Death certificate system flawed, says Shipman inquiry

The British system of doctors certifying deaths provides no protection against a GP intent on murder, the inquiry into mass murderer Dr Harold Shipman heard yesterday.

Despite being intended to protect the public against the concealment of homicide, the certificate needs no counter signature if the patient has been seen by their doctor within the last 14 days.

The certificate also removes the need for a compulsory post mortem. Caroline Swift, QC, counsel for the inquiry looking at the failure of safeguards to prevent Shipman's 23-year-long killing spree, said the system had "permitted 215 killings to go undetected".

Shipman's crimes eventually came to light only because he had forged the £375,000 will of his last victim and not by reason of any "warning bell" activated by the system covering death certificates, she told the hearing in Manchester Town Hall.

The bereaved daughter whose suspicions led police to arrest Shipman told the inquiry yesterday that a second doctor should look at all deaths before a certificate was signed and said existing procedures were "remarkably lax".

Angela Woodruff, the daughter of 81-year-old Kathleen Grundy, said Shipman had been "strangely vague" about her mother's condition when she saw him after her death.

She spoke of the "growing sense of unease" she and her husband felt but said there was an "enormous barrier" to cross to believe a trusted GP could forge her mother's will and commit murder.

Mrs Woodruff said: "We kept thinking that Dr Shipman had done something but we couldn't believe it. We were thinking we were going mad."

Shipman had telephoned the coroner's office and told them he was certifying Mrs Grundy's death as due to old age.

Miss Swift said given Mrs Grundy's good health, any examination of the records would show that cause to be false. But "the police, coroner's office and registrar" were not to know that and "those who knew her were never asked to confirm information given by Shipman to the coroner's office".

Mrs Woodruff said she only discovered at Shipman's trial, two years ago, that the coroner's office would not have recorded Shipman's telephone calls about her mother's death and that one was fielded by a secretary.

"I would have thought the coroner or his deputy should have taken the call and any call should be logged," Mrs Woodruff said.

The inquiry continues today.