Changes to the way coroners record deaths in response to the serial murders committed by Harold Shipman are not enough to prevent a repeat case, the judge who led the inquiry into his crimes has claimed.
A shake-up of the coroner's system was ordered after Shipman (pictured), from Hyde, near Manchester, managed to circumvent the coroner's office by signing death certificates himself.
The Shipman Inquiry concluded nearly five years ago that loopholes in the system had allowed the family doctor to murder at least 215 victims between 1975 to 1998 by giving lethal morphine injections.
In 2000, Shipman was jailed for life after being convicted of murdering 15 patients. He died in 2004 after being found hanging in his cell at Wakefield Prison.
The head of the inquiry into his crimes Dame Janet Smith told the BBC she was concerned about the lack of progress in implementing her recommendations on tightening up the way deaths are recorded.
She said she was shocked at how totally the system of death certification is dependent upon the honesty and integrity of a single doctor.
Planned changes to the coroner's system include the need for a second doctor to review deaths which have not been referred to a coroner.