A "tragic systems failure" allowed Harold Shipman's crimes to go undetected but more needs to be done to reassure the public it could not happen again, doctors leaders have said.
Dr John Chisholm, chairman of the British Medical Association's General Practitioners' Committee, said doctors shared the public's horror at what had been revealed.
"The findings of this inquiry demonstrate that Shipman was a uniquely evil man who abused his position as a doctor and betrayed both patients and fellow professionals in an unprecedented way."
He said "a tragic systems failure" had allowed Shipman's crimes to go undetected for so many years.
"Some measures have been introduced, but we have to do much more to reassure the public that it could not happen again."
He said the BMA had been calling for years for changes in the way in which deaths and cremation are recorded and analysed.
"There was an extraordinary pattern here that should have been picked up years ago, including deaths on practice premises, a very rare event," he said.
The number of sudden and unexpected deaths among Shipman's older patients was very high, and these should have come to notice much earlier.
Dr Chisholm said since Shipman's conviction new quality-assurance procedures had been introduced into the NHS by the British government, with the co-operation of the medical and nursing professions.
But he said: "I think there is more that needs to be done in monitoring the use of controlled drugs, an issue in the Shipman case, and monitoring and analysing death and cremation information." He said more could also be done to train doctors, nurses, coroners and crematorium referees. Everybody needs to be more vigilant and more aware of their obligations to report suspicions.
"One of the reasons Shipman's crimes eventually came to light was through whistleblowing by the medical profession."
Prof David Haslam, chairman of the Royal College of General Practitioners, said: "General practitioners are among the most trusted members of any community. For a GP to betray this hard-earned trust in such a chilling way is horrific."
The second phase of the inquiry will look at how the system failed to detect a serial killer for so long.
"The Royal College of General Practitioners is committed to doing all it can, with others, to make sure the lessons from this case are addressed," he said.
The horror of the Shipman affair should not "erode the bond of trust" between doctors and patients, the official spokesman of the British Prime Minister, Mr Tony Blair, said yesterday.
"The fact that this report essentially confirms what everybody suspected in terms of the extent of his crimes in no way diminishes their horror and our thoughts are obviously with the families of his victims at what must be a very difficult time," he said.
"It is important, however, to not go from the specific to the general and allow this to erode the bond of trust that exists between doctors and patients.
"The Government stands ready to look very carefully at whatever it concludes," he said. - (PA)