A series of failings at Leeds Teaching Hospitals Trust in West Yorkshire allowed former nurse Colin Norris to kill four elderly patients, an independent inquiry has found.
The report from Yorkshire and the Humber strategic health authority found that a combination of “organisational, systems and cultural factors” provided an opportunity for Colin Norris to use lethal amounts of insulin to kill four patients at the trust in 2002.
Norris was convicted of the murders of four female patients and the attempted murder of a fifth elderly woman in March 2008.
The independent report, commissioned by NHS Yorks and the Humber in August 2008, identified poor quality record keeping and medicines management practices as being at fault.
It said that systems in place at the trust to monitor the supply and administration of drugs were not “robust enough to identify and prevent malpractice”.
The report also identified issues associated with poor nursing practice, such as staff shortages, poor communication with patients and little opportunity for ward sisters to develop management skills.
Recommendations from the report include a review of trust policy on safeguarding adults and the trust has now employed a nurse consultant to lead on safeguarding patients.
In May 2007 a new nursing and midwifery strategy was introduced providing a detailed action plan on the trust’s vision for nursing and midwifery up to 2012.
NHS Yorkshire and the Humber chief nurse Professor Sue Proctor said: “The Strategic Health Authority welcomes the findings of this inquiry as it will further strengthen systems and processes to protect patients in Leeds and across the region.
“We will act on recommendations swiftly and ensure that the lessons learned are shared across the wider NHS.”