A report by the inquiry, set up by the West Pennine Health Authority after a psychiatric patient was convicted of the manslaughter of a pensioner, recommended 47 improvements to be made by the Oldham NHS Trust.
Mental health groups welcomed the report, which also investigated the suicides of three patients and the death of another at the Royal Oldham Hospital unit within two years.
But the charity Sane criticised the inquiry panel for not going far enough and identifying the patients and staff involved. Sane chief executive Marjorie Wallace accused the health authority of a "cover-up" and added that without detailed recommendations the report would be a "waste of time".
"The value of the inquiry is defeated by the failure to disclose the detailed circumstances which led to these five tragedies," she said.
The inquiry was triggered by the death of 79-year-old Harry Johnstone, bludgeoned to death by Paul Medley, 36, who walked out of the unit in September 1994. In the following 20 months, two in-patients and one patient in the community committed suicide and a further unit resident was found dead.
The inquiry found inadequate operating procedures, poor staff training and support and little or no risk assessment of patients. The report also condemned the trust's own investigations into the deaths, saying they were "poorly done" and the patients' families had not been sufficiently involved.
However, the team concluded that no individual member of staff could be blamed for the five unrelated deaths.
Oldham NHS Trust chief executive Gloria Oates said the authority accepted the inquiry's conclusions "without reservation", but added that much had already been done to improve services. A plan was in place to implement the recommendations and a pounds 6m purpose-built 66-bed unit on the Oldham hospital site was due to replace the accommodation described as "unsuitable" by spring 1998.
"We accept there were problems and we have been working since the inquiry was set up to put new procedures in place," she said. More than 300 staff had been extensively retrained and the trust was "comforted" that no individual had been found negligent by the report. Staff had been "deeply shocked and saddened by the deaths of patients in their care", she said.
The mental health charity Mind, which has pressed for the inquiry, welcomed the report, in particular recommendations for improved assessment of patients before they were discharged. "We hope the inquiry will have the effect of continuing the trust's new-found interest and increased prioritisation of mental health services in Oldham," Martin Kirkbride, spokesman for the charity, said.Reuse content