Police probably could have prevented family doctor Harold Shipman from murdering his last three victims if they had properly conducted their initial investigation, an inquiry ruled Monday.
The two detectives in charge of a 1998 probe into Shipman's activities, which found no cause for concern, lacked experience, said the chair of the inquiry, said High Court Judge Janet Smith.
After the investigation, Shipman killed three more women. He was subsequently arrested and convicted of murdering 15 elderly patients, although Smith later said Shipman murdered at least 200 other people during a 23-year killing spree.
On Monday, Smith called for a complete overhaul of the way coroners investigate deaths so they can better detect cases of homicide, error and neglect.
"There must be radical reform and a complete break from the past, as to organization, philosophy, sense of purpose and mode of operation," Smith told a news conference in Manchester, northern England.
Shipman, who worked in the nearby town of Hyde, preyed largely on elderly woman, killing them with lethal injections. His crimes horrified the nation and raised questions about how he was able to evade detection for so many years.
Smith's report found that the coroner system failed because the death certificates Shipman issued, stating "natural causes," were not cross-checked.
"A way must be found to ensure that all deaths receive a degree of scrutiny and investigation appropriate to their facts and circumstances," Smith said.
Greater Manchester Police on Monday said it would learn lessons from the report and apologized for mishandling the first investigation.
"We have publicly acknowledged that mistakes were made during the first police investigation into Shipman's activities, and our sincere apologies to the families of the three women who later died," the department said.
Smith said that in the March 1998 investigation, Chief Superintendent David Sykes failed to realize he was too inexperienced to supervise the case and Detective Inspector David Smith, who held direct responsibility for the probe, was "out of his depth."
She also said David Smith subsequently lied to a number of internal investigations and to the Shipman Inquiry.
The first police inquiry was launched after another doctor, whom Shipman had asked to co-sign some cremation certificates, expressed concern at the number of deaths among Shipman's patients. Police concluded there wasn't enough evidence to pursue charges.
The investigation was reopened months later after the daughter of an 81-year-old widow discovered her mother apparently had changed her will to leave everything to Shipman.