Protecting patients

If medical staff recorded that the first three of Norris's victims were hypo-glycaemic, as they should have done when filling out the necessary death certificates, suspicions about his behaviour might have come to light much sooner.

Instead, the correct procedures were not followed and the wards concerned suffered from an absence of leadership, according to the inquiry conducted by Professor Pat Cantrill of Sheffield Hallam University.

These are familiar failings. They also apply, equally, to those social services departments that have let down so many at-risk children.

As well as making two national recommendations over the vetting of job references for nurses, and the accuracy of death certificates, most of Professor Cantrill's guidelines centre on the Leeds hospitals.

However, the issue is the capability of Leeds Teaching Hospitals NHS Trust to deliver vital changes which are intended to protect the interests of patients in its care. Having previously promised to reform its procedures, it is perturbing that these measures were not introduced – with many junior doctors, according to the inquiry team, evidently confused about their responsibilities.

Another inspection will be essential in 12 months time to ensure that the trust's response is far more effective this time, and that warning signs are not missed in future.