A "dishonest, malevolent doctor" could still get away with murder, five years after the inquiry into serial killer GP Harold Shipman, its chairwoman says.
In a BBC interview, Dame Janet Smith, who chaired the Harold Shipman Inquiry, criticised the system of death certification in England and Wales.
Shipman went undetected as he killed more than 200 patients, certifying their deaths as natural causes.
The government says its new Coroners and Justice Bill will prevent a repeat.
But speaking to BBC Radio 4, Dame Janet said "I really was shocked to find how totally our system of death certification is dependent upon the honesty and integrity of a single doctor."
"Once you realise that you can have a dishonest doctor and a malevolent doctor, then it is obvious that under our system that doctor can get away with murder," she added.
The inquiry into Shipman's crimes closed nearly five years ago. Yet the government did not publish its Bill setting out the proposed reform of the coroner's system in England and Wales until January 2009.
The possibility of something as horrific as Shipman will have very, very little chance of happening again
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