Allitt

The Allitt Inquiry, formally known as the Clothier Inquiry, was established to investigate the tragic events surrounding the actions of Beverly Allitt, a nurse who murdered four children and injured nine others at Grantham and Kesteven Hospital in Lincolnshire in 1991. The inquiry was chaired by Sir Cecil Clothier QC and was initiated in May 1993, following Allitt's conviction.

The inquiry aimed to examine the circumstances that allowed Allitt's crimes to go undetected for so long and to identify lessons that could be learned to prevent similar tragedies in the future. The Clothier Report, published in February 1994, provided a comprehensive account of the events and highlighted several failures in the hospital's management and communication systems.

One of the key findings of the inquiry was that the hospital staff lacked the necessary leadership, energy, and drive to piece together the medical evidence that pointed to Allitt's malevolent actions. The report emphasized that a determined and secret criminal could defeat even the best-regulated organization. However, it also acknowledged that no measures could offer complete protection against such a determined miscreant.

The inquiry made 12 recommendations aimed at tightening procedures to safeguard children in hospitals. These included:

• Ensuring that no one should be employed as a nurse if there is evidence of a major personality disorder.

• Implementing formal health screening for nurses when they obtain their first posts after qualifying.

• Studying nurses' records of sick days before giving them jobs.

• Requiring coroners to send copies of post-mortem examination reports to any consultant involved in the patient's care.

The report concluded that while the tragic events were the product of a malevolent, deranged criminal mind, there were significant failures in the hospital's response that needed to be addressed. The findings and recommendations of the Clothier Report were intended to be absorbed and applied throughout the National Health Service with diligence and dispatch.