The inquiry, held in private, produced a 122-page summary of evidence it heard, and made 12 recommendations which the Department of Health and Home Office said yesterday would be acted upon.
'The principal failure of those concerned lay in not collecting together pieces of evidence,' the report, chaired by Sir Cecil Clothier QC, a former health service ombudsman, said.
'Civilised society has very little defence against the aimless malice of a deranged mind.' Sir Cecil said the report sought no scapegoats - 'those whom we have criticised were subjected by chance to a test more severe than any which most of us encounter in a lifetime'.
There were nine shortcomings in Allitt's career as student and nurse at Grantham and Kesteven District Hospital, Lincolnshire.
She was hired without full consultation of her alarming medical history. She worked on an understaffed ward hamstrung by 'dilatory and ineffective action by management', including Moira Onions, the nursing manager.
The two consultant paediatricians, Charith Nanayakkara and Nelson Porter, although overworked, should have begun vigorous investigation of patient attacks earlier, the report said.
Doctors at the Queen's Medical Centre in Nottingham, to whom seven Allitt victims were referred, also failed to realise promptly that a 'malevolent cause' might be responsible.
The Grantham coroner, Thomas Pert, refused a specialist autopsy of Allitt's first victim. A specialised pathologist might have discovered that the baby had been killed; two other mistaken causes of death were recorded after post-mortem examinations.
Laboratory tests and chest X-rays could also have alerted doctors in Grantham and Nottingham to the possibility of malice. The clues were either missed, or the response indecisive.
Report recommendations include closer observation of Whitehall guidelines on staffing levels in NHS hospitals.
Nurses should not be employed without reference to the total time they have taken off because of sickness. 'No candidate for nursing in whom there is evidence of major personality disorder should be employed in the profession. Coroners should send copies of post-mortem reports to any consultant involved in the patient's care prior to death,' the report said.
Specialised paediatric autopsies should be carried out in every case of unexpected or clinically unaccountable death. Hospitals should be able to order a specialist post-mortem examination without the coroner's permission.
Family doctors could be asked to certify there was nothing in the medical history of a prospective nurse which would make him or her unsuitable. Occupational health departments could provide more effective screening of nurses and student nurses so that any alarming incidents in their health can be reported to hospital managers. A single channel for reporting 'serious untoward incidents' should be established by health authorities.Reuse content