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Inquiry into serial killer criticises hospital's response

BMJ 1994; 308 doi: https://doi.org/10.1136/bmj.308.6927.491 (Published 19 February 1994) Cite this as: BMJ 1994;308:491
  1. C Dyer

    Vital clues that could have pointed to nurse Beverly Allitt being a serial killer were missed during the 58 days she worked on the children's ward at Grantham and Kesteven Hospital in Lincolnshire, according to the report of the independent inquiry into the tragedy. The inquiry, chaired by Sir Cecil Clothier, criticises the hospital's two consultant paediatricians, the ward sister, the clinical services manager, and other middle managers. It paints a picture of a hospital “on the edge of viability,” operating on a shoestring budget. Sir Cecil, however, dismissed staff shortages as “a tangential issue.”

    * Clothier said that steps taken after children's deaths were feeble

    (Fig Omitted)

    Allitt, aged 35, is in Rampton Special Hospital after being given 13 life sentences last May for murdering four children and attacking nine others while working as an enrolled nurse on ward 4 between February and April 1991.

    The report criticises the hospital's “sloppy” appointments procedures in recruiting Allitt but doubts that she would have been detected as unsuitable at that stage even if everything had been done correctly. “The main lesson is that the Grantham disaster should serve to heighten awareness in all those caring for children of the possibility of malevolent intervention as a cause of unexplained clinical events.”

    The health secretary, Virginia Bottomley, promised government action on the inquiry's 12 recommendations, which are aimed at preventing repeats of such tragedies. These are mainly designed to screen out unsuitable candidates from nursing posts and improve procedures for postmortem examinations on children and reporting of untoward incidents.

    The inquiry team was “struck by the way in which fragments of medical evidence which, if assembled, would have pointed to Allitt as the malevolent cause of the unexpected collapses of children lay neglected or were missed altogether.” Taken together, “they would have amounted to an unmistakeable portrait of malevolence. The principal failure of those concerned lay in not collecting together those pieces of evidence.”

    The two consultants, Dr Nelson Porter and Dr Charith Nanayakkara, are criticised for “failure to grasp sooner than they did the significance of the cascade of collapses with which they had to deal.” There were no doctors in the middle grades, and the two consultants and two senior house officers worked a one in two rota, but the inquiry could “only speculate as to whether the two consultants would have reacted more quickly and effectively to the series of collapses had they had more time to reflect.”

    Efforts by Dr Nanayakkara to have a paediatric pathologist carry out a postmortem examination on Allitt's first victim, Liam Taylor, were thwarted by the corner's officer and the locum pathologist, Dr Terry Marshall. Had this been done “the whole train of events might have been brought to a halt,” the report says.

    The first clear evidence of foul play came on 12 April, when Dr Porter was given the results of a blood test on one victim, Paul Crampton, showing a large quantity of exogenous insulin. The steps taken after that were “feeble and indecisive while Allitt continued on her deadly course.” The police were not called in until 30 April, more than a week after the last victim died.

    The report concedes that in the only two other known cases of serial killings by nurses, in the US and Canada, the crimes took even longer to be detected. The British Paediatric Association, in its evidence to the inquiry, said: “It is probable that many paediatricians would have had similar difficulty in recognising the criminal acts which occurred in Grantham.” In a small hospital with a small supporting staff the consultants were “not in a strong position to address an unexpected tragedy of this magnitude.”

    David Southall, professor of paediatrics at Keele University, who has been involved in 50 cases of Munchausen's syndrome by proxy, told the inquiry that the delay in diagnosing it on ward 4 was no longer than that in other cases. Parents of Allitt's victims attacked the report as a “cover up.” One mother said: “They have got rid of the nurses and the doctors but we have not seen anything happen to the management.”

    The consultants, clinical services manager Moira Onions, and ward sister Barbara Barker have all been made redundant in a shake up of paediatric services after the Allitt affair. The consultants are appealing to Mrs Bottomley under paragraph 190 of their terms and conditions of service. Paediatric services in Grantham are to be run by Queen's Medical Centre, Nottingham, which is also criticised in the report for having failed to realise when seven victims were referred there that a “malevolent cause” might be responsible.

    The two consultants rejected the report's criticism of them as unfair. Dr Nanayakkara said: “I have already publicly stated that if blame is to be attached to those who were prepared to think the unthinkable then I may be fairly criticised.” Dr Porter added: “It's easy to be wise after the event. I believe that if anyone else had been in my shoes they would not have done any better.”

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