Yorkshire 'killer nurse' findings in full

'Catalogue of failure' exposed as killer' nurse left in charge of Yorkshire hospital

Apology too little too late, says victim

Anne Grigg-Booth "was not a Beverly Allitt or a Colin Norris in that her actions were almost entirely open".

It was unlikely Grigg-Booth "deliberately set out to harm patients".

Although some staff found the senior nurse intimidating and a bully, "almost without exception medical and nursing colleagues recognised that she was a hard working, experienced and caring nurse who could be relied on in a crisis".

At night Grigg-Booth was "effectively in charge of the hospital".

The NHS Trust which runs the hospital failed to recognise that the nurse was "part, if not a symbol, of a system that was not working".

The trust believed it was dealing with a "rogue nurse" and that "all else was well". This was untrue.

Part of the problem was that the trust appeared to be very successful in many of its activities but the board was unaware of what was happening at the hospital during the night.

Senior night nurses, of which Grigg-Booth was the most senior, took on additional tasks overnight to reduce the workload on junior doctors.

The board was unaware nurses were administering intravenous opiates for many years which was against hospital policy - "they all reasonably believed that they were permitted to do so". This had been going on from at least the mid 1990s.

Grigg-Booth, on occasions, went well beyond the boundaries of acceptable nursing practice and beyond the boundaries of her own clinical understanding.

She "acted unlawfully from time to time" because it was against the law for anyone other than doctors to prescribe opiate drugs.

Many doctors working at night believed the senior nurses could prescribe opiates.

Pharmacists did not check prescriptions were signed by doctors.

The night practices at the hospital successfully reduced the working hours of junior doctors but "no-one asked how it was being done".

The nurses' actions were not hidden. They were all recorded and were there to be seen by doctors and managers.

Senior managers either knew or should have known about these practices - "they did nothing about it".

The trust has made "very significant improvements" since 2005.