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  1. L Donaldson
  1. Chief Medical Officer, Department of Health, Richmond House, 79 Whitehall, London SW1A 2NS, UK;

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    When the guilty verdicts were brought in on the murder of 15 of Harold Shipman’s patients in the winter of 2000,1 I was asked by the then Secretary of State for Health whether there was any way in which we could establish whether there had been other clinically suspicious deaths. It was on this basis that I commissioned a clinical audit of Shipman’s practice from Professor Richard Baker. The question by the Secretary of State for Health to me as Chief Medical Officer and my decision to establish the clinical investigation were quite unprecedented.

    The fact that the subsequent report of the clinical audit2 judged it likely that Shipman had murdered more than 200 of his patients was shocking. The subsequent analysis of deaths by the rigorous legal processes of the judicial inquiry3 arrived at broadly similar numbers. Baker’s medical detective work was ground breaking and has set a gold standard in methodology for the investigation of apparently untoward deaths in clinical practice.

    In the paper in this issue of the journal, Baker provides a particularly insightful account of the lessons for general practice for the whole Shipman affair.

    The challenges are big ones but, as Baker makes clear, failure to address them is not an option. Developing further the ethos of clinical governance4,5 within every clinical team, every general practice, and every primary care organisation is undoubtedly the most important step. A clinical culture which recognises and deals with poor practice, which is founded on team work (not isolated practice), and which is open about problems is at the heart of the transformation required. Linking a culture like this that focuses on the quality and safety of care to strong systems and good information to maintain and assess the quality of practice is the other important component.

    Baker rightly points to the importance of good monitoring data for general practice. This is by no means as easy as it sounds but the development of such data should be a priority. Inevitably, given the imminence of the introduction of an electronic health record, any monitoring requirements will have to be designed into such a system.

    Ultimately, the most unforgiving test of the ability of the NHS to improve the quality of care and to protect patients from harm must and should be its ability to learn.