Article in the Telegraph
"An exhaustive inquiry into at least 215 murders by the GP made 200 recommendations for vital changes to the way doctors work, but three years after Dame Janet Smith published her findings, many of them have not been implemented.
In particular, Dame Janet suggested a raft of changes to the way deaths are certified, with checks and balances built into the system. Shipman was able to escape detection for years because he had the authority to pronounce his victims dead, invent a seemingly natural cause, and then issue a death certificate with little or no involvement from anyone else.
Dame Janet said deaths should be certified not only by the medic who confirms death, but also by the deceased's main doctor, with the facts checked with the family. An independent investigator should then review all the facts before deciding which deaths need further inquiry.
But John Pollard, the coroner who called in police when concerns about Shipman were raised in Hyde, Greater Manchester, said no legislative changes had been made, meaning a serial killer could strike again."