Shipman was arrested in September 1998 and the inquiry commenced shortly after he was found guilty of 15 murders in January 2000.
[5] On 1 February 2000, the Secretary of State for Health, Alan Milburn, announced that an independent private inquiry would take place into Shipman's activities.
Many families of the victims along with certain sections of the British media called for a Judicial Review in the High Court.
[7] The Administration of the Inquiry was managed by Henry Palin, who was supported by Michael Taylor and later Mark Dillon.
There were four main areas investigated:[8] The inquiry found major flaws in the processes of death registration, prescription of drugs and monitoring of doctors.
It called for coroners to be better trained and underlined that better controls on the use of schedule 2, 3 and 4 drugs by doctors and pharmacists were needed.