To those who worked alongside her, nursing sister Anne Grigg-Booth cut an imposing figure. Tall with cropped hair, the 52-year-old nurse rode a motorbike and wore leathers when off duty from Airedale General Hospital in Keighley, West Yorkshire, where she considered herself an "old-style matron" left to run the hospital night shift alone.
Those who fell short of her imperious standards and punishing work ethic found themselves the subject of criticism and considered her a bully. Her admirers, by contrast, regarded her as a highly competent nurse who, while on holiday in Northern Ireland, had been one of the first to help victims at the scene at the Omagh bombing.
When she was found dead at her home in Nelson, Lancashire, following an accidental overdose in August 2005, the former sister was due to face trial on three counts of murder, one of attempted murder and 13 of administering noxious substances to patients. At the time police said she may have killed many more in her 25-year career.
But yesterday, a long-awaited independent inquiry found that far from being a "rogue nurse", Ms Grigg-Booth was the "symbol" of widespread systemic failure at the top-rated West Yorkshire hospital. The report, by NHS Yorkshire and the Humber, revealed a catalogue of systemic failures in the way Ms Grigg-Booth was allowed to carry out her work as a night nurse practitioner at Airedale NHS Trust.
It rejected the idea that she had "deliberately set out to harm patients" by injecting them with powerful painkillers or that she could be compared to Beverley Allitt, the nurse who murdered children in her care.
But the report concluded that Ms Grigg-Booth acted illegally by prescribing morphine herself between 2000 and 2002 and was "utterly convinced of her own clinical prowess". It added: "We have no doubt that on occasions she went well beyond the boundaries of acceptable nursing practice at that time and beyond the boundaries of her own clinical understanding."
That the senior nurse was a difficult character was well-known throughout the hospital. She treated management structures with contempt, the report found, deliberately flouting hospital rules including bringing in a parrot to cheer up patients.
But this was overlooked. "She was not subject to effective supervision, either from a managerial perspective or a professional perspective," the report added. And while the Trust "appeared" to be very successful, enjoying the highest three-star rating, there were problems over the supervision of the night shift where nurses had been administering opiates. The report said: "The most striking failure was in the disconnection between what was happening on the wards at night and what the board knew. The board had no idea."
Even after the police investigation began, the report said: "The Trust board's understanding and approach was that here was a rogue nurse and that all else was well. That this was untrue should have been known about at board level long before December 2002 and at every stage thereafter."
However, it added management at the Trust had improved since 2005.
The nurse was accused of murdering June Driver, 67, in July 2000, who was being treated for an infection after a hip replacement; Eva Blackburn, 75, in November 2001 and 96-year-old Annie Midgley in July 2002, after she was admitted with abdominal pain.
She was also facing 13 counts of unlawfully administering poison to 12 other patients and another of attempting to murder Michael Parker, 42, in June 2002. Police said she always denied the charges.
An inquest in 2006 heard that Ms Grigg-Booth died when she accidentally overdosed on anti-depressant drugs after suffering from problems with alcohol.
Bridget Fletcher, chief nurse at Airedale NHS Foundation Trust, offered condolences to those affected. She added: "The trust has made significant improvements, particularly since 2005, and we would like to reassure both patients and the local community that patient safety is, and always will be, our highest priority."