The Shipman Inquiry

Dame Janet Smith's inquiry into the GP Harold Shipman found major flaws in death registration, the prescribing of drugs and the monitoring of doctors. The most serious, she wrote, was that death certification depended on the integrity and judgment of a single doctor. Proof that reform can take decades: independent medical examiners now review the cause of death proposed by the attending doctor before registration, check the records, flag concerns about care and talk to the family. That system only gained statutory force on September 9, 2024, roughly two decades after Smith's reports. It is the entry to read for how long an inquiry's recommendations can wait.