The two consultants in charge of 13 children attacked at Grantham and Kesteven district hospital, Lincolnshire, failed to grasp that the 'cascade of collapses' in the medical conditions of patients was due to a 'malevolent cause', concluded the inquiry, chaired by Sir Cecil Clothier QC.
The Grantham coroner, Thomas Pert, refused requests by a consultant for a specialised post-mortem examination on Allitt's first victim, Liam Taylor, aged seven weeks. He thwarted an line of inquiry that 'could have brought to a halt the whole train of events', the report said. Other post-mortem examinations overlooked vital murder clues.
The nursing manager, Moira Onions, and other middle management are criticised for 'dilatory and ineffective action' when suspicions of murder were aroused. When firm evidence was produced that one child had been injected with a massively poisonous dose of insulin, doctors in Grantham and at the Queen's Medical Centre, Nottingham, responded with 'ineptitude'. Another 18 days elapsed before the police were called, during which Allitt killed a baby girl and assaulted three other Ward 4 patients.
Allitt, 25, is at Rampton special hospital after being given 13 life sentences in May for 26 attacks, including four murders, during 58 days in 1991. The report, published on the third anniversary of her employment, said severly inadequate medical and nursing staff levels meant she was left with 'quite inappropriate' responsibilities.
Virginia Bottomley, Secretary of State for Health, said the Government would take 'immediate action' on 12 recommendations. They include better staffing, closer monitoring of nurses for signs of illness or disorder, and powers for hospitals to conduct specialised post- mortem examinations of children.
Mrs Bottomley said the Allitt case was complex, but the Clothier inquiry had been fair-minded and balanced; health service management had been asked to report on staffing levels by 1 May.
'Ultimately, responsibility rests with Allitt herself,' Mrs Bottomley said. 'From the outset, we must all acknowledge - as the report does - that the tragic events in Grantham were the product of a malevolent, deranged, criminal mind.
'Everything else must be seen in that light. The Clothier report does identify and criticise failures of management and communication in the hospital and it is important that lessons are learnt from these throughout the National Health Service. . . . However, it refutes any suggestion that Allitt could easily have been detected or stopped.'
The number of qualified nurses for sick children at Grantham had doubled, and four consultant paediatricians had been appointed. The Independent has learnt each consultant will work one day a week.
The consultants in charge of Ward 4 during Allitt's employment have lost their jobs. Charith Nanayakkara and Nelson Porter yesterday claimed the report reached unfair conclusions. Dr Porter said: 'We were working in such circumstances that the clinical demands of caring for our patients consumed our qualities of leadership, energy and drive. These demands were compounded by the lack of staffing and resources.'
Dr Nanayakkara said he had been pressing since his appointment for the recruitment of more ward medical and nursing staff. He had done his best to introduce a regular system of audit to raise standards of care and motivate staff.
Parents of victims, dismayed by Mrs Bottomley's decision to hold the inquiry in private, described the report as 'an exercise in concealment'. They have asked the European Court of Human Rights to tell Whitehall to hold a public one.
Judith Gibson, whose five-year-old son Bradley was attacked, said: 'It's like shutting the gate after the horse has bolted. It is just unbelievable they did not know what kind of person she was.'
Report 'cover up', page 3Reuse content