Healthcare Serial Killers: Recognizing the Red Flags

By Kelly M. Pyrek

Nurses serving in a forensic capacity often are the first responders to victims sustaining suspicious injuries; however, what if the nurse is the perpetrator of these injuries or even death? Healthcare serial killers are nothing new, but lately they have been making headlines far more frequently.

One of the more chilling cases was that of Kristen Gilbert, a 30-year-old nurse indicted in 1998 for murdering four of her patients and attempting to kill three others by injecting them with epinephrine. Gilbert worked at a Veterans Administration medical center in Northampton, Mass., and although her patients often were elderly, the majority was not in acute distress or immediate danger of death, and investigators maintained they were not mercy killings. Prosecutors charged that Gilbert enjoyed injecting epi into her patients and then calling codes so she could meet up with a security guard with whom she was having an affair. Defense attorneys argued that the government could not prove foul play; considerable amounts of circumstantial evidence as well as Gilbert’s inculpatory statements were met with a lack of eyewitness testimony. According to presiding judge Michael Ponsor, “The trial presented ... a classic battle of experts” he said in a Boston Globe article, adding that the extensive prosecution and defense teams of experts cost more than $1.6 million of taxpayers’ money.

More than 250 motions and hundreds of hours of hearings later, the jury began its deliberations. On March 14, 2001, after 12 days of deliberation, the jury delivered its verdict of guilty on three counts of first-degree murder as well as several lesser charges. The complexity of the Gilbert case may explain why the jury, in the penalty phase of this capital case, pronounced themselves deadlocked, and imposed the default sentence of mandatory life imprisonment without possibility of release. Three jurors said that while the evidence was strong enough to prove guilt beyond a reasonable doubt, it was too weak to justify the death penalty. There is no state death penalty in Massachusetts, but Gilbert was eligible for it under federal law because her crimes took place on federal property at the VA hospital.

On March 27, 2001, Ponsor sentenced Gilbert to four consecutive life terms without the possibility of parole for killing four patients, and also sentenced her to two 20-year terms for trying to kill two other patients. Assistant U.S. Attorney William Welch had called Gilbert “a shell of a human being” who deserved to die for the calculating way she murdered her victims. On July 25, 2003, Gilbert dropped her federal appeal. If she had won a new trial on appeal, a recent U.S. Supreme Court ruling would have allowed prosecutors to seek the death penalty.

The Gilbert killings are some of at least 35 other serial murders committed by healthcare personnel (mainly nurses, but also including a respiratory therapist and several physicians) since the mid- 1970s, says Beatrice Crofts Yorker, RD, JD, FAAN, an associate professor of psychiatric mental health nursing at Georgia State University. Four occurred in the 1970s; 12 in the 1980s; 14 in the 1990s and at least five in the 2000s, including the more recent cases of Richard Williams in Missouri in 1992, Orville Lynn Majors in Indiana in 1995 and Vicki Dawn Jackson in Texas in 2000. According to her analysis, York says at least 26 murders occurred in hospitals, nine of which took place in the ICU. The nurses used injection of non-controlled medication such as insulin, digoxin, lidocaine, epinephrine and other respiratory paralysis agents. Males are disproportionately represented, York says, accounting for 38 percent of the perpetrators.

“Serial killers in healthcare appear to come in basically one of five guises: those who kill out of mercy, those who want to feel like God, those who kill for an erotic thrill, those who are mentally ill, and those who just feel overburdened,” says Katherine Ramsland, PhD, who teaches forensic psychology at DeSales University in Pennsylvania. “All of these types have been around because all of these motives arise out of human nature.”

“Since 1974, at least 12 nurses have been charged with murder following mysterious epidemics of adverse patient incidents,” York wrote in the Journal of Nursing Law. “In some cases, the CDC confirmed an epidemic of cardiopulmonary arrests and attributed them to the presence of a particular nurse ... Until recently, social scientists dismissed the idea that female serial killers existed. Since the 1970s, however, research shows that female serial killers do exist and are convicted. Holmes and Holmes discuss five types of female serial killers: women who kill in response to voices or visions; women who kill for money; hedonistic killers who obtain pleasure from killing; disciples who kill under the influence of charismatic leaders; and power seekers who deliberately put their patients at risk so they can rush in and save them to appear heroic.”

Ramsland says that even though they are easier to spot these days, they are driven by centuries- old motivations. “They have had access to poisons since the earliest of times. It’s more difficult for them now, because victim counts stand out, professionals are more alert to killers among them, there are better surveillance methods, and we have methods of accountability that did not exist decades ago. We know more about them now because we have better documentation, but they have been around for centuries.”

Many experts speculate that healthcare has contributed more serial killers than all the other professions combined and that the field attracts a disproportionately high number of people with a pathological interest in life and death.

“Males tend to be more involved in playing God, feeling power over human life, and finding an erotic thrill in that, although we’ve certainly had cases of nurses who found killing so exciting that they immediately had to have sex,” Ramsland explains. “More healthcare workers claim they killed patients out of a sense of mercy, yet further analysis tends to dispel this motivation.

Often they’re seeking attention, they’re acting from some delusion, or they’re trying to prove something. I think it’s a myth that most healthcare workers who kill do so because they want to do a kindness.”

While profiling has played a significant role in catching killers, Ramsland says, “There’s no way to provide a general psychological type, because each killer that I’ve studied is quite unique in his or her own framework. One man killed to ease his workload. Another to experiment. Two women killed to prove their love to each other. Another liked watching her boyfriend come running in an emergency. A male nurse talked about supernatural issues. Another was suffering from Munchhausen syndrome. As with most other types of crime, each case is unique to the person.”

Ramsland says the most susceptible patients are children, especially babies, and the elderly, because their deaths can be easily explained as natural causes. Even using epidemiological data to connect an unusually high number of these deaths from seeming “natural causes” has not been foolproof in building and trying a case. In one case in Maryland where an epidemiologist testified that patients of a particular nurse were 47.5 times more likely to have a cardiac arrest (100 times more likely on the night shift), the judge ruled the evidence in the case was only circumstantial and could not be used as evidence of intentional acts, York says, because the mens rea, or state-of-mind element of proof was missing. While not effective in a criminal case, this kind of statistical evidence can be very persuasive evidence in a wrongful death lawsuit, York says, due to differences in burden of proof between criminal and civil suits. In the Maryland case, although the nurse was acquitted of murder, she faced eight civil suits that settled for $8.5 million.

Regardless of the outcome, the real challenge may be in warranting the arrest and bringing the case to trial in the first place. For six months, Gilbert went on a killing spree before several of her nursing colleagues could no longer ignore the number of sudden deaths occurring on Gilbert’s watch.

“It is common that people get away with murder in a hospital or community health setting for quite a while,” Ramsland says, “partly because of denial. Many people cannot believe that someone in a helping profession would actually kill his or her patients. Many people also cannot believe that women would commit serial murder (though we have many, many cases). Sometimes people are protected by a hospital trying to avoid bad publicity, so they’re sent away but not stopped, as in the case of Dr. Michael Swango. I believe that Dr. Harold Shipman, who may be the worst serial killer among them with a victim count over 200, often made house calls and had such a kindly air that no one suspected. For the most part, it does seem that the medical community has a code of protection and people are loathe to turn someone in, especially if circumstances are ambiguous. We’ve seen cases where whistleblowers get fired or bullied, while the killer continues to work. It’s often a delicate situation, and good psychopaths know how to manipulate it to their advantage.”

Investigators have pinpointed the red flags that signal suspicious activity. Bruce Sackman, special agent in charge of the Northeast field office for the Office of the Inspector General, was one of the investigators on the team that played a key role in bringing Gilbert to justice.

He offers the following list:

• Statistically, a patient’s risk of harm is significantly greater when treated by the subject The subject is uncommonly accurate in predicting patients’ demise
• Patient deaths were unexpected by staff or family, and the family was not at the patient’s bedside
• Death certificate cites the patient’s last illness as the cause of death, or a catch-all is noted, such as cardiac arrest
• Initial review usually finds insufficient evidence to pursue the case, with buy-in from management
• The subject often continues patient care during investigation, and is removed only after allegations become public knowledge
• Fellow employees often report allegations to investigators, not management
• There are no eyewitness to the crime _ Witnesses say they saw the subject with the patient shortly before the patient died
• The weapon of choice is usually a sudden death chemical readily available on the ward and often considered non-detectable or not checked at autopsy
• Syringes, IV lines and feeding tubes are the most likely portals of entry if poison is used
• If a code is called, EKG strips should be in the chart; their absence should raise suspicions
• Subjects are often charming and friendly, yet have difficulty with personal relationships
• The subject receives good written reviews from supervisors _ Prior employment records show questionable incidents
• The subject is given nicknames by the staff while still employed
• Drugs, poisons and related books are found in the subject’s home
• Killing is non-confrontational
• The subject insists patients died of natural causes
• The subjects never show remorse for their victims
• Other patients complain about the subject but their comments often are ignored
• The subjects crave notoriety
• Evidence exists that the subject killed or attempted to kill off duty as well as on duty

Experts like Sackman and Ramsland agree that forensic nurses are in an excellent position to detect suspicious activity in their healthcare facilities.

“If they get trained in criminal behavior, forensic nurses would have a better eye for this behavior, but not all programs offer that,” Ramsland says. “A high victim count on someone’s shift is generally the first red flag. A regular incidence of patients going downhill after a particular doctor or nurse has been in their room; a healthcare worker who appears to have antisocial tendencies, who likes to talk about violence, who shows a high degree of excitement in emergencies, who is secretive, and whose emotional response to incidents seems shallow or superficial is someone to watch. If medicines that may cause coma or death are missing, that’s a red flag. A person who pays a lot of attention to the fatalities for entertainment value rather than to learn could be showing signs of a problem. But again, there’s no general psychological type. No matter what might be offered in terms of a set of red flags, psychology is a field full of novelties. There’s no way to predict what new behavior might arise that we haven’t seen before. But we can study the details of past cases and learn from them in order to see potential red flags sooner.”

Evidence goes to the heart of any criminal investigation, and Ramsland says forensic nurses should do everything they can to identify, collect and preserve it.

“Everything is potential evidence,” Ramsland emphasizes. “One never knows what small item will make all the difference in a guilty or not guilty verdict. Even nonphysical items, such as a man discussing his fantasy of seeing children die, can have evidentiary value (and has). Forensic nurses are trained to understand the importance of handling evidence, chain of custody, ensuring that specimens are protected from degrading, etc. They may be trained in character disorders common to criminal behavior in ways that other nurses are not, and they can spot some of the signals more quickly. They can also use their education in criminality to put pressure on medical boards and administrators to be alert to the cases. Above all, they can keep educating themselves in these cases, because the more one knows about what has happened in the past, the more one is able to recognize an ongoing linked series of incidents and to believe that a serial killer might indeed be in their midst. Education is the best way to erode denial and naivete, perhaps the serial killer’s most lethal allies in the medical system.”

With several cases pending and the news of serial killers in the newspapers, one would think the medical boards and institutions are responding to this seeming epidemic of healthcare serial killers, but Ramsland says healthcare is guarded about the situation.

“My impression is that the medical community in general views serial killing as an anomaly and deals with each case after the fact,” she adds. “I think there’s a general atmosphere of institutional self-protection and no one wants to have to make specific policies, other than to ensure better supervision. To do so would be to publicly admit that medical facilities are vulnerable to delusional workers or serial killers. That’s not good for business.”

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