AT least one child's life could have been saved if vital clues which

led to the eventual unmasking of nurse Beverley Allitt as a serial

killer were followed up sooner, an official inquiry found yesterday.

The suffering of three other children may also have been prevented if

staff had acted earlier to piece together fragments of medical evidence

which would have painted ''an unmistakable portrait of malevolence''.

However, staff lacked the necessary leadership, energy, and drive to

piece together the jigsaw -- allowing Allitt to pursue her deadly


The official inquiry, into how Allitt murdered four children and

attacked nine others at Grantham and Kesteven Hospital, Lincolnshire,

highlights a series of failures at the hospital.

But it's conclusion, that no single person or circumstance is to

blame, prompted allegations of a ''whitewash'' from unions and parents

of children murdered by Allitt.

Sir Cecil Clothier, the inquiry's chairman, said: ''The dreadful

lesson we have learnt is that no matter how numerous and skilful the

staff of a hospital may be, a malevolent, cunning, and deranged person

can nevertheless continue to commit his or her crimes.''

In future, people must be prepared to ''think the unthinkable''

whenever a patient's condition could not be accounted for.

The report, based on evidence from 94 people in the inquiry, held

behind closed doors, -- makes 12 recommendations aimed at tightening

procedures to safeguard children in hospital.

Mrs Virginia Bottomley, Health Secretary, promised action would be

taken on all the recommendations and added it was important that lessons

were learned throughout the health service.

She said: ''From the outset, we must all acknowledge -- as the report

does -- that the tragic events in Grantham were the product of a

malevolent, deranged, criminal mind. Everything else must be seen in

that light.

''The Clothier Report does identify and criticise failures of

management and communication in the hospital and it is important that

lessons are learnt from these throughout the National Health Service.

''It draws attention to the failure to take quicker action after the

first evidence of possible foul play. However, it refutes any suggestion

that Allitt could easily have been detected or stopped.''

Sir Cecil's findings and recommendations would be absorbed and applied

throughout the Health Service with ''diligence and despatch,'' Mrs

Bottomley said.

The recommendations are:

* No-one should be employed as a nurse if there is evidence of a major

personality disorder.

* Nurses should undergo formal health screening when they obtain their

first posts after qualifying.

* Employers should study nurses' record of days off sick before giving

them jobs.

* Coroners should always send copies of post-mortem examination

reports on patients to any consultant involved in their care.

* Child pathology services should be reviewed so a post mortem

examination is carried out by a specialist each time a child dies

unexpectedly or inexplicably.

* Consideration should be given to requiring a medical reference from

a GP to certify NHS candidates have nothing in their medical history

which would make them unsuitable for their chosen occupation.

* Department of Health guidelines that two sick children nurses should

be on duty at all times should be more closely observed.

* Reports of serious untoward incidents should be made in writing and

through a single known channel.

* If an alarm system fails on monitoring equipment, an untoward

incident report should be filed and equipment serviced.

* A review should be conducted of whether occupational health

departments should have access to sickness records.

* Clear procedures should be laid down for management queries to

occupational health departments about staff.

* Further consideration should be given to whether training applicants

who show signs of uncertain mental health should be refused unless they

have lived an independent life for two years.

The report says there was a breakdown in communications at the

hospital. It says there were sloppy recruitment procedures, inadequate

staffing levels on Ward Four -- the scene of the crimes -- and

indecisive senior managers who had poor operational procedures.

Two consultant paediatricians, while praised for their skill, should

have grasped sooner the ''significance of the cascade of collapses''

with which they had to deal.

The report also points to the failure of the pathology department, and

occupational health services, which did not pick up on Allitt's record.

In a statement, Sir Cecil said: ''It takes only two minutues alone

with a helpless patient to kill or injure. Nurses are bound to be alone

with their patients sometimes.

''But henceforward we must be prepared to think the unthinkable

whenever a patient's condition cannot be medically accounted for; a

member of staff might be responsible.''

Allitt probably would have satisfied her urge in almost any hospital,

the report said.

However, Grantham and Kesteven Hospital was ''on the borderline of

viability''. This probably exacerbated delays in detection.

Sir Cecil said proper staffing levels would not have prevented Allitt

from striking out -- but would have made it more difficult.

The report upset unions and staff, who claimed they were being

unfairly made to take the blame.

The two doctors criticised in the report rejected the criticisms made

against them.

Consultant paediatricians Nelson Porter and Charith Nanayakkara said

the report failed to take into account problems posed by the extreme

staff shortages on their ward.

They attacked Sir Cecil Clothier for holding the inquiry behind closed

doors and for not taking any evidence from paediatric experts.

Dr Porter said: ''Without the benefit of hindsight it is not

reasonable to suggest that the children on the ward needed protection.

''No professional, within the hospital or outside it, has ever

suggested that we should have been looking for a potential mass murderer

at this or any stage,'' he added.

Dr Nanayakkara said he found it ''most amazing'' that Sir Cecil had

criticised him and his colleague Dr Porter.

Nobody inside or outside the hospital had brought the matter to the

notice of the management or the police until the doctors did so, he


Both the Royal College of Nursing and the Royal College of Midwives

said something must be done to increase staffing levels.

Mr Bob Quick, of the union Unison, said the regional health authority

should have shouldered responsibility. Instead the finger of blame was

pointed at junior staff.

''If there had been more nurses on the ward it would have dramatically

reduced the chances of Allitt harming the children,'' he said.

Mrs Creswen Peasgood, whose eight-week-old son suffered two

respiratory arrests, led calls from parents for a public inquiry.

She said that although the report stated that managers had to take a

certain blame, they had not lost their jobs.

Mrs Judith Gibson, the mother of another victim, said she believed the

report's recommendations should have been implemented already.