Hospital managers under fire after patient deaths inquiry

Dark practices on night shift at death hospital

A highly critical independent inquiry has concluded senior nurse Anne Grigg-Booth, who was charged with murdering three patients at Airedale Hospital, near Keighley, did not set out to harm patients.

But it said a combination of individual and procedural failings were to blame for a culture which enabled some night shift staff to work in a "vacuum" without effective supervision.

The inquiry uncovered evidence dating back to 1996 that other night nurse practitioners were breaking hospital rules by giving the painkillers to patients, while Mrs Grigg-Booth behaved unlawfully by prescribing them herself instead of getting permission from doctors.

It was "almost by chance" their actions were uncovered in a routine audit of deaths. The 52-year-old nurse died from an accidental drugs overdose before facing a court accused of killing three patients, attempting to murder another and 13 counts of administering noxious substances from 2000-2002.

The nurse was charged with murdering June Driver, 67, in July 2000; Eva Blackburn, 75, in November 2001, and 96-year-old Annie Midgley in July 2002. After her death in 2005, detectives said they believed she could have killed many more patients.

The inquiry said she did not act in the same way as Grantham nurse Beverly Allitt or Colin Norris, who murdered four patients in Leeds in 2002, and it was unlikely she set out to hurt patients but her behaviour put patients at risk and could have been stopped earlier.

Eddie Kinsella, an inquiry team member, said Anne Grigg-Booth acted unprofessionally, outside her capabilities and sometimes unlawfully.

But he added: "She should not be demonised. She and other senior night nurse practitioners reasonably believed they were acting with the authority of the board as a whole.

"Had that been picked up. as it should have been, it's reasonable to assume a criminal inquiry would not need to have taken place. Some patients were put at risk. Systems and policies themselves weren't adequate.

"Unfortunately at night there was a disconnect between what the board thought was happening and reality."

Karen Hanson, who received two "illegal and dangerous" infusions of morphine by Anne Grigg-Booth in 2000 only two months after giving birth, yesterday said she felt "lucky to be alive".

"I think it is shocking that the first time an apology is given to me is only after an independent investigation has ruled out any scope for them to avoid responsibility," she said.

Bridget Fletcher, chief nurse at Airedale NHS Foundation Trust, said a new executive team had taken over in 2005 and had "completely changed the way we run the hospital".

Night nurse practitioners were no longer in post and instead a team of doctors and nurses worked in shifts through the day to treat the sickest patients.

In a joint statement, West Yorkshire Police and the Crown Prosecution Services said: "We are aware of the findings of the inquiry, which was not a criminal inquiry, held into the Airedale General Hospital.

"We are satisfied that the West Yorkshire Police investigation was thorough and the decision by the CPS to prosecute was the correct one."

NURSE 'EFFECTIVELY LEFT IN CHARGE' OF HOSPITAL AT NIGHT

The inquiry into the activities of night nurse practitioner Anne Grigg-Booth found that she was effectively in charge of Airedale Hospital at night.

She acted unlawfully "from time to time" in prescribing opiate painkillers, which can only be done by doctors, but recorded what she was doing in medical notes.

Although some staff found her intimidating and a bully, "medical and nursing colleagues recognised that she was a hard working, experienced and caring nurse who could be relied on in a crisis".

The inquiry report found that hospital bosses failed to recognise the nurse was "part, if not a symbol, of a system that was not working".

Managers had believed they were dealing with a "rogue nurse" and that "all else was well".

The organisation appeared to be very successful but the board was unaware of what was happening at the hospital at night.

It did not know nurses had been administering intravenous opiates since at least the mid-1990s against hospital policy and that the nurses "all reasonably believed that they were permitted to do so".

The inquiry found some managers "knew or should have known what was

going on. They did nothing about it".