A trial closes a case. It does not close the question of how long the offender was able to go on. In Britain and Canada that question has repeatedly been handed to a judge, an inspector of constabulary or a health authority, each asked to read the paperwork of a case that police and prosecutors had already finished. The documents that came out of those reviews share some habits. They tend to blame systems more than individuals. They propose machinery: a card index replaced, case-management rules written into regulation, death certificates looked at again. And they get read a second time, years later, by the next inquiry, which asks what became of the last one.
Eight such reviews follow, set beside the cases that produced them. For each the questions are the same: who ordered it, what it concluded, what changed, and what the record shows about whether the changes held. Where the public record is thin on the last point, it is left thin.
Peter Sutcliffe was convicted at the Central Criminal Court on May 22, 1981, of the murders of 13 women between 1975 and 1980. He had earlier pleaded guilty to seven counts of attempted murder. During the five years of those offenses West Yorkshire Police interviewed him nine times and did not arrest him.
The hunt for him had been the largest criminal investigation in British history. The Home Secretary later told Parliament that a squad of about 200 officers had carried out more than 130,000 interviews and checked 150,000 cars, at a cost of about 2.5 million police hours. Much of that effort went toward a man who did not exist. From March 1978 the inquiry received letters signed "Jack the Ripper," and in June 1979 a cassette tape arrived for Assistant Chief Constable George Oldfield. Dialect experts placed the voice near Sunderland, and some 40,000 men in the North East were investigated. Voice experts and some detectives warned that the material was a hoax. Sutcliffe was from Bradford.
After the conviction the Home Secretary asked Lawrence Byford, one of Her Majesty’s Inspectors of Constabulary, to review the investigation. He was assisted by the external advisory team set up in November 1980 and heard from relatives of the victims. The government gave Parliament his conclusions in a statement in the House of Lords on January 19, 1982. The police had made "major errors of judgment," and there had been inefficiencies at several levels. "Excessive credence was given to the letters and tape from a man claiming responsibility," the statement said. The major incident room at Millgarth police station in Leeds, which kept its information on a card index, had become overloaded and ineffective, with a growing mass of unprocessed material. Officers sent to interview Sutcliffe had often been inadequately briefed, and too little attention had been paid to the common features of the photofits drawn from the accounts of women who survived. Had those errors not been made, the statement said, he would have been identified as a prime suspect sooner, and there was little doubt that he should have been arrested earlier. Byford also recorded that most officers had worked diligently. In the Lords, Lord Elwyn-Jones said that lives could have been saved.
The report itself did not become public for nearly a quarter of a century. The Home Office released it on June 1, 2006, with a section withheld. What it said about Sutcliffe’s other offenses stayed contested: it described an "unexplained lull" in his recorded activity between 1969 and 1975, called it "highly improbable" that the crimes for which he was convicted were the only ones he had committed, and concluded that he was probably responsible for other assaults he had not admitted. In 2016 and 2017 West Yorkshire detectives reviewed unsolved assaults from the 1970s and were reported to have questioned Sutcliffe in prison. He denied responsibility, and no charge followed.
As for what changed, the public record on Byford is mostly a record of reputation. On the day Sutcliffe died, November 13, 2020, the Press Association ran a headline saying that the response to blunders in the Ripper investigation had shaped modern police inquiries. On that day the chief constable of West Yorkshire, John Robins, apologized to the victims' families for "the language, tone and terminology used by senior officers at the time in relation to Peter Sutcliffe’s victims." He said the Byford and Sampson reviews had not fully addressed how those victims were portrayed and described, and that the effect was still felt by surviving relatives. Thirty-eight years after Byford reported, a chief constable was naming a gap in it.
Paul Bernardo was convicted in Toronto on September 1, 1995, of the first-degree murders of two schoolgirls, Leslie Mahaffy, 14, and Kristen French, 15, and was declared a dangerous offender two months later. By then the Ontario government had commissioned a judge to examine how he had gone so long without being stopped. Justice Archie Campbell’s Bernardo Investigation Review was released in 1996.
The chronology it had to explain was short and damning. Between May 1987 and May 1990, Campbell concluded, Bernardo stalked and assaulted 14 young women in Scarborough and one in Mississauga. Toronto police interviewed him in November 1990 and took a blood sample as a routine step. The sample sat untested at the province’s Centre of Forensic Sciences for more than two years, among those of more than 200 other suspects. In early 1993 it was matched to the Scarborough assaults. By then Leslie Mahaffy and Kristen French were dead, and so was Tammy Homolka, 15, who died in December 1990 and whose death Campbell’s review attributed to Bernardo. (Sources disagree on the legal outcome of that death. Canadian Press reports since 2018 have said Bernardo was convicted of manslaughter, but no court record confirming it has been published.)
Campbell set out four questions the public wanted answered. Why had it taken almost six years to catch Bernardo? Why had the coroner and the Niagara police decided that Tammy Homolka died of natural causes? Why was Bernardo not recognized earlier as a strong suspect? And why had the forensic laboratory taken more than two years to test his sample? His answer was that the system had failed, not any one officer. "It is often the case that systemic failures as opposed to individual mistakes are the real cause of public disasters," he wrote. "The Bernardo case shows that the motivation, investigative skill and the dedication of officers is not enough." The work of skilled investigators could be defeated by the lack of an effective case management system, and he added a sentence that later readers have quoted more than any other: "We seem to be incapable of learning from previous experiences." Public Safety Canada later summarized his central finding as a lack of "cooperation, coordination and communication between police and other justice system partners."
His main recommendation was a common case management system, backed by regulation, for investigating homicides and sexual assaults across police forces. Ontario announced in 1997 that it would carry out the recommendations and set aside 25 million dollars over five years. A ViCLAS centre for linking violent crimes opened in December 1996, and reporting to it became mandatory under the Police Services Act in February 1997. The Ontario Major Case Management System was introduced in 2000, and since January 1, 2005, a regulation under the Police Services Act has required every police service in the province to use it.
Campbell’s review also had an afterlife. On January 24, 2012, the commission of inquiry in British Columbia that was examining the Pickton case quoted Campbell’s findings on systemic failure as still relevant.
Harold Shipman, a family doctor in Hyde, Greater Manchester, was convicted at Preston Crown Court on January 31, 2000, of murdering 15 of his patients and of forging the will of the last of them. The judge, Mr Justice Forbes, told him that life must mean life. The same day, Associated Press reported that Britain would investigate, and the Shipman Inquiry, chaired by the High Court judge Dame Janet Smith, followed.
A narrower review came first. Richard Baker’s clinical audit of Shipman’s practice, commissioned by the Chief Medical Officer and published in January 2001, concluded that the excess of deaths among his patients was evident from his first years in practice and continued throughout his career. It counted 98 more deaths among women than expected between 1987 and 1998.
Dame Janet’s inquiry produced six reports. The First Report, in July 2002, concluded that Shipman had killed at least 215 patients, between 1975 and 1998. These were findings of an inquiry, not convictions: prosecutors had decided that no second trial could be fair, and Shipman never admitted any killing. The Second Report, published on July 14, 2003, examined the police investigation of March 1998, which had turned up nothing against him; he was caught that summer only because a patient’s daughter, a solicitor, refused to believe the will he had produced in her mother’s name. The Third Report, published the same day, looked at death certification and the investigation of deaths by coroners, the machinery that had allowed one doctor to sign off so many deaths himself. The Fifth Report followed in 2004. The Final Report, on January 27, 2005, put the total at about 250 patients between 1971 and 1998.
Shipman did not live to read any of it. He died in custody at Wakefield prison on January 13, 2004.
What changed took a long time. In February 2007 the Department of Health published an overview of its action programme, "Learning from tragedy, keeping patients safe," and a separate response to the Inquiry’s fifth report and to three other inquiries into doctors. In June 2007 the Calder Valley member of Parliament, Chris McCafferty, used a Westminster Hall debate to say that Shipman, after being caught abusing drugs in Todmorden in the 1970s, had been "able to go down the road and carry on practising in Hyde, with no monitoring at all." On the question that the Third Report addressed, the date is plain enough. On September 9, 2024, the Welsh health secretary, Mark Drakeford, issued a written statement on the coming into force of the death certification and medical examiner reforms. That is 21 years after the Third Report, and 24 years after the conviction.
Beverley Allitt, a nurse, was convicted at Nottingham Crown Court in May 1993 of four murders, three attempted murders and six counts of causing grievous bodily harm with intent. All 13 counts concerned children on the children’s ward of Grantham and Kesteven General Hospital in Lincolnshire in the spring of 1991, and on May 28, 1993, Mr Justice Latham gave her 13 life sentences. The Health Secretary, Virginia Bottomley, ordered an independent inquiry under Sir Cecil Clothier. She reported its findings to the Commons on February 11, 1994.
The central finding was about time. A laboratory result showing that one baby had been harmed deliberately reached the ward on April 12, 1991. The police were not called until April 30. In between, another child died. The inquiry’s main lesson was that everyone caring for children should keep in mind the possibility of deliberate harm. Bottomley told the Commons that staffing by trained children’s nurses on the ward was below the regional health authority’s standard. She also summarized the inquiry’s conclusion on Allitt’s own sickness record: nothing in her absences suggested she was a danger to the children in her care. David Blunkett, Labour’s health spokesman, counted 26 incidents involving 13 children over 61 days.
Thirty years later another inquiry took the Clothier report down from the shelf. The Thirlwall Inquiry, examining the case of the nurse Lucy Letby at the Countess of Chester Hospital, announced on May 17, 2024, a review of the implementation of recommendations from previous inquiries into healthcare issues. Its legal team published a table of inquiries and reviews, the recommendations each had made and whether they had been carried out. Its summary of Clothier records, among other things, that pre-employment checks on Allitt had been unsatisfactory. The inquiry took a witness statement from Bottomley in July 2024, and on September 10, 2024, the Press Association reported that it had been told Allitt’s case was part of Letby’s training. What the Thirlwall Inquiry concluded about how far Clothier’s recommendations were carried out has not been reported.
Allitt herself has stayed in hospital, not prison. She was held at Rampton Secure Hospital by February 1994 and was still there in October 2023, when she asked a mental health panel to move her to a prison. Her minimum term of 30 years expired in November 2021, but a patient held in hospital cannot be considered by the Parole Board.
Robert Pickton, of Port Coquitlam, British Columbia, was convicted on December 9, 2007, of the second-degree murders of six women from Vancouver’s Downtown Eastside: Sereena Abotsway, Mona Wilson, Andrea Joesbury, Brenda Ann Wolfe, Georgina Faith Papin and Marnie Frey. Twenty further murder counts were stayed on August 4, 2010. He had been charged with attempted murder in April 1997, and the charges were stayed in January 1998 because, according to The Canadian Encyclopedia, prosecutors did not consider the complainant a competent witness. He was not arrested for murder until February 2002.
The first review came from inside the police. Doug LePard, a Vancouver deputy chief, examined his own department’s handling of the case. His report, about 400 pages and based on more than 20,000 police documents, was released in August 2010. It concluded that police had received information pointing to Pickton in 1998 and 1999 that should have led to a more vigorous investigation of him. Most of the blame for the delays fell on the RCMP, in whose territory the property lay, but Vancouver’s senior officers had also failed to press the RCMP to act, and management had not recognized early enough that a serial offender was targeting women in the Downtown Eastside. LePard said bias against the women was partly to blame, that the unit handling the missing-women files lacked resources, training and leadership, and that the delays likely cost the lives of more than a dozen women. Of a January 2000 RCMP interview of Pickton, LePard testified: "There didn’t appear to be an interview strategy at all."
The province then announced a public inquiry in August 2010, and the Missing Women Commission of Inquiry was established that year with Wally Oppal, a former judge and attorney general, as commissioner. His report, Forsaken, is dated November 19, 2012, and was released on December 17. Oppal concluded that "the initiation and conduct of the missing and murdered women investigations were a blatant failure." He identified seven critical police failures: poor report taking and follow-up; faulty risk analysis and assessment; an inadequate proactive strategy in the Downtown Eastside; failure to follow major case management; failure to pursue all investigative strategies; failure to deal with problems that crossed jurisdictions; and failure of internal review and outside accountability. He examined discrimination, institutional bias and public indifference as underlying causes. The commission reported that Aboriginal women made up about 3 percent of the province’s female population but about a third of the missing and murdered women it examined, and said the women had been treated as "nobodies," a word it chose on purpose. They had been, Oppal wrote, "forsaken by society at large and then again by the police."
The sixth item on his list, failure to deal with problems that crossed jurisdictions, and the fourth, failure to follow major case management, echo Campbell’s findings of sixteen years earlier.
The report made 63 recommendations, among them a regional police force for Greater Vancouver and compensation for the children of the missing women. The RCMP apologized to the victims' families in January 2012, and the Vancouver police apologized in December 2012. In March 2014 Canada, British Columbia and Vancouver announced a joint compensation framework, and the children of the women received 4.9 million dollars. Vancouver police changed their missing-persons procedures, among other things keeping files open until the person is located. The Vancouver police chief, Jim Chu, declined to commit to a regional force, the one recommendation that would have changed the structure.
Bruce McArthur pleaded guilty on January 29, 2019, to the first-degree murders of eight men in Toronto between September 2010 and June 2017: Skandaraj Navaratnam, Abdulbasir Faizi, Majeed Kayhan, Soroush Mahmudi, Kirushna Kumar Kanagaratnam, Dean Lisowick, Selim Esen and Andrew Kinsman. Justice John McMahon sentenced him on February 8, 2019, to life imprisonment with no parole eligibility for 25 years.
The Independent Civilian Review into Missing Person Investigations, led by the retired judge Gloria Epstein, delivered its report, Missing and Missed, to the Toronto Police Services Board on April 9, 2021. Volume II reconstructs how the police handled the disappearances. In November 2012 Toronto police had formed a task force, Project Houston, to investigate the disappearances of Navaratnam, Faizi and Kayhan. One line of inquiry, the review recorded, was an alleged ring of men interested in cannibalism, which proved irrelevant. The Board, the review said, did not know about Project Houston while it was active.
Officers interviewed McArthur as a witness on November 11, 2013. According to court documents unsealed in 2019 and reported by CP24, they had traced his online username and phone number in Navaratnam’s email contacts, and the same username in a notepad that belonged to Faizi. He admitted a past relationship with Kayhan and was not treated as a person of interest. CP24 reported that it was unclear whether investigators ran a background check, which would have shown his 2003 convictions for assault with a weapon and assault causing bodily harm. In June 2016 he was arrested and released without charge after another man reported an assault. The word "Bruce" on Andrew Kinsman’s calendar and video of Kinsman getting into a van gave a second task force its lead in 2017, and McArthur was arrested on January 18, 2018.
Global News described the review as "damning," and said it concluded that systemic discrimination had factored into the investigations. Xtra’s summary of the review ran under the headline "Profound systemic failure." On August 23, 2021, CP24 reported that the Toronto officer who had arrested and released McArthur in 2016 had been cleared of disciplinary charges, which left individual responsibility where Campbell, Byford and Oppal had each left it: not the document’s subject.
Stephen Port, a chef from Barking in east London, was convicted at the Old Bailey on November 23, 2016, of the murders of four young men, Anthony Walgate, 23, Gabriel Kovari, 22, Daniel Whitworth, 21, and Jack Taylor, 25, between June 2014 and September 2015, and of 18 further offenses against other young men who survived. Mr Justice Openshaw ordered on November 25, 2016, a whole life order. Port had already been convicted in March 2015 of perverting the course of justice over his lies about Walgate’s death, and had been jailed for eight months.
The review came late and from the coroner’s court. Fresh inquests into the four deaths, before a jury, ran at Barking Town Hall in the autumn of 2021. They examined the police investigations more closely than the trial had. The evidence recorded that in the Walgate investigation sexual swabs were not sent for DNA testing, and that a check on the Police National Database was run on Walgate but not on Port, a check that would have shown a 2012 allegation and a British Transport Police record from June 2014. Port’s laptop was seized and not sent for forensic analysis for about 10 months. The senior detective on the case, Detective Sergeant Martin O’Donnell, told the inquests: "It was there on his laptop and we should have got it." He called his failure to log the 2012 allegation "a terrible mistake." The Kovari death was classed as non-suspicious within five hours. In the Whitworth case items carrying Port’s DNA or fingerprints were never sent for forensic tests, and the detective who closed the case admitted he had missed a statement from Whitworth’s partner. The police closed those two investigations in January 2015.
Witnesses told the inquests that homophobia in the Metropolitan Police had led officers to dismiss evidence, the Press Association reported on November 5, 2021. On December 2 it reported, under the headline "Homophobia issue ruled out in Stephen Port victims' inquests," that the issue was ruled out. On December 10, 2021, the jury returned its conclusions. All four men had been unlawfully killed, and failings in the police investigation had probably contributed to the deaths of the last three. A coroner’s report covered on January 25, 2022, identified what the Press Association called basic investigative failings.
The police watchdog had been involved long before the inquests; the Independent Police Complaints Commission reported in March 2017 that its investigation was moving into the interview phase. After the inquests, the Independent Office for Police Conduct said it would reinvestigate, and Police Professional reported the decision on June 23, 2022. On November 16, 2023, the IOPC announced that eight Metropolitan Police officers, current and former, faced gross misconduct investigations. As the record stands, that is where the Port review sits: seven years after the murder convictions, eight officers under investigation, and no finding yet reported against any of them.
Colin Norris, a Glasgow-born staff nurse, was convicted at Newcastle upon Tyne Crown Court on March 3, 2008, by a majority of 11 to 1, of murdering four elderly women patients on orthopedic wards in Leeds in 2002 (Doris Ludlam, 80, Bridget Bourke, 88, Irene Crookes, 79, and Ethel Hall, 86) and of attempting to murder a fifth patient. On March 4, 2008, he was sentenced to life with a minimum term of 30 years. He has denied the offenses throughout. After the verdicts Ethel Hall’s son called for an independent inquiry.
The one that followed was commissioned by NHS Yorkshire and the Humber, the regional health authority, and was concerned with Norris’s path into the profession. Times Higher Education reported in February 2010 that the inquiry had established that his training at the University of Dundee had been extended because of poor attendance at clinical placements, and that he "had difficulties dealing with authority." The Courier, describing the same inquiry, said witnesses had described him as aggressive toward lecturers. The university said its reference followed standard practice across the sector, that it had included details of his absences, and that no concerns about his care of elderly patients had been raised while he was a student.
This is the thinnest of the eight reviews in the public record, and the case is the only one of the eight in which the conviction itself has been tested again on fresh evidence. The Criminal Cases Review Commission referred the convictions back to the Court of Appeal in a decision dated February 12, 2021, on fresh expert evidence about how rare severe hypoglycemia is in frail hospital patients. The court heard that evidence, and on June 26, 2025, three judges dismissed the appeals; they said they had no doubt that each of the five convictions was safe. On September 23, 2025, certification of a point of law for the Supreme Court was refused. In 2025 the Court of Appeal’s judgment named him Colin Campbell, formerly Colin Norris.
Laid side by side, the eight documents ask the same few questions. Who had the information, and who was told? Which record sat unprocessed, whether a card index at Millgarth, a blood sample in a Toronto laboratory, a laptop in Barking? The answers are usually structural. Byford wrote of an incident room that could not cope; Campbell, of the lack of a case management system; Smith, of death certification; Clothier, of a hospital slow to act; Oppal and Epstein, of police forces that did not look hard enough for missing people.
What moved is also fairly consistent. Rules that could be written down moved: a regulation in Ontario, a reform in Wales, new missing-persons procedures in Vancouver. Reforms that depended on structure or on attitude moved slowly or not at all: the regional police force that Oppal proposed, the language that Byford left untouched until a chief constable apologized for it in 2020. And in three of the cases, Allitt, Pickton and Port, the later record is the record of a second inquiry reading the first. Campbell wrote that "we seem to be incapable of learning from previous experiences." Twenty-eight years later, the Thirlwall Inquiry set about measuring exactly that.
• January 19, 1982: The government gives the House of Lords the conclusions of the Byford review.
• November 1990: Toronto police interview Paul Bernardo and take a blood sample.
• 1991: Allitt case: a laboratory result reaches the ward on April 12; police are called on April 30.
• Early 1993: The forensic laboratory matches Bernardo’s sample to the Scarborough assaults.
• May 28, 1993: Beverley Allitt receives 13 life sentences.
• February 11, 1994: Virginia Bottomley reports the Clothier inquiry findings to the Commons.
• September 1, 1995: Bernardo is convicted of two first-degree murders.
• 1996: Justice Campbell’s Bernardo Investigation Review is released.
• January 31, 2000: Harold Shipman is convicted of 15 murders and forgery.
• January 27, 2005: The Shipman Inquiry’s final report.
• June 1, 2006: The Byford Report is released by the Home Office.
• December 9, 2007: Robert Pickton is convicted of six counts of second-degree murder.
• March 3, 2008: Colin Norris is convicted of four murders and one attempted murder.
• August 2010: LePard’s review of the Vancouver police is released.
• November 19, 2012: Wally Oppal’s report, Forsaken, is dated; it is released on December 17.
• November 23, 2016: Stephen Port is convicted of four murders.
• February 8, 2019: Bruce McArthur is sentenced to life with no parole eligibility for 25 years.
• April 9, 2021: Gloria Epstein’s Missing and Missed is transmitted to the Toronto Police Services Board.
• December 10, 2021: The Port inquest jury concludes that police failings probably contributed to three of the deaths.
• May 17, 2024: The Thirlwall Inquiry announces a review of implementation of recommendations from earlier inquiries.
• September 9, 2024: Wales brings the death certification and medical examiner reforms into force.
• June 26, 2025: The Court of Appeal dismisses the Norris appeals.