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Leeds killer nurse: Systems failings revealed UPDATED
A shocking catalogue of systems failings which let nurse Colin Norris murder four elderly patients over six months is revealed by an independent probe into Leeds NHS Trust.
The faults were identified in an Independent Inquiry by the Yorkshire and Humber Strategic Health Authority.
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Officials at Leeds Hospitals NHS Trust claim many recommendations of an "action plan" to avoid a repeat agreed in the wake of the murders are already in place.
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But many of the recommendations were only put in place last year – seven years after Norris poisoned five women – killing four – with insulin.
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Today Stuart Hall, a relative whose mother Ethel, 86, died in December 2002 after suffering brain damage from insulin given to her at Leeds Infirmary, gave a reserved welcome to the plan.
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He said: "It has been a long time coming and it covers an awful lot of items nationally as well as in Leeds.
"There are a lot of recommendations, but it is a matter of it being translated into action and reality on the wards. I recognise there is a risk with everything."
He welcome news that matters of "patient dissatisfaction" could now be recorded and registered buy patients and relatives via the internet.
The independent inquiry by the strategic health authority covering the period July 2001 to December 2008, followed an earlier internal Leeds Hospitals NHS Trust investigation into the two "Serious Untoward Incident"(SUI) involving Norris. One was his five insulin 2002 patient poisonings - four at Leeds Infirmary and one at St James's Hospital.
The second was Norris helping cover up a major theft by another nurse of the pain killing drug Pethidine soon after starting work at Leeds Infirmary in July 2001.
Failings identified in the earlier Leeds Hospitals Trust internal inquiry and the new strategic health authority independent inquiry include :
* Supply and administration of drugs;
* Lack of monitoring unexplained unexpected deaths;
* Lack of monitoring of hypoglycaemia among not diabetics;
* Inaccurate death certificates;
* The Trust taking two years to investigate and four years and four years to plan changes;
* Failures to listen to relatives' concerns;
* Problems over clinical management and responsibilities.
After the new report was revealed, Dr Peter Belfield who became the Trust's Medical Director of Leeds Hospitals only in November, said: "Systems are now in place to pick up on such situations which mean that patients are safer in 2010 than they were previously. But we can always improve."
He said much work had been done since 2002.
"I know the plan we have produced addresses the commendations in the Independent Inquiry Reporter."
"At the time the hospital staff were not expecting to work with a killer and Norris was a determined killer," said Dr Belfield.
"The Trust had picked up on the hypoglycaemia. New reviews of patients had been introduced in the last five years.
"We have more robust systems than we had in 2002 and the qualify of care is as safe as it can be."
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