Colin Norris: The failings that allowed killer nurse to murder four patients

Staff nurse Norris gave the elderly women fatal doses of the diabetes drug insulin while they were being treated at two Leeds hospitals.

According to an NHS Yorkshire and the Humber independent inquiry report, problems including relatives' concerns going unheeded, staff knowledge of clinical governance policies and systems, record-keeping and medicines management, all contributed to the opportunities Norris had to get hold of drugs and murder patients.

In 2008, a judge at Newcastle Crown Court handed Norris four life sentences for murdering Doris Ludlum, 80, Bridget Bourke, 88, Irene Crookes, 79, and Ethel Hall, 86, while he worked at the Leeds General Infirmary (LGI) and the city's St James's Hospital in 2002.

A 20-year minimum sentence, to run concurrently, was imposed for the attempted murder of 90-year-old Vera Wilby, who survived a coma induced by an insulin injection.

Today's report stated: "Colin Norris was a trained nurse who had access to drug cupboard keys and the means to administer lethal injections to elderly and vulnerable patients.

"There is evidence to suggest that the systems in place at the trust to monitor the supply and administration of drugs at the time of the incidents were not robust enough to identify and prevent malpractice."

It went on to say that actions taken by the consultant and medical director following the collapse of Ethel Hall in November 2002 were "prompt and effective", but if the earlier unexplained deaths of the other women had been reviewed and death certificates accurately completed, Norris's actions might have been spotted earlier.

In addition, problems with references when he was first employed and the merger of the United Leeds Teaching Hospitals Trust and St James' University Hospitals NHS Trust meant staff did not have a clear understanding of new systems.

Dr Peter Belfield, medical director of Leeds Teaching Hospitals, said the eight-year period between Norris's crimes and the publication of the inquiry report was due to extraneous factors, and work was being done to improve on issues raised in the report. He said: "The actual report itself was delayed because of the trial of Colin Norris, the investigation, and Colin Norris's subsequent appeal.

"The work that we've done in the trust to make improvements started in 2003, immediately after these sad events.

"A determined killer like Colin Norris would be difficult to spot in any NHS organisation but I believe the systems we now have in place would make it much more likely to pick up on someone like this."

Problems with references when Norris was first employed and the merger of the United Leeds Teaching Hospitals Trust and St James' University Hospitals NHS Trust meant staff did not have a clear understanding of new systems.

Nine key issues were identified by the Independent Inquiry Team. These were:

Listening to and supporting relatives: the independent inquiry team found that there were issues around relatives' complaints and concerns (both written and verbal) not being responded to at the time of the incidents;

Clinical governance: staff knowledge and understanding of clinical governance policies, structures, systems and processes, was lacking. No clear line of accountability;

Clinical records: Problems surrounded the lack of recorded timings, signatures and legible notes in the medical records;

Training and human resources issues: As a student, Norris had poor attendance at clinical placements and his behaviour and communication with some lecturers was unacceptable. His training in clinical placements (caring for elderly people) was sub-standard and had to be extended;

Professional standard of nursing and nursing management: Progress made in pressures on ward leaders and other senior nurses, and variation in clinical supervision and the extent of multidisciplinary team working;

Professional standards of doctors: Outstanding issues surrounding confirmation and certification of death, communication with relatives, escalating concerns to senior colleagues and reporting to the coroner's office;

Supporting staff: Insufficient support provided to staff during and following the criminal investigation and trial of Norris;

Security: Progress made in installing a modern, fit-for-purpose security system;

Medicines management: Systems, procedures, policies and practices regarding medicines management lacking, but improvements are in progress.

The report concludes that "organisational, systems and cultural factors" all provided an opportunity for Norris to harm patients, but added: "The responsibility for the intentional harming and subsequent death of patients rests with Colin Norris.

"It is difficult for an organisation to design and implement systems and processes that will totally eradicate the risks posed by an individual with that intent."

Dr Belfield said Norris was a "clever person" who managed to mask the fact that he disliked working with elderly patients, and the trust had taken action to work on the recommendations put forward by the report.

He added: "This is a highly unusual case. I have been medical director for a short while but I would hope in my working career not to come across another such individual.

"We employ 13,500 staff. This was one nurse who was a criminal.

"The message is twofold - I, on behalf of the trust, express really sincere condolences to all the families who have had an extraordinarily difficult time, that has lasted a long time, and I hope this report helps in that process.

"Secondly, to our current patients, to assure them that to the best of our abilities, services in Leeds are as safe as they can be at this point in time."