A report into a nurse who was charged with murdering three patients concluded today she was "not a Beverley Allitt" and suggested a "combination of individual and systems failure" were to blame.
The independent inquiry revealed a catalogue of systemic failures in the way Anne Grigg-Booth was allowed to carry out her work as a night nurse practitioner at Airedale NHS Trust.
The damning report said Grigg-Booth was "utterly convinced of her own clinical prowess" and at night "she was effectively in charge of the hospital".
Grigg-Booth, from Nelson, Lancashire, died before she could go on trial at Bradford Crown Court. She was 52.
The charges related to her injecting patients with high doses of painkilling drugs such as morphine and diamorphine on the night shift at Airedale General Hospital near Keighley, West Yorkshire, where she worked.
After her death, detectives from West Yorkshire Police said they believed she could have killed many more patients in her 25-year career.
But today, an independent inquiry report concluded that it was unlikely that Grigg-Booth "deliberately set out to harm patients" and said the events investigated "occurred as a result of a combination of individual and systems failure".
The report concluded that the board was wrong to think they were just dealing with a "rogue nurse" instead of systemic failure.
"The most striking failure was in the disconnection between what was happening on the wards at night, and what the board knew," the report concluded.
As well as the murder charges, Grigg-Booth faced 13 counts of unlawfully administering poison to 12 other patients and another of attempting to murder a 42-year-old man.
As a night nurse practitioner (NNP), Grigg-Booth was one of the most senior nurses at the hospital and she was often in charge at night.
Detectives charged Grigg-Booth in September 2004 and she was due to go on trial in April 2006.
Police were alerted after a routine audit at the hospital picked up irregularities.
The nurse was charged with murdering June Driver, 67, in July 2000; Eva Blackburn, 75, in November 2001; and 96-year-old Annie Midgley in July 2002.
She was also accused of trying to kill 42-year-old Michael Parker in June 2002.
Police said she never gave them any clue about what her motivation was and always denied the charges.
An inquest in 2006 heard that Grigg-Booth died when she accidentally overdosed on anti-depressant drugs after suffering from problems with alcohol.
Today, Bridget Fletcher, chief nurse at Airedale NHS Foundation Trust, said: "We would like to offer our sincere condolences to all those affected by these events.
"We hope that this final stage of the process has now fully explained the details concerning each patient, as well as the actions of Sister Grigg-Booth, other staff and the Trust at the time of the events, eight years ago.
"We are sorry for any additional distress that was caused at what was already an anxious time for relatives, having lost a family member, due to any delays in the investigation or inquiry process.
"As outlined in the report, the Trust has made significant improvements, particularly since 2005, thanks to the enormous efforts by the Trust board and staff at every level and we would like to reassure both patients and the local community that patient safety is, and always will be, our highest priority."
Eddie Kinsella, an independent inquiry team report member, said Grigg-Booth should not be "demonised" following the publication of today's report.
"She and other senior night nurse practitioners reasonably believed they were acting with the authority of the board as a whole. The board did not understand that," he said.
NNPs were used to reduce the workload of junior doctors.
The four NNPs the inquiry looked at all administered intravenous opiates.
"This was against official hospital policy. They did so for years. The board was unaware that this was going on. Senior managers knew or should have known it was going on. They did nothing about it," the report said.
The report said Grigg-Booth was "entirely open" in her actions and recorded what she was doing in clinical records, prescription charts and notes.
Beverly Allitt, who is serving 13 life sentences for attacking and murdering children in the hospital where she was a nurse, must serve a minimum of 30 years in custody, a High Court judge ruled.Reuse content