Thirty-two changes ordered after nurse killed four

Colin Norris is serving a minimum of 30 years imprisonment for the murder of four frail elderly patients at Leeds General Infirmary and St James's Hospital, Leeds, using injections of insulin to induce fatal comas.

Yesterday an independent inquiry said a catalogue of failings allowed him to commit his crimes undetected over seven months in 2002.

It made 32 recommendations covering patient safety, hospital security and drug audits and urged national action for better checks on newly qualified nurses and death certification.

The report, which points to disturbing links between the case and that of serial killer doctor Harold Shipman, said a combination of factors gave Norris the opportunity to commit his crimes at the Leeds health trust.

But it was only when the final victim, 86-year-old patient Ethel Hall, died after collapsing into a hypoglycaemic coma that concerns were raised.

"Had the earlier unexpected and unexplained deaths and incident of hypoglycaemia been reviewed effectively and investigated, and if death certificates had been accurately completed, Colin Norris's actions may have been identified earlier," it said.

It found nearly 150 recommendations for changes had been made by internal hospital inquiries dating back as far as 2005, but some had still not been implemented.

Last night Mrs Hall's son Stuart said: "In some ways I feel more hurt now knowing that the trust could have avoided my mother's death.

"The report highlights many changes and suggestions that have been made in the past but these are not yet implemented and being followed.

"I just hope that the trust can now get its act together and take the necessary steps to make sure this does not happen again."

Medical law expert Linda Smith at solicitors Irwin Mitchell which is representing some of the victims' families, said the report made "disturbing reading".

"It clearly shows that these four deaths could have been avoided," she said. "We have another report now in 2010 and the concern is whether or not the NHS has learnt from previous tragedies."

Former assistant chief nursing officer Prof Pat Cantrill, who led the inquiry, said incidents of severe hypoglycaemia were so rare they should have triggered early investigations.

But she said auditing of deaths was now much more effective, adding: "I don't think there is any way you can put in place a system that can prevent someone like Colin Norris harming patients, unfortunately, because he and other people like him have a malicious intent to harm patients."

The Leeds hospitals medical director Peter Belfield said: "There have been considerable developments in our services since 2002.

"A determined killer like Colin Norris would be difficult to spot in any NHS organisation but I believe the systems we now have in place would make it much more likely to pick up on someone like this."