The Oxford Radcliffe Hospitals NHS Trust has been cleared of any responsibility following the murder of two patients and assault of a further 15 by killer nurse Benjamin Geen.

In April this year Geen, 25, was found guilty of murdering David Onley and Anthony Bateman and causing grievous bodily harm to a further 15 patients between December 2003 and February 2004 while working as a nurse at The Horton hospital in Banbury.

Following a three month trial, Geen was jailed for life with a recommendation to serve a minimum of 30 years behind bars.

The report published yesterday followed a seven-month independent review by the South Central Strategic Health Authority into the circumstances surrounding Geen's actions.

It said the "sole responsibility for the harm inflicted on 17 patients at the Horton Hospital lies with Benjamin Geen".

It also recognises the "high level of expertise and commitment shown by staff at the Horton Hospital over the past two years in what has been a difficult time for patients, families and staff at the hospital."

Geen carried out his deadly injections, which caused patients to stop breathing, over a period of 64 days. It was only after his 17th assault that staff began to formally suspect something was amiss.

However the report states that staff acted promptly and identified Geen's actions early enough to prevent further harm being done to other patients.

The conclusion has been welcomed by the trust but not by two survivors of Geen's attacks.

Trust chief executive Trevor Campbell Davis said: "The report makes clear that the blame for these terrible incidents lies with Benjamin Geen alone, and that there is nothing which doctors and nurses should have done differently which might have prevented him, or caught him any earlier.

"It is reassuring that our clinical staff are praised for the way in which they conducted themselves in the aftermath of the arrest and throughout the investigation - their commitment to maintaining patient care during many very difficult months has been exemplary."

The Horton hospital director Mike Fleming said the news had helped staff morale: "Our staff carried a sense of guilt and a feeling that they could have prevented this and done something, but this report says clearly that they could not have done anything.

"Clearly there are lessons to be learned and that is what we are looking at now."

However, Geen victims Robert Robinson and John Thorburn both felt that 64 days and 17 victims was far too long and too many.

Mr Robinson said: "I would not say it was prompt action at all on the hospital's behalf. This should have been picked up much, much earlier. How many people have to stop breathing inexplicably before you start asking questions? To be honest, I am shocked that they have reached this conclusion.

"I also think that there were failings in the way in which drugs were administered. There should have been much more stringent checks."

Mr Thorburn added: "I don't think 16 incidents is rare. If my wife had not been with me at the time I stopped breathing, I would have died. I'm afraid I am not too impressed with the conclusions.

"I feel aggrieved because there could have been much better controls of the drugs and there should surely have been more than one person around to administer drugs."

Findings at a glance

* The report stated the independent review was 'not about laying blame, but about identifying lessons to be learnt to improve the performance of services in relation to safeguarding patients in the future' * The only person responsible for the death of two patients and the harm inflicted on a number of others was Ben Geen himself * It is very difficult to stop a nurse or any other healthcare professional from betraying the trust of patients by harming them deliberately * It was only thanks to the skills and knowledge of the nurses and doctors at the Horton Hospital that quickly identified his activities and prevented more deaths and injuries.

Recommendations

* Review and establish a systematic risk assessment in the Emergency Department * Review the way incidents are investigated including proper analysis of reporting forms, and results used in service areas to inform staff and improve patient experience * Review procedures for recruiting nurses straight from training, considering their progress, evidence of passing exams and their ability to undertake the role for which they are being recruited * Develop a uniform system to enable the performance of all staff to be recorded, particularly for all staff that undertake disciplinary interviews.

Victims of evil thrill-seeker

DAVID LONG, 53. Geen shouted out that he had stopped breathing. Experts said he had been injected with an anaesthetic.

DAVID NELSON, 77. Moved to the resuscitation room where he stopped breathing. Urine tests found traces of the sedative midazolam.

ROBERT ROBINSON, 51.

Suffered respiratory arrest.

Stopped breathing when given an anaesthetic he didn't need.

HILDA WIGRAM, 89.

Collapsed and stopped breathing when medication was injected by Geen.

Doctors felt it was administered too quickly.

WALTER COATES, 61.

Doctors prescribed morphine and a saline drip, and Geen injected him. Medics were called back when Mr Coates became distressed and started to turn blue around his mouth.

JOHN MONCUR THORBURN, 73, suffered respiratory arrest. Put on a ventilator, and next morning was breathing on his own again.

SHEILA GRAY-SNOOK, 73. She suffered a respiratory arrest, but later recovered.

ANTHONY BATEMAN, 65. He was so ill it was decided not to ventilate him artificially, and he died.

JONATHAN FELTHAM, 22. Arrived at 7.07pm and collapsed at 7.30pm. He recovered within three hours.

HAROLD BOSS, 66. Doctors reduced his oxygen intake before he was sent for an X-ray. His breathing deteriorated and doctors realised his oxygen intake had been increased.

NOREEN BROOKS, 55. Within an hour, she had suffered respiratory arrest.

DAVID ONLEY, 75. Given insulin on a drip and remained in A&E all night. He started to recover but suffered a heart attack and was taken to the JR, where he died.

ARTHUR MARLOW, 79. Staff found Geen trying to resuscitate him.

GRACE VERA FOX, 88, was given an anti-sickness drug and told she would be sent to a ward.

ESTHER JORDAN, 79, arrived by ambulance and was dealt with by Geen. Within 10 minutes, he was shouting for help.

HERLINE PROBERT, 67.

Prescribed morphine which was drawn up and administered by Geen. Inexplicably suffered a respiratory arrest.

TIMOTHY STUBBS, 41. Analysis found a muscle relaxant which he had not been authorised to receive - instead of a sedative.