I watched the movie, "The Good Nurse" on Netflix several nights ago with amazement and horror. How could such an outwardly appearing kind and caring man want to inflict so much heartbreak, pain, and death? As an experienced nurse, Charles Cullen had no difficulty in finding employment in approximately 9 hospitals in Pennsylvania and New Jersey over 16 years. Each of the hospitals had an increase in inexplicable deaths soon after he began working. A nurse on the night shift who became friends with Charles figured out how he was killing random patients. He would go to the storage area where the intravenous fluid bags were kept and inject them with insulin and/or digoxin. Since the bags were randomly taken by other nurses for patient care, it was unknown when the tainted fluids would be used and who the recipient of the tainted fluids would be. It is estimated that he is the most prolific serial killer in the United States, killing 300 to 400 patients. Risk management investigations in the hospitals linked him through various methods to the strange occurrences and fired him on several pretexts. He was sentenced for the murder of 29 patients and is currently serving 18 life sentences consecutively. At the end of the movie, it was noted that none of the hospitals faced any repercussions for simply firing him.

Thus, I was intrigued by the thought of a nurse wanting to kill a patient. I went to the scholarly literature and was surprised at the wealth of information related to nurses who were serial killers. The US Federal Bureau of Investigation defines serial killing as the same offender unlawfully killing 2 or more people in separate events.1 A healthcare professional serial killer is defined as a professional who purposively kills 2 or more of his or her patients in the healthcare environment unrelated to physician-assisted suicide or euthanasia.2 There have been 90 criminal prosecutions of healthcare providers as serial killers across 20 countries between 1970 and 2006, of which 86% were nurses.3 The patients were random and can be any age, including neonates. The majority of healthcare facilities in which patients were killed were acute care facilities, and of that, the most frequent units were the nurse was employed was the medical-surgical floor and intensive/coronary care units.

Intentionally killing a newborn within the first 24 hours of life is known as neonaticide.2,4 The mother is typically identified as the perpetrator, who delivers at home, has not planned the pregnancy or care of the newborn, and does not have a history of long-term mental illness.2,4 It is unusual for a nurse to attempt neonaticide; however, there was a nurse in Brazil working in the low-risk nursery who tried to kill 11 newborns.2 She had been employed by the hospital for 2 years in the neonatal intensive care unit but was transferred to the nursery because she worked so well with the mothers and their babies. Because she believed the physicians lacked competency in caring for the newborns and prescribing medications, she would create a life-threatening situation so she could provide the baby with support. She used a syringe to drip morphine, benzodiazepines, and barbiturates into the newborn's mouth. When symptoms of intoxication became evident, she would then seek assistance and provide support to the family. Although the unexpected situations only occurred on the days when she worked, the hospital security camera caught her giving high doses of morphine to a neonate. When apprehended, she had a syringes and controlled medications in her fanny pack, as well as controlled medications in her locker. The nurse evidenced no empathy or remorse and would not accept responsibility for her actions.

How can a nurse serial killer be recognized? The nurse is most often between the ages of 31 and 40 years and can be of either gender.5 Five "red flags" repeatedly were found in known cases that could be used to identify a nurse who is a threat to patients.5 The first red flag found that there tended to be a high incidence of death on a particular nurse's shifts, but the fact should not be used on its own. Remember Cullen injected the intravenous bags that other nurses used randomly, so the deaths did not always occur when he was present. Sixty-three percent of the cases found a history of depression or mental illness. Just over half of the cases had colleagues feeling anxious or suspicious about the nurse's capabilities or professional approach. Approximately half of the nurse serial killers had nonprescription medications in their work lockers or at home. The last red flag was that 50% of the killers had a personality disorder, although a specific one was not mentioned.

Not much attention has been given to healthcare professionals who are serial killers, unlike that in the literature on the topic of serial homicide. We need to know more about nurse and other provider serial killers because they work in environments that have many tools that are advantages for predatory behaviors. In addition, because of their knowledge, they may escape detection for long periods of time. It is our responsibility, as well as that of the public and hospital administrators, to be observant and capable of communicating openly regarding health professional serial killers. Research has shown that once a healthcare professional begins to kill their patients, they will not stop until they are caught.5 Of those convicted, they were found guilty, on average, of 5 to 9 murders.5 It is believed that the professionals convicted of higher numbers of murders generally had a longer period of time to kill their patients.

-M. Terese Verklan, PhD, CCNS, RNC, FAAN

Professor and Neonatal Clinical Nurse Specialist

University of Texas Medical Branch

Graduate School of Biological Sciences

School of Nursing

Galveston, Texas

References