The suicide of British serial killer Harold Shipman could not have been prevented, a report released today concluded.
Family doctor Shipman, who authorities say murdered more than 250 patients, was found hanging from the window of his cell in Wakefield Prison the day before his 58th birthday last January, apparently having used his bed sheets as a ligature.
Prisons and Probation Ombudsman Stephen Shaw said although there were procedural issues over his suicide that needed addressing, the death was unavoidable.
Shipman, a physician from Hyde near Manchester, was jailed in 2000 after being found guilty of killing 15 patients.
A subsequent independent inquiry ruled Shipman had started his killing spree as a junior hospital doctor in the 1970s. It estimated he had killed at least 250 victims and was probably responsible for many more including that of a four-year-old girl.
He never admitted his guilt, expressed remorse or explained his motives.
He was moved to Wakefield Prison in northern England in June 2003 but, although he was considered a long-term suicide risk, he was not thought likely to take his own life as a result of the move and was not subject to any special measures.
The report made a number of criticisms including the decision to reduce Shipman's prison privileges because he refused to take part in offending behaviour courses.
It also said it was "extremely regrettable" that Shipman's wife Primrose learnt of the death from a family member who had heard about it on the radio before the police spoke to her.
But Mr Shaw dismissed allegations made by other inmates that Shipman had been abused by prison officers.
In April, an inquest at Leeds Crown Court ruled he had killed himself because he could not face life in prison and because if he lived beyond 60 his pension lump sum due to his wife would be reduced.