A nurse was able to murder four frail elderly patients due to a catalogue of failings, a new report has concluded.

Staff nurse Colin Norris gave the women fatal doses of the diabetes drug insulin while they were being treated at two Leeds hospitals.

An interview with Peter Bellfield, Medical Director, Leeds Teaching Hospitals Trust

According to an NHS Yorkshire and the Humber independent inquiry report, problems including relatives’ concerns going unheeded, staff knowledge of clinical governance policies and systems, record-keeping and medicines management, all contributed to the opportunities Norris had to get hold of drugs and murder patients.

In 2008, a judge at Newcastle Crown Court handed Norris four life sentences for murdering Doris Ludlum, 80, of Pudsey, Ethel Hall, 86, of Calverley, and Bridget Bourke, 88, and Irene Crookes, 79, both of Leeds, while he worked at the Leeds General Infirmary (LGI) and the city’s St James’s Hospital in 2002.

A 20-year minimum sentence, to run concurrently, was imposed for the attempted murder of 90-year-old Vera Wilby, of Rawdon, who survived a coma induced by an insulin injection.

The report published yesterday states: “Colin Norris was a trained nurse who had access to drug cupboard keys and the means to administer lethal injections to elderly and vulnerable patients.

“There is evidence to suggest that the systems in place at the trust to monitor the supply and administration of drugs at the time of the incidents were not robust enough to identify and prevent malpractice.”

It goes on to say that actions taken by the consultant and medical director following the collapse of Ethel Hall in November 2002 were “prompt and effective”, but if the earlier unexplained deaths of the other women had been reviewed and death certificates accurately completed, Norris’s actions might have been spotted earlier.

Dr Peter Belfield, medical director of Leeds Teaching Hospitals, said work was being done to improve on issues raised in the report.

He said: “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.”

Stuart Hall, whose mother Ethel Hall died of irreversible brain damage after being given a high dose of insulin, said the report offered little comfort in explaining or alleviating the effects of his mother’s death.

He 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 that this does not happen again."