Intensive Care Med (2004) 30:1495–1496DOI 10.1007/s00134-004-2290-9 N E W S

Cory Franklin The best place to commit the perfect murder

Received: 15 March 2004Accepted: 22 March 2004Published online: 1 May 2004� Springer-Verlag 2004

C. Franklin ())905 Ottawa Lane, Wilmette, IL, 60091, USAe-mail: cmfranklin@aol.comTel.: +1-847-251-4832Fax: +1-847-251-5792

If you wanted to commit the perfect murder, where wouldyou go to do it? It seems it would be hard to pick a betterplace than a hospital. In February, The New York Timesreported the details of the case of American critical carenurse Charles Cullen, who recently admitted to killing atleast 40 patients over a 16-year career at health care fa-cilities in Pennsylvania and New Jersey. Cullen is cur-rently refusing to cooperate with authorities in an ongoinginvestigation of over 150 deaths in two states spanningnine hospitals and a rehabilitation center. Several of thesuspected victims were thought to be killed with inten-tional overdoses of digoxin and other medications readilyavailable in the intensive care unit. Cullen’s work recordwas spotty and he was under suspicion at several hospitalsyet he continually managed to find new employmentwithout undue difficulty.

Cullen joins a health care rogue’s gallery of serialkillers that includes hospital orderly Donald Harvey whokilled over 70 patients primarily with cyanide injections,nurse Orville Lee Majors, who killed over 100 patients byinjecting them with potassium and epinephrine, and Brit-ish physician Harold Shipman suspected of killing be-tween 200 and 500 patients in the United Kingdom (al-though many of these were outpatients). Nor are the vic-tims always adults. Genene Jones, a pediatric nurse inTexas in the early 1980s, was convicted of killing severalinfants and suspected of killing more than 20 by lethalinjection. How could these people, as well as other doc-

tors, nurses, and therapists who have deliberately killedscores of patients, go could undetected for so long? It’s alegitimate question and surveillance procedures for in-vestigating and reporting suspicious hospital deaths inmany institutions do little to prevent such occurrences.

If not literally caught in the act, a clever health careprofessional who attempts to kill a terminally ill or dyingpatient by injecting a difficult-to-detect medication willmost likely elude detection. That assumes they do it justonce. But the perpetrators who have been caught havecommitted large numbers of murders, with essentially nodifferent modus operandi from other serial killers. Theygenerally become bolder as the number of victims grows.Few of these killers confess willingly and even in theseegregious situations, they have been caught only becausean outsider or colleague became suspicious (the story ofGenene Jones is the subject of The Death Shift, a grippingbook by Peter Elkind about the murders, whose title refersto the name her fellow nurses gave her shifts in the pe-diatric intensive care unit). Detection did not occurthrough the routine procedures of the medical system orexamination of the medical records.

This bespeaks a woeful inadequacy in the Americanmedical system. In most hospitals, the circumstancessurrounding hospital deaths, not just those that are sus-picious but all hospital deaths, are not reviewed to un-cover unsuspected medical mishaps as a routine matter.Combine this with a trend of hospital autopsy rates thathas been falling for decades and it is clear we don’t al-ways know what is going on when hospitalized patientsdie. There may not be many serial killers roaming ourhospitals (though in some cases we are talking about asingle individual being responsible for a hundred deaths)but what other kinds of problems are we missing withsuch a slipshod system?

An isolated case of a health care professional causingdeliberate death is difficult to detect. But many caseswould begin to raise questions if someone simply both-ered to examine the medical records. Suspicious patterns

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of personnel, time of day and mode of death eventuallyemerge. This kind of evidence is not sufficient for crim-inal prosecution but is certainly enough to put the medicalstaff on a high state of alert when suspicions are raised.

The failure to perform adequate investigation of hos-pital deaths has other consequences. One of the problemsdocumented by The New York Times in the Cullen casethat was true of other medical serial killers is that themedical system has allowed these people to go untrackedas they move from job to job. This has occurred in partbecause the hospitals where the crimes have been com-mitted have not done their homework in documenting thekillers’ culpability. Without such documentation, institu-tions are afraid to take quick action or report because theyare afraid they may be sued by the accused.

With the accumulated knowledge we have gained inmedicine, toxicology, forensics, and epidemiology, it isnothing short of scandalous that the hospital is the safestplace for a killer to operate. Professional nursing andphysicians’ societies have said and done nothing about thisproblem. The same is true of federal and state govern-ments in the United States that are responsible for hospitalsafety. Neither the American plaintiff’s bar nor the in-surance industry, which both tout their role in medical

litigation as one of keeping patients safe, has weighed inon the issue.

As of this writing, Charles Cullen’s lawyer has statedhis client will cooperate with prosecutors only if theyagree not to pursue the death penalty. He has beencharged with murder and attempted murder in one countybut charges in at least five other counties are on hold asthe investigation into many of the deaths proceeds. All thewhile, families remain shrouded in doubt, agony, andpain. One thing is certain. While it is scary and somewhatdiscomforting to think about, history tells us there areother Charles Cullens out there waiting to act, armed witha ready supply of sedatives, muscle relaxants, cardiacstimulants, and depressants. The Cullen episode is awarning to every hospital in the United States that it mustincrease its surveillance procedures for patients who diein the hospital. The Federal Government should convenea conference with the appropriate medical and law en-forcement agencies and mandate certain reporting re-quirements for hospitals. These medical killers generallyact with a disdain for hospital procedures under the im-pression there is no way they can be caught. The safe-guards must be put into place to dispel them of that il-lusion.