Sir Cecil Clothier is due to report his inquiry's findings early in the new year, but one key failure to have emerged from evidence was the lack of a proper reporting system at the hospital where Allitt murdered or injured 13 children.
The Secretary of State for Health is awaiting recommendations but is determined to ensure that hospitals have a proper medical audit to sound an early alarm and prevent such a case recurring.
Allitt murdered four children and injured nine others while working as a nurse at Grantham and Kesteven Hospital, in Trent region.
The killings on Ward Four began when a baby with a heavy cold died after an inexplicable cardiac arrest. Seven other children suffered 14 cardiac or respiratory arrests within the next six weeks. However, in spite of speculation within the hospital, the cause of the sudden outbreak was not identified until too late. Allitt, later given a record 13 life sentences, was suffering from a severe personality disorder, Munchausen's syndrome by proxy, which drove her to harm others. There was no system of overall review or medical audit.
Mrs Bottomley has told colleagues it would be wrong to imply other nurses were likely to carry out such crimes. However, she is keen to ensure there is no chance of repetition, and will warn hospitals of the need to establish an effective system of reporting.
She sees parallels with the need for proper reporting of child abuse cases which emerged from the Cleveland inquiry.
'It is almost a taboo issue but we do need to ensure that those in the health service know what mechanisms there are for reporting suspicious circumstances, in the same way that the chief medical officer has been ensuring doctors know how to report concerns they may have about mispractice,' Mrs Bottomley told colleagues.
Parents of the victims and the Royal College of Nursing fought unsuccessfully through the courts to have a public inquiry into the Allitt case. They protested that the Clothier inquiry could become a cover-up. However, Mrs Bottomley is adamant that her decision to hold the inquiry in private will be vindicated by the report, which she expects to be hard-hitting and which will be published.
She said no key witness had refused to give evidence, despite criticism that Sir Cecil lacked the powers of a public tribunal.
The report is likely to focus attention on the medical profession, as the complaints procedure for doctors is also being reviewed. Mrs Bottomley intends to tell them they must be prepared to face more open scrutiny from the public. Social workers, who face a shake-up over training, are another target.Reuse content