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Shipman and the Anaesthetist

2005; Wiley; Volume: 60; Issue: 2 Linguagem: Inglês

10.1111/j.1365-2044.2004.04116.x

1365-2044

Mike Harmer,

Cardiac, Anesthesia and Surgical Outcomes

The fifth report of the Shipman Inquiry has recently been published [1]. In the findings of Dame Janet Smith are widespread criticisms of how the medical profession regulates itself and recommendations over how matters should be dealt with in the future. The impact of this inquiry will take time to percolate through all areas of medicine but is likely to produce another round of changes in how we provide and manage healthcare. The events leading up to the conviction of Dr Harold Shipman and the subsequent inquiry are not to be understated in any way – the growing realisation that one man may have been responsible for more than 200 deaths is almost beyond comprehension. How could such events happen in modern medical practice where most clinicians feel that they are more scrutinised than ever by increasing levels of bureaucracy? But happen it most certainly did, and it is clear that changes have to be made to give the public reassurance about doctors – or perhaps for politicians to show that they are doing something. One thing is certain: Dr Shipman was a mass murderer. The fact that he was a doctor meant that he was able to kill his victims with seeming ease and without drawing excessive attention to himself. However, the fact that he was a doctor surely should not imply that all doctors are capable of similar actions and therefore must be subject to even tighter regulation. Yet that is precisely what is proposed. So how does this all impact on us as anaesthetists? Dr Shipman worked in an entirely different environment to most, if not all, of us. He was a single-handed general practitioner who was able to ‘cover his tracks’ most efficiently; most of us work in a very open and accountable system where even the most minor misdemeanour becomes common knowledge throughout the hospital in a matter of seconds. Given this difference in circumstances, surely there is nothing for us to fear from any of the reports from the inquiry or their repercussions? Oh that life was that logical! The implications of the five reports from the Shipman Inquiry will probably take many years to achieve their full impact and, as with any document running into thousands of pages, the full content and implications will take time to be realised. On scanning through the main findings of the various reports, there are a number of areas that are likely, directly or indirectly, to impact upon our clinical practice. Much of the following is pure personal speculation, but past experience of reports and inquiries would suggest expectation of the worst to be realistic. The first report, published in July 2002 [2] sought to identify how many patients were killed by Dr Shipman, as well as the means employed and the period over which the killings took place. The initial extent of the crime was based on the conviction of Dr Shipman for the murder of 15 of his patients. Further information was available as a result of an earlier review commissioned by the Chief Medical Officer [3]. Both the review and the first report provided similar information and a growing realisation that Dr Shipman may have been responsible for more deaths than the 15 for which he was convicted, with some believing the figure to be around 200. In hindsight, there were clear patterns to the deaths, but their significance was not appreciated. The majority of deaths were in elderly females, usually occurring at home either whilst Dr Shipman was present or soon after a home visit; the most common causes of death were from cardiac problems. The method of killing was predominantly overdosage with opioid, the availability of which would be covered in subsequent reports. The second report [4] concentrated on the police investigation of March 1998 which failed to fully uncover Dr Shipman's crimes. There is clear criticism of those involved in that investigation and questions as to its thoroughness, but the fact that a full police investigation struggled to unearth the full extent of his crimes must show how good Dr Shipman was at covering his tracks and how the community helped him by being supportive of a doctor whom they saw as a caring general practitioner. The ability to withstand such close scrutiny must make one wonder whether any appraisal or assessment system would have identified him as a criminal. One major criticism from the inquiry centred on the mechanisms for certification of death and the role of the coroner in identifying unusual patterns of death [5]. The role of fellow local GPs in the events surrounding these deaths has been fully investigated and has already been the subject of General Medical Council (GMC) action. It is easy with hindsight to think that colleagues or neighbouring practices should have been more vigilant. Is there a lesson to be learned for anaesthetists? Probably not, unless you happen to be involved in matters pertaining to cremation fees. There is a distinct possibility though that any unexpected death will receive additional scrutiny from the coroner and his officer. The current trend to investigate an increasing number of deaths with a view to bringing manslaughter charges is hardly likely to decrease within this climate of suspicion. One aspect of the series of deaths that should cause concern was the ease with which Dr Shipman was able to obtain and administer large amounts of controlled drugs without any record being kept. The fourth report tackles this and makes recommendations [6]. The main thrust centres on the way in which general practitioners can obtain and keep controlled drugs, and on the dispensing of such drugs in the community. On the surface, the recommendations apply to the community rather than hospital practice and thus would not appear to impact directly on anaesthetists, unless you happen to practise in pain. The rational use of opioids for chronic pain conditions has been the subject of a recent document produced by the British Pain Society [7]. The guidance is sensible and depends upon the availability of controlled drugs dispensed in the community; it can only be hoped that sensitivities surrounding the Shipman Inquiry will not lead to patients who would benefit being deprived of drugs. It is also possible that such sensitivities could impact upon pain practice within the hospital. Two such areas might be to prevent the push for greater availability of Oromorph 5 mg (not a controlled drug but often treated as such) for acute pain, and potential problems in the developing guidance for nurse prescribing. The Association of Anaesthetists is currently producing a guidance booklet on the Use of Controlled Drugs and the impact of the Shipman Inquiry will certainly be taken into account. The final report [1] is the one that is most likely to have the greatest impact on all of us. In this report, Dame Judith Smith examines the role of local NHS Primary Care organisations and the GMC in monitoring the performance of doctors, and makes recommendations to ensure the protection of patients in the future. The findings include that, ‘‘although there have been significant changes in clinical governance in the NHS in the years since Shipman practised as a GP, there has not yet been the change in culture within the GMC that will ensure that patient protection is given sufficient priority over the interests of the medical profession’’. The recommendations include a restructuring of the GMC and greater openness and availability of information to the public. Part of the aftermath of the Bristol affair was a drastic change in the structure of the GMC to make it more accountable. The introduction of appraisal and revalidation was intended to ensure that doctors are not only safe to practise but also keep up to date. Even before the revalidation process has started (apart from trial revalidation for Presidents of Royal Colleges and notable national figures), it seems like these recommendations may change everything. One has to have some sympathy for the GMC as I believe that under the Presidency of Graeme Catto, it has made huge strides to ensure fairness for doctors as well as protecting patients. If one has a criticism, from personal involvement in several cases, it would be that the emphasis has been on the protection of patients rather than the publicly-perceived role of protecting the doctor. What further changes will take place are yet to be decided. Perhaps the current process for revalidation will be allowed to run a reasonable course before being scrapped. It is perhaps relevant to remember that the appraisal scheme in which all hospital doctors have had to participate for several years has not yet become compulsory for GPs. It seems bizarre for the Inquiry to be critical of a scheme that has not even started and perhaps sense will prevail and allow the GPs to catch up with their hospital colleagues in the appraisal and revalidation process. One worrying aspect of this fifth report is the term ‘increased public availability of information’. Some have interpreted this to mean that every patient has the right to know everything about a doctor who is treating him/her. It has been mooted that any doctor who has been subject to disciplinary action or suspended at any time during their career must declare this to any patient and offer an alternate colleague should the patient desire. That seems simple enough until you think it through – will any patient want you to anaesthetise them when you tell them that you have been suspended in the past (remember, it could be for the serious crime of taking croutons!)? One can only hope that this route will not be explored any further and sense will again prevail. One thing is certain: the outcome of the Shipman Inquiry will change medical practice. Many recommendations will be made and immense time and effort will go into their implementation. What will be the effect? Will it protect patients from another Harold Shipman? It is, in my opinion, likely that, if another mass-murdering doctor were ever to appear again, even the tightest checks could be evaded. Dr Shipman was investigated by police and the GMC and yet was able to withhold the true enormity of his crime – regular appraisal and revalidation would probably not pose a major problem. What increasing regulation of doctors is more likely to do is hasten retirement. At a time when there is active encouragement for people to delay retirement, this is likely to have the opposite effect. As a parting thought over the impact that the Shipman Inquiry will have on all of medicine, including anaesthesia, it is interesting that such criticism is levelled at the GMC by a member of the legal profession, which hardly has an open system of regulation!