The children kept arriving in Nottingham from Grantham. In the first four months of 1990, the children's ward at Grantham and Kesteven General Hospital had sent three patients to the specialist units at the Queen's Medical Centre; in the same months of 1989 it had sent two. In the spring of 1991 it sent three in four days at the end of March and kept sending them into April, and the doctors receiving them could not account for what they were seeing. A five-month-old whose blood sugar crashed again and again. A five-year-old with pneumonia whose heart stopped. A baby girl with five broken ribs. On April 29 a group of Nottingham pediatricians met to compare five of the transfers. They found nothing the children had in common, and they wrote down that every one of them had followed "a clinical course completely out of context to their presenting illness." They were worried, they said, about "an extrinsic factor."
The extrinsic factor was a 22-year-old enrolled nurse named Beverley Allitt, who had started work on Ward Four on February 19, 1991. In the fifty-nine days that followed she attacked thirteen children, some of them several times, and four died. When the government inquiry into the ward reported three years later, it listed the things a single meeting of the staff might have noticed, and put one of them first: "the alarm was raised each time by Beverly Allitt."
The first was Liam Taylor, admitted on February 21 with a chest infection. Court reporting in 2007 gave his age as seven weeks; some later accounts say seven months. Allitt made a point of reassuring his parents, Chris and Joanne Taylor, and persuaded them to go home and get some sleep. When they came back she told them Liam had had a breathing emergency and come through it. She volunteered for extra night duty to watch him, and his parents stayed at the hospital. On February 24, after a period alone with her, he turned deathly pale, red blotches came up on his face, and he went into cardiac arrest. The monitor alarm that should have sounded when he stopped breathing did not. He was left brain damaged and kept alive by machines until his parents, on medical advice, agreed to let him go. His death was recorded as heart failure. A first post mortem found damage to the heart and no cause for it; a pediatric pathologist who re-examined the case later concluded that he had been given a noxious substance.
Timothy Hardwick was eleven and had cerebral palsy. He came onto the ward after an epileptic seizure on March 5, and Allitt took over his care. After a stretch alone with him she called the resuscitation team, who found him blue and without a pulse. A pediatric specialist was among those who worked on him, and he died that day. The autopsy found no obvious cause, and his epilepsy was blamed.
Kayley Desmond, about a year old, had been admitted on March 3 with a chest infection and was recovering. On March 10, in the same bed where Liam Taylor had collapsed, she collapsed twice and was transferred to the Queen's Medical Centre, where she survived. Doctors there found a puncture mark under her armpit with a pocket of air near it and put it down to an accidental injection. An X-ray showed air in her upper right arm and armpit, consistent with air introduced into a vein. The inquiry later asked whether that would have been caught had a pediatric radiologist formally reviewed the film. Nobody did.
Paul Crampton, five months old, came in on March 20 with a minor bronchial infection and was close to going home when the hypoglycemic episodes began: March 23, March 24 and March 28, each time with Allitt nursing him, each time a slide toward coma that doctors reversed without being able to explain. After the third he was sent to Nottingham. Allitt rode in the ambulance with him, and on arrival his insulin was again too high. A blood sample taken during the March 28 episode went to a laboratory in Cardiff. It held so much insulin that it was beyond the range of the equipment used to measure it, and almost no C-peptide, the compound the body releases alongside its own insulin. The combination meant only one thing: the insulin had been injected. The result was telephoned to the ward's consultant, Dr. Nelson Porter, on April 12, and by then five more children had collapsed.
On March 30, Bradley Gibson, five years old and being treated for pneumonia, complained of pain at the site of his intravenous drip, lost consciousness and went into cardiac arrest. A blood test an hour later showed potassium at 6.2 mmol/L, against a normal range of 3.7 to 5.0, and his insulin was high as well. He was revived, and that night, after a visit from Allitt, his heart stopped again. He was transferred to Nottingham and lived. It was the seventh unexplained collapse on the ward in about four weeks, enough that Porter sat down and listed them for his own reference. The inquiry's view was that the right course at that point was a conference of every discipline on the ward, going through each case in turn. None was called. The next day, March 31, two-year-old Yik Hung Chan turned blue and collapsed twice. He responded to oxygen and was transferred to Nottingham, where his symptoms were put down to a skull fracture from a fall.
Becky and Katie Phillips were twins, born prematurely and two months old. Becky was admitted on April 1 with gastroenteritis, and Allitt took charge of her. Two days later Allitt raised the alarm, saying the baby seemed hypoglycemic and cold to the touch. Nothing was found, and Becky went home on April 4. That night she had convulsions and screamed as if in pain; the doctor who was called suggested colic, and her parents took her into their bed to keep an eye on her. In the early hours of April 5 she collapsed, and she was dead on arrival at Grantham. The post mortem found no clear cause. Blood tests run after the Crampton result suggested she too had been injected with insulin.
Katie was admitted to Ward Four the same day as a precaution, and Allitt was on duty. Katie stopped breathing later that day and was revived. On April 7 she collapsed twice more, her lungs collapsed, and she was sent to Nottingham, where doctors found five broken ribs and brain damage from lack of oxygen. She survived with cerebral palsy, partial paralysis, and damage to her sight and hearing. Her mother, Sue Phillips, grateful to the nurse she believed had saved her daughter, asked Allitt to be Katie's godmother. Allitt said yes.
Michael Davidson collapsed on April 9. Christopher Peasgood collapsed twice on April 13 and again on the 14th. Christopher King collapsed three times on April 16, and Patrick Elstone twice on April 18. All four survived. Then, on April 22, came Claire Peck, fifteen months old, an asthmatic who needed a breathing tube. Within minutes of being left with Allitt she went into cardiac arrest. The team brought her back. Left alone with Allitt again, she arrested a second time and could not be revived. Her potassium, measured forty-five minutes after the collapse, was above 10 mmol/L, a figure the prolonged arrest may partly explain. Testing of her blood in 1993 found lignocaine, a heart drug never given to a baby, which none of the doctors remembered using; the inquiry noted that the amount was consistent with a massive dose before she collapsed, since her body would have kept clearing it until she died.
Claire Peck died ten days after the Cardiff result reached the ward. Sir Cecil Clothier's inquiry was blunt about those days. The first clear evidence of foul play had arrived on April 12, it said, and the delay before anyone called the police "cannot be justified." More prompt action, it concluded, "might well have saved the life of Claire Peck and the sufferings of three other children." On April 11, the day before the result came in, the two ward consultants had shown the regional director of public health around Ward Four and mentioned the unusual number of collapses; asked the cause, they told him it might be a virus. During the interval both consultants were away at a conference for part of the time. Porter heard a talk there on Munchausen syndrome by proxy, the pattern in which a caregiver harms a child to draw attention, and came back wanting video cameras on the ward. Between April 19 and 22 he asked two managers for surveillance. The unit general manager, Martin Gibson, told the inquiry Porter had a reputation for "fanciful ideas." Another manager called him "a bit unpredictable."
What ended the waiting came from Nottingham. Professor Sir David Hull, the senior pediatrician at the Queen's Medical Centre, heard about the Crampton blood results on Friday, April 26, and called the meeting of April 29 that produced the note about an extrinsic factor. He phoned Porter the same day and told him to go straight to senior management and have them call the police. Porter caught Gibson on his way to a meeting. Gibson said he would call in the morning, and on April 30, 1991, the Grantham police were told.
The ward the police walked onto had been short of nurses for more than a year, and people had said so in writing. Ward Four was funded for 10.66 full-time nurses and had between 8.86 and 9.57 in post that winter; only three full-time nurses and one part-timer held the Registered Sick Children's Nurse qualification, against a standard that called for at least one on duty around the clock. The night services manager, Jean Savill, had raised it in November 1990 and twice in January. On April 4, 1991, she wrote again, saying she was distressed by the situation on Ward Four and hoped a solution could be found "before a tragedy occurs." She died before the inquiry sat, and its report recorded her efforts by name. The shortage mattered in a particular way. Allitt, newly qualified, was often one of only two trained nurses on the ward, and so she was the one left to watch the sickest children and the one sent with them in the ambulance to Nottingham, a job normally given to someone far more experienced. Her colleagues noticed that she was always there when a child went down. Some of them teased her about being bad luck.
The inquiry could not say for certain how she did it. It never established where she got the drugs, and in many of the cases it could not say which drug she used; expert evidence was that a child could be seriously harmed or killed in a short time with no drug at all and no marks, and it thought suffocation may well have been her method in some cases. On at least four occasions a monitor alarm that should have sounded when a child collapsed stayed silent, and the likeliest explanation was that she switched them off first; nobody investigated at the time. The hospital pharmacy's records showed no unusual demand for any drug on Ward Four. Insulin use on the ward actually went down. But on February 14, 1991, five days before she started as an enrolled nurse, Allitt had been handed the ward keys to fetch eye drops from the drug refrigerator and reported afterward that its key was missing from a sturdy ring. The lock was changed the next day. Nobody on the ward knew that every drug refrigerator in the hospital used the same lock.
Detective Superintendent Stuart Clifton led the investigation. His team eventually identified twenty-five suspicious episodes involving thirteen children, and the only thing common to all of them was the nurse on duty. The ward's nursing log for the days Paul Crampton was on Ward Four had gone missing; parts of it turned up in a search of Allitt's home. She was first arrested and questioned on May 21, 1991. She was calm, denied everything, and said she had only been caring for the children. It took until November for the police to put together enough from the tangled record of those weeks to charge her.
She was born on October 4, 1968, to Richard and Lillian Allitt, and grew up in Corby Glen, a village near Grantham, with two sisters and a brother. Her father worked in a liquor store and her mother cleaned at a school. She went to the Charles Read Secondary Modern School after failing the entrance test for the girls' grammar school, took babysitting jobs, and left at sixteen for a pre-nursing course at Grantham College. The inquiry traced a pattern back that far. At school she was often seen in a bandage or with an arm in a sling. At college the injuries came more often, and she showed them to her tutors in a way that seemed to be about the attention. In her second year she missed 52 of 180 days. As a pupil nurse she missed 126 days of a 110-week course and referred herself to the hospital's occupational health department fifteen times. In October 1990 her appendix was removed and found to be normal, and the wound became infected twice, which in hindsight raised the possibility that she had interfered with it. A senior physiotherapist who kept seeing her went to the nurse adviser to say that Allitt seemed to lack the maturity to care for others. There is no record of what happened to that warning, and nothing came of it.
She passed her enrolled nurse exams in December 1990 but still owed time on the wards before she could qualify. She asked to do it on Ward Four, a placement the inquiry said did not fit her training needs. Then, through a recruitment process that took no references, she was given a six-month contract there. Occupational health had passed her fit to nurse twice, both times on the strength of what she told them.
Out on bail in the summer of 1991, she became a patient herself. In July, in a hospital in Peterborough, doctors first raised the possibility of Munchausen syndrome after she pushed thermometer readings to temperatures her condition could not have produced and complained of a swollen breast that had three small puncture marks in it, probably where she had injected herself with water. By the time of trial she had lost about five stone, some seventy pounds, and was diagnosed with anorexia nervosa. The inquiry, looking back, called the diagnosis irrefutable, and it also said that nothing in her record when she was hired to Ward Four would have justified suspecting it.
Her trial opened at Nottingham Crown Court on February 15, 1993. The inquiry recorded the charges as four murders, nine attempted murders and nine counts of causing grievous bodily harm with intent against the children, plus attempted murder and grievous bodily harm against two adults elsewhere; other accounts count eleven attempted murders and eleven assaults, a difference in how alternative counts were tallied. Illness kept her out of court for much of the trial, and by one account she attended on only sixteen days. The prosecution showed the jury that she had been present at every episode and that the episodes stopped when she was off the ward. Professor Roy Meadow, the pediatrician who had given Munchausen syndrome by proxy its name, explained the condition to the jury.
The verdicts came in between May 13 and 17, 1993. She was convicted of murdering Liam Taylor, Timothy Hardwick, Becky Phillips and Claire Peck; of attempting to murder Paul Crampton, Bradley Gibson and Katie Phillips; and of causing grievous bodily harm with intent to Kayley Desmond, Yik Hung Chan, Michael Davidson, Christopher Peasgood, Christopher King and Patrick Elstone. She was acquitted on the counts involving the two adults. On May 28, Mr. Justice Latham gave her thirteen concurrent life sentences and told her she was a serious danger to others who was unlikely ever to be considered safe to release. That October, The Independent reported under the headline "Child murderer confesses at last" that she had begun to admit what she had done; later accounts say she admitted three of the murders and six of the attacks. She has never given a full public account of why.
The inquiry was commissioned by the Health Secretary, Virginia Bottomley, and chaired by Clothier, a former judge, with a nurse, Anne MacDonald, and a doctor, Professor David Shaw. Families and part of the press wanted a public inquiry and did not get one. Its report, published in February 1994, made twelve recommendations: that nursing applicants' sickness records be obtained along with their references, that no one with evidence of a major personality disorder be employed as a nurse, that pediatric pathologists be brought in on every unexpected child death, and that any failure of a monitor alarm be written up as an incident and the equipment serviced before reuse. Its closing judgment was that fragments of medical evidence, each unremarkable alone, would together "have amounted to an unmistakable portrait of malevolence," and that nobody at the hospital had gathered them up.
Allitt was sent not to prison but to Rampton, a high-security psychiatric hospital in Nottinghamshire, and she has been there since. Reports from Rampton described her swallowing ground glass and pouring boiling water on her hand, and in 2001 the press reported that she planned to marry a fellow patient, Mark Heggie. On December 6, 2007, Mr. Justice Stanley Burnton in the High Court confirmed a minimum term of thirty years. Liam Taylor's parents were in court. Some of the families had believed for years that the figure was forty.
The thirty years ran out in November 2021, and it changed less than it sounded. A patient held at Rampton cannot go before the Parole Board; only a transfer to a mainstream prison would open that door. In October 2023 she went before a mental health tribunal seeking one; had it been granted, she could have gone before the Parole Board within about six months. On December 8, 2023, it was reported that the tribunal had ruled she should remain a patient at Rampton, and that it could be as long as three years before she was assessed again. The families have said, year after year, that she should never come out. Steve Gibson and David Crampton, whose sons she nearly killed, said so publicly in 2023, thirty years after they sat in the courtroom in Nottingham.
In 2023, after Lucy Letby was convicted of murders on a neonatal unit in Chester, convictions she continues to contest, Stuart Clifton suggested in a television documentary that Letby might have copied Allitt's methods. The key to the Ward Four drug refrigerator, the one Allitt reported missing on February 14, 1991, was never found.