Shipman was convicted of drugs offences in 1976
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Killer GP Harold Shipman got away with illegally stockpiling drugs because safeguards in the system failed for 20 years to detect what he was doing.
The public inquiry into the killings heard Shipman freely got hold of drugs by either prescribing them for patients and not administering them or by over-prescribing.
His growing stockpile of diamorphine, which he used to kill his victims, went unnoticed, despite Shipman's previous conviction for drugs offences.
In 1976, Shipman was convicted of obtaining pethidine by deception and forging prescriptions at his former surgery in Todmorden, West Yorkshire.
Christopher Melton QC told the inquiry that under the present system there was no record of what happened to controlled drugs once they left a pharmacy unless they were administered by a district nurse.
The systems in place neither prevented him from [stockpiling drugs] nor detected he had done so
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"They are regarded as the property of the patient," he told the inquiry chairman, Dame Janet Smith.
After his conviction in 1976, the General Medical Council only admonished him and the Home Office took no action to prevent him from prescribing controlled drugs, said Mr Melton.
"For about two decades Shipman successfully misappropriated large quantities of diamorphine," Mr Melton said.
"The systems in place to prevent such diversion neither
prevented him from doing so nor detected he had done so."
Shipman is serving life after his conviction at Preston Crown Court in January 2000 for the murders of 15 patients.
The public inquiry has already found that the 57-year-old claimed the lives of at least 215 patients in his practices in Hyde and Todmorden.
Andrew Spink QC, representing the families of Shipman's victims, said there was a "pressing need" for a close investigation into how he got away with stockpiling the drugs.
"He could simply by-pass the system," said Mr Spink.