The proposals of the independent public inquiry into the issues arising from the case of Harold Shipman, as currently listed on The Shipman Inquiry website, include the recommendation that coroner's investigators should be trained to ‘think dirty’.1
Doctors will soon learn that medical coroners are keen to discover medical error and that such a search should occur after every death. Donald Berwick predicted the response that such a search will produce, ‘Any good foreman knows how clever a frightened workforce can be. Practically no system of measurement is robust enough to survive the fear of those who are measured’.2
The government is committed to implementing the Shipman Inquiry's proposals. General practitioners will then have a regular (typically every 2–3 weeks) interrogation by coroner's investigators ‘thinking dirty’. It is likely that investigators will receive only superficial help in a climate of fear.
We estimate that 10% of all deaths have potentially contributory factors that may have been prevented in primary or secondary care, but only rarely have these caused the death.3 A distinction now needs to be made between ‘medical errors’ that have caused the death and those that may have contributed to the death.
Everyone hopes that the Inquiry will indeed serve to protect the living.4 To do this, it is vital that GPs and other doctors who have treated the deceased are informed of the medical coroner's conclusions and the reasons for them.
Fearful doctors could easily, and probably justifiably, over-investigate, over-refer and over-hospitalise the main group of people who die, the frail, chronically-sick elderly. The Shipman tragedy may still cast an even longer shadow.
- © British Journal of General Practice, 2004.
