Inexperience, dishonesty and serious professional failures by police allowed Harold Shipman to continue his serial killings undetected, an inquiry ruled today.
Shipman, a family doctor nicknamed "Dr Death", was convictedin 2000 of murdering 15 of his patients and sentenced to life in prison. An inquiry later ruled that he had murdered at least 215 of his patients with heroin injections.
Dame Janet Smith, the judge conducting the latest inquiry,said two police officers at the head of the investigation were "inexperienced" and "not fit for the case".
The lives of three of Shipman's victims "would probably havebeen saved" if police had done their job properly, she said in a report.
The inquiry also recommended wholesale changes in Britain's system of death certification and coroners' investigations.
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Ms Smith singled out for blame Chief Superintendent David Sykes and Detective Inspector David Smith, both of Greater Manchester Police in northern England.
Chief Supt Sykes had "failed to recognise" that Det Insp Smith was "out of his depth." Det Insp Smith misled colleagues, sought to blame others for his own failures and lied to the inquiry, she said.Det Insp Smith also "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 investigationbefore it was complete," she added.
Ms Smith's inquiry also urged a complete overhaul of Britain's system of death certification and the investigation of deaths bycoroners.
"A way must be found to ensure that all deaths receive adegree of scrutiny and investigation appropriate to their facts and circumstances."
Ms Smith's first report, published last year, foundShipman had murdered his victims quietly, coldly andsystematically over 23 years, ending the life of patient after patient in a betrayal of trust "unparalleled in history".
His motives remain a mystery and he has consistently refusedto confess to any of the killings.