Could a 'Dr Death' work undetected in Canada?

Our safeguards are little better than Britain's were at the
time of Dr Shipman's killing spree

By Owen Dyer

Dr Harold Shipman murdered at least 250 patients over a period of 22 years. He was only finally detected because he crudely forged the will of his last victim, in what the Shipman Inquiry speculated was a deliberate attempt to get caught. Everyone failed to notice what he was doing — his partners and other colleagues, his local National Health Service Trust, the police and most significantly, the General Medical Council (GMC).

The GMC, which has a disciplinary role similar to our Royal Colleges, now faces imposed reform or even the loss of its power to punish bad doctors. Meanwhile, a root and branch re-writing of the rules on physician monitoring will make British family doctors the most heavily scrutinized on earth.

But of course the next probably won't be British. He could just as easily be Canadian. Could Dr Shipman have gotten away with it here? More importantly, are our current safeguards up to the job of stopping a serial killer with a medical licence?

The first known medical psychopath was, in fact, a Canadian and a graduate of McGill medical school. Dr Thomas Neill Cream murdered patients here and in the United States in the late 19th century, before finally being arrested and hanged in Britain. Dr Cream was able to keep practising even after dead bodies turned up in his garden shed. Indeed, his second stint as a doctor in Britain came after he had served 10 years for murdering a patient in Chicago.

Things have improved a little since then. But stopping the Dr Creams and Dr Shipmans of this world is still difficult for two fundamental reasons. First, patients die, no matter how good or conscientious their doctor may be. Even Shipman lost patients he wanted to keep. Second, there is a natural assumption that doctors are trying to help and not to harm.

This was the GMC's argument when facing the Shipman Inquiry: "Shipman betrayed his patients and his profession in a way that was not reasonably foreseeable. Until he was found to have perpetrated his murders, systems were not designed to take the possibility of such extreme wickedness into account."

The GMC apparently applies that logic only to itself, for it has since charged six of Dr Shipman's local colleagues with failing to raise concerns when countersigning cremation forms. But the six doctors in question each only countersigned an average of three forms a year for his victims, hardly enough to raise suspicions.

Now, there are various methods proposed for monitoring physicians' performances by detailed clinical audit, or simply by counting patient deaths. The biggest problem with death rate counts is that they are likely to pick out not murderers nor even incompetents, but rather doctors with unhealthy patients. When the Shipman Inquiry identified 12 other family physicians who also had 'unacceptable' death rates, detailed analysis revealed that all had taken on nursing home commitments which accounted for the excess. The last thing we need is a system that encourages doctors to steer clear of the sickest patients.

As for clinical audits, Canada already has them in the shape of medical practice assessments, but only so many doctors can be looked at in depth — Saskatchewan, for instance, reviews about a hundred a year. But even the prolific serial killer Dr Shipman had years in which his death rate was not unusual. Had he been audited in one of those years, he would have qualified to become an assessor himself!

Medical practice assessment in Canada is similar to the system that had been operating in Britain before Shipman's arrest, in that its primary goal is to give the conscientious physician the information needed to improve standards of care. But the Canadian version has a few extra teeth, most notably the assessor's duty to report dangerous doctors to the provincial Royal College.

The audits are generally fairly comprehensive, but the average doctor can expect less than one per decade. That leaves time for quite a killing spree.

All in all, the Canadian environment is not so very different from the one Shipman operated in. Like Britain's system in the 80s and 90s, our system has never gone seriously wrong — as far as we know. There is no public pressure to change it, and so nobody will.

After all, there's little doubt that Dr Harold Shipman was a very rare bird indeed. We can probably get away with waiting a few years to see what rigorous monitoring produces in Britain without anything terrible happening. If the British start turning up medical serial killers left, right and centre, it might be time to think about a change in our own approach.