Police also failed to check Shipman's criminal record or his General Medical Council (GMC) history.
Gradually, Shipman's bearing revealed that he saw himself as the principal victim in the case.
She said Shipman had caused "unimaginable distress and grief" and suggested he was addicted to murder.
One immediate question is why Shipman was not on suicide watch at Wakefield Prison.
The inquiry comes as Greater Manchester Police faces questions about why it failed to arrest Shipman earlier.
She previously led the Shipman Inquiry, which examined the activities of serial killer GP Dr Harold Shipman.
Another 71 patients were killed during when Shipman moved to the Donneybrook House group practice in Hyde.
When Virginia Kraft Payson and her late husband Charles Shipman Payson first arrived at the St.
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It is a case that will live in the public's memory long after the death of Harold Shipman.
Dame Janet previously led the Shipman Inquiry, which examined the activities of serial killer GP Dr Harold Shipman.
Shipman, former principle with State Street Global Advisors, perhaps the largest private pension investment management firm in the world.
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Dr Shipman was accused of "browbeating" and "bludgeoning" relatives of his alleged victims to persuade them against demanding post-mortems.
The inquiry chairman is Sir Thayne Forbes, who was the High Court judge in the Harold Shipman murder trial.
The remaining 143 were murdered after 1992 when Shipman became a solo GP, working on Market Street in Hyde.
These include the cases of the surgeon Rodney Ledward, the seriel killer Harold Shipman and the Bristol babies scandal.
Shipman was Britain's most prolific serial killer, having murdered 215 of his patients.
But detectives, tipped off by the coroner, did not notice Shipman had altered some of his victims' medical records retrospectively.
During the film, he boasted of being asked to defend killers including Shipman, Jeremy Bamber, Kenneth Noye and Linda Calvey.
Caroline Swift QC, counsel to the inquiry, had earlier said Shipman, manipulated systems in order to commit murder without detection.
"They're coming in buying shovels, ice melts and sleds, " said Atton Shipman, who works at Back Bay Hardware in Boston.
It was from Texas that Capt Nowak began her long drive to Florida to confront her rival, Capt Colleen Shipman.
Compared to them, Shipman seemed pathetic, a small, colourless man, with grey close-cropped hair and beard, and an unhealthy prison pallor.
According to the 2, 000-page report, Shipman's first victim was Eva Lyons, killed the day before her 71st birthday in March 1975.
The GMC has been under the spotlight over a number of scandals, including serial killer Harold Shipman and disgraced gynaecologist Rodney Ledward.
Until well into the trial, many of his patients were convinced Shipman was innocent, and sure the police had got it wrong.
Mr Scott told MPs he was concerned about issues raised by the Shipman case and had written to health secretary Alan Milburn.
The Shipman Inquiry has previously recommended measures including the establishment of a drugs inspectorate to prevent doctors stockpiling drugs as Shipman did.
This included "the involvement of doctors in state sponsored killings, personified by Josef Mengele, and the devastating private enterprise of Harold Shipman".
Mr Milburn also agreed to consider setting up a helpline for people worried their relatives or friends may have been victims of Shipman.
Several times Shipman upbraided his own counsel for her convoluted language, insisting she rephrase the question, though he had clearly understood it all along.
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