This is the fourth report of the Shipman Inquiry, set up to investigate the circumstances surrounding the murders of over 200 patients by their GP, Dr. Harold Shipman. It follows on from previous reports on the police investigation (Cm 5853, ISBN 0101585322) and the death certification system and the investigation of deaths by coroners (Cm 5854, ISBN 010158542X). This report focuses on the regulation of controlled drugs in the community, in light of the fact that Shipman was able to acquire large quantities of diamorphine over a period of 23 years without being detected. The inquiry report makes a number of recommendations designed to improve systems of inspection and monitoring in order to deter or detect the activities of dishonest doctors seeking to obtain drugs illicitly, as well as promote the safety and welfare of patients for whom controlled drugs are prescribed. Key recommendations include the creation of a controlled drugs inspectorate to establish a rigorous system of inspection and monitoring in pharmacies, dispensaries and surgeries. Other recommendations relate to: the prescribing rights of GPs; the use of prescription forms; safe custody and record keeping of GPs; the dispensing of controlled drugs in the pharmacy and the community
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