Prison officers had no sign of Shipman's suicidal tendencies
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《英国医生杂志》
The death of the serial killer Harold Shipman in his cell "could not have been predicted or prevented," an official investigation has found. But the ombudsman for prisons and probation, Stephen Shaw, said officers at Wakefield Prison "do not appear to have been alerted to the man抯 long term risk of suicide or what might finally trigger it."
Mr Shaw examined how the former GP was able to hang himself in his cell in January 2004. Shipman was convicted of murdering 15 patients but is thought to have killed another 235.
Mr Shaw said the death raised "procedural issues relating to the management of the incident." But a review of Shipman抯 medical care, carried out for the ombudsman by Northumberland Care Trust, found that his treatment "was appropriate at all times" and that staff had not missed any warning signs. He was not taking any drugs that might have caused depression.
The report says that officers who found Shipman hanging in his cell laid him on a bed while attempting resuscitation, instead of a hard surface as guidance recommends. Mr Shaw said he was "critical" of the officers?failure to call an ambulance despite repeated requests by the prison nurse. Paramedics called to a death at the prison a week earlier had complained about being called out unnecessarily.
Poor record keeping meant the exact timing of events leading to Shipman抯 death could not be established. But a doctor was not called until more than 30 minutes after the body was found and took more than an hour to arrive. Mr Shaw said there was "no reason to believe" he could have got there any faster, as he lived on the other side of Leeds, the nearest big city, about 30 km north of Wakefield. The doctor called out said that "he was not, in fact, the on-call doctor" that day.
The report shows that shortly before his death Shipman had protested against having his privileges reduced, which meant he could not phone his wife. He was concerned about her difficulties in claiming state benefits. He killed himself a day before his 58th birthday. As he was under 60 his wife was able to receive his full NHS pension, but the ombudsman said this did not explain why Shipman took his life when he did.
The report makes 17 recommendations. It says paramedics should be called to all emergencies unless a healthcare professional decides otherwise. The ombudsman also calls on the Department of Health to issue guidance on when not to attempt or to end resuscitation. Current guidance at Wakefield says officers should resuscitate unless rigor mortis has set in. The report also calls on the prison service to ensure "that long-term but dormant suicide risk issues are communicated" between prisons.
The ombudsman said it was "extremely regrettable" that Shipman抯 wife learned of his death from radio news before the police contacted her.(Kaye McIntosh)
Mr Shaw examined how the former GP was able to hang himself in his cell in January 2004. Shipman was convicted of murdering 15 patients but is thought to have killed another 235.
Mr Shaw said the death raised "procedural issues relating to the management of the incident." But a review of Shipman抯 medical care, carried out for the ombudsman by Northumberland Care Trust, found that his treatment "was appropriate at all times" and that staff had not missed any warning signs. He was not taking any drugs that might have caused depression.
The report says that officers who found Shipman hanging in his cell laid him on a bed while attempting resuscitation, instead of a hard surface as guidance recommends. Mr Shaw said he was "critical" of the officers?failure to call an ambulance despite repeated requests by the prison nurse. Paramedics called to a death at the prison a week earlier had complained about being called out unnecessarily.
Poor record keeping meant the exact timing of events leading to Shipman抯 death could not be established. But a doctor was not called until more than 30 minutes after the body was found and took more than an hour to arrive. Mr Shaw said there was "no reason to believe" he could have got there any faster, as he lived on the other side of Leeds, the nearest big city, about 30 km north of Wakefield. The doctor called out said that "he was not, in fact, the on-call doctor" that day.
The report shows that shortly before his death Shipman had protested against having his privileges reduced, which meant he could not phone his wife. He was concerned about her difficulties in claiming state benefits. He killed himself a day before his 58th birthday. As he was under 60 his wife was able to receive his full NHS pension, but the ombudsman said this did not explain why Shipman took his life when he did.
The report makes 17 recommendations. It says paramedics should be called to all emergencies unless a healthcare professional decides otherwise. The ombudsman also calls on the Department of Health to issue guidance on when not to attempt or to end resuscitation. Current guidance at Wakefield says officers should resuscitate unless rigor mortis has set in. The report also calls on the prison service to ensure "that long-term but dormant suicide risk issues are communicated" between prisons.
The ombudsman said it was "extremely regrettable" that Shipman抯 wife learned of his death from radio news before the police contacted her.(Kaye McIntosh)