner system had to be radically reformed if it was to prevent a case like Shipman's happening again.
She said an opportunity to uncover his crimes was missed in 1994 when Renate Overton was admitted to hospital after Shipman injected her with diamorphine. She was in a coma for 14 months but died in April 1995.
An autopsy that concluded Mrs Overton died of natural causes was described as "seriously deficient" by Dame Janet. She said a new and properly resourced Coroner Service should contain legally qualified and medically qualified coroners.
The Home Office said work was under way to identify how to reform the coroner system.
The blunders that cost lives
¿ After a woman, 47, dies from diamorphine in April 1995, the coroner fails to order ann inquest and the pathologist concludes death from natural causes.
¿ In the investigation by Detective Inspector David Smith in March 1998, he fails to find Shipman's criminal record for dishonesty, does not take notes, does not order a post-mortem, and fails to ask for help though he is "out of his depth".
¿ The senior officer in that investigation, Chief Superintendent David Sykes, offers little supervision, and is not considered to be experienced enough.
¿ Doctor asked to review 15 of Shipman's dead patients fails to spot any suspicious trends.
¿ Police clear Shipman of wrongdoing in April 1998.
¿ Internal review of the original police investigation concludes that it was "appropriate at the time".
The women who could have saved
By Maxine Frith
WINIFRED MELLOR Mrs Mellor was the first of the three women to be murdered by Harold Shipman after the initial police investigation was closed. She was 73 when she was killed on 11 May 1998. Her two sons and three daughters did not learn the details of the botched investigation until the independent inquiry into Shipman last year.
Mrs Mellor's son Danny said: "I used to have the utmost respect for the police - that has been completely shattered."
Mrs Mellor had been a patient of Shipman for years. Her son said: "She had always said how friendly and caring he was. He had taken great care of my dad before he died [his father has been ruled out as a victim of Shipman] and my mum never forgot that."
Mrs Mellor had gone walking with her other son James two weeks before her death. Two days before her death, she had phoned Danny to tell him of a trip she had booked to the Holy Land. But 48 hours later, his sister called to say their mother had died.
He said that, from the start, "we had suspicions. On the day my mum died, [Shipman] was very cold and callous to my sisters, and that seemed strange after all we'd been told about him. She had always told us what a nice man he was, and we had no reason to suspect him."
Shipman told the family that Mrs Mellor had been suffering from angina, but had refused to take any medication and had not wanted her children to know. Her son said: "We were surprised, as Mum was very particular about her health and would have definitely taken tablets if she needed them."
Shipman claimed that he had arrived at her house to find shopping on the kitchen table and Mrs Mellor dead in her chair.
What he didn't say was that he had visited Mrs Mellor earlier in the day and administered a fatal injection of diamorphine.
The Mellor family now want to see the officers who were investigating disciplined.
Her son said: "I can't bring myself to think about Shipman. If I did, I would get eaten up with rage, and I don't want that. But if I ever met him, I would probably tear him to pieces."
JOAN MELIA Mrs Melia was a sprightly 73-year-old with her independenceand a love of designer clothes.
She was murdered by Shipman on 12 June 1998, only 12 days before he killed for the final time.
Her niece Jean Pinder is still struggling to cope with the fact that she encouraged her aunt to see Shipman on that fateful day. Mrs Melia had been complaining of a chest problem, and Mrs Pinder told her to make an appointment to see Shipman. Mrs Pinder said: "We are punished by visions of him calling in the afternoon. Auntie Joan would have let him in with open arms."
Mrs Melia, who was divorced, went to see Shipman in the morning. He then visited her at home in the afternoon and killed her. She was found dead in her chair by her partner, Derek Steele.
As with Mrs Mellor's children, Shipman wasrude to Mrs Melia's family after her death.
Now they have discovered that her murder could have been prevented.
KATHLEEN GRUNDY Mrs Grundy's death sparked a police investigation and ended Shipman's 23-year killing spree. But what brought him to justice was the tenacity of her daughter Angela Woodruff.
Mrs Grundy died on 24 June 1998. She was found dead in her home by friends, who sent for her GP - Shipman.
He told Mrs Woodruff her mother had died of "old age". But she became suspicious after a will emerged leaving her mother's entire estate to Shipman. Mrs Woodruff found the two witnesses, who denied signing it.
She said: "We kept thinking it looked as though Mr Shipman had done something, but it couldn't be and we couldn't believe it."
On 24 July she went to the police and told them of her suspicions. Shipman was finally arrested on 7 September.Reuse content