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Kristen Gilbert Case Explored in New Book
M. William Phelps, author of Perfect Poison, shared his views
on healthcare serial killers with Forensic Nurse editor Kelly M. Pyrek:
 Q: Are healthcare serial killers getting smarter these days?
A: "For many sociopaths like Kristen Gilbert who work in the
healthcare industry, their work environment plays into their already twisted
theory that they think they can get away with it because of who they are and
where they work. Secondly, if they honestly believe-which many do-that they're
smarter than their colleagues and management, they will always feel superior. I
believe there's a complete breakdown within the system of management around
them, along with the way some hospitals have kept track of medications,
ultimately allowing the serial killer, at the least, some sort of a veil of
protection to hide behind. In the Gilbert case, there was no structure or method
in place to keep track of epinephrine, which was under an automatic restock
policy. Whenever the drug went missing from the satellite pharmacy or crash
cart, it was immediately restocked without question. Even if the VA hospital in
Northampton had kept a simple handwritten inventory of the drug, it would have
realized quickly that the drug was routinely coming up missing-about 125
ampoules altogether. Epinephrine is, potentially, a killer in the wrong hands.
Why, I asked myself time and again while doing research for the book, wasn't it
accounted for? We can never forget that this type of killer is usually a very
intelligent person who has studied various ways in which he or she can kill. If
hospitals cannot put policies and procedures in place-and demand their employees
take responsibility-specifically designed to watch out for this type of
sociopath, he or she will pop up time and again."
Q: Is there a profile of the typical healthcare serial killer that has any
real meaning to investigators?
 A: The profile consists of the most trustworthy and intelligent nurse
on staff, like Gilbert was-someone who is, on paper, the least likely to be
involved. There's also the anti-social person, the outcast, the person who keeps
to him- or herself. Most are generally well-liked, highly motivated and
successful-at home, at work, on a social level. Most of these killers have
thought out their crimes for a long period of time. Premeditation is ubiquitous
in a majority of these cases. These types of serial killers are waiting for the
perfect time to start killing. It is the vocation that supports the crime. A
tremendous amount of trust is placed in the hands of a nurse-and rightly so. We
put our lives in their hands. But things can happen. If a nurse puts the decimal
point in the wrong place on a computerized IV machine, a patient could easily
end up dead. It's happened before. The nurse who is prone to criminal behavior
might choose her vocation carefully in the same way a pedophile might choose to
be a coach, a teacher, a daycare worker."
Q: What is the prime motivation to kill?
A: "It is my opinion the motivation to kill lies in the narcissistic
or anti-social psyche of these people. They yearn for a high they get from
committing their crimes. Nursing allows the narcissist to perform (work) on a
stage in front of an audience (coworkers). For the narcissistic or borderline
personality nurse, the need to increase that high continues to increase the more
they kill, in the same way a heroin addict would need more dope to maintain the
addiction. After she commits a crime, she feels she has gotten away with
something. That is the high. The same way a thief might get high from stealing,
the healthcare serial killer chases this same euphoric state. But when it
becomes routine or easier to get away with it, the thrill is gone. As Gilbert
continued to get away with killing her patients, she began to drop clues and
kill her patients right under the noses of coworkers. There were about six
nurses near her when she tried killing one of her last victims. I have to
believe that it wasn't enough for her after a period of time to just kill. She
had to continually up the ante or it wouldn't give her that manic high she
craved. Serial killers don't wake up one day and say to themselves, 'I think
I'll begin killing people today.' This behavior is wired into the brain at some
point during childhood. They are intelligent and narcissistic -- it's all about
them. They must be the center of attention."
Q: Is it common for murders to continue for a while before the healthcare
facility intercedes?
A: "Until this problem is addressed specifically, it will continue.
Management needs to first understand there is a problem and admit it. I don't
see that they are doing that. The focus should be put on video surveillance in
hospital rooms (with an eye in the sky, a nurse might think twice about what he
or she is doing), drug testing of employees, psychological evaluations on an
annual basis, and, perhaps most important, a staff that is not ashamed to admit
that it might have a problem nurse. Management should have their feet put to the
fire, too. There should be a cap on how long a person can stay in the same
position. Complacency can be the ultimate mistake. Management needs to step up,
admit its weaknesses and move on. A nurse should never feel threatened about
coming forward. There should be an anonymous system in place for whistleblowers.
Nurses are afraid of being ostracized. Many times nurses will have the 'I can't
believe it' syndrome. I was told by some that Gilbert's superiors later said,
'We didn't go to work looking for a serial killer.' Well, maybe they should!
There should be a system in place where a hospital employee can go in and report
something without feeling threatened about being branded a rat or fired. I don't
think that's the case right now. I still talk to a few nurses on a weekly basis
who tell me things haven't changed all that much."
Q: Why are suspected killers sometimes allowed to continue in their jobs
even when there might be actionable proof for an arrest?
A: "Everyone seems to be afraid of lawsuits and the ramifications of
bringing false accusations against someone in the healthcare community. As a
potential patient, I find that unacceptable. As an investigative journalist, I
find it to be one of the main reasons why there are often several deaths
involved in a lot of these cases. People in white-collar positions don't act
fast enough. They make sure all the T's are crossed and the I's are dotted
before any action on the floor is taken. That's nonsense. If a nurse is
suspected of negligence or criminal behavior, he or she should be placed on
leave immediately and an investigation initiated."
Q: What are the red flags that point to a healthcare serial killer?
A: "Coincidences and statistics. Numbers do not lie. In Gilbert's
case, between 1990 and 1991, there were approximately 30 code blues on her
shift, on her ward. She had called 22 of them herself. I spoke to several nurses
who told me that they haven't seen 30 codes in all their years as nurses. One
nurse told me that in 20 years she might have seen 10 codes, and maybe called
one or two herself. Moreover, a simple graph or chart of Gilbert's shift
throughout the years she'd worked in Northampton-I'm talking the early years, a
half decade before she was suspected of killing people-shows a remarkable
increase in the amount of deaths and codes-not in the entire hospital, mind you,
but on her shift alone, signed off by her. In 1990, on her ward, on her shift,
there were 30 deaths. On all other shifts and wards combined, 28. In 1991, her
shift yielded 31 deaths, whereas all other shifts and wards combined had about
20. 1992, 27 on her shift/ward, 25 on all others. 1993, 30 on hers, 25 on the
others. 1995, 38 on hers, 15 on all others. There's an obvious pattern of
something going on. Both before she was hired and after she left the hospital
the numbers were about where they should have been: there were approximately the
same number of deaths-considerably lower, at about an average of 22 combined-on
each shift on each ward. When Gilbert was around, the numbers for codes and
deaths not only increased, but they doubled and tripled. Dr. Michael Baden told
me that when he first began to look at all the medical records involved, the
first thing that stood out to him was all of the deaths Gilbert had signed off
on. One statistician calculated it at about a 1 in 100 million chance that it
could have been a coincidence. Investigators are more aware of what to look but
they cannot begin looking until someone on the floor brings it to their
attention. That's where the breakdown is. Maybe we should have medical
investigators on site, and not rely on quality management, who, at least in the
Gilbert case, failed horribly at their jobs."
Q: Are the medical boards responding to this seeming epidemic of
healthcare serial killers?
A: "Absolutely not! In the Gilbert case, a medical emergency committee
met once a month to discuss conduct by nurses and doctors during codes-had the
staff done their jobs, in other words? In fact, Gilbert's boss was the head of
that committee. Why did that committee miss this? Codes and deaths were out of
hand for seven years. Gilbert acquired the nickname 'angel of death' (in a
joking fashion, by the way), from her colleagues back in 1990. Complacency! The
mentality is: This cannot be happening here. Why, I have to ask, couldn't an
internal 'study,' if nothing else, be done to see what was going on? In many of
these cases, we need to understand, these patients weren't on their deathbeds;
many were in the VA for routine matters. For some reason, their lives ended
abruptly. Whenever that is the case, Baden clearly explained to me during one of
many conversations I had with him, it means that a third party or third element
contributed to the patient's death. I often ask people associated with the
Gilbert case if that medical emergency committee had played cards and talked
sports during their meetings-because they certainly weren't doing their jobs.
That is utterly obvious in the evidence. Moreover, a colleague of nurse
Gilbert's had been shooting heroin for many years, yet he still received stellar
work performance evaluations year after year and, on some nights, was the nurse
in charge on her shift, in her ward. How can this happen?"
Q: How can forensic nurses ensure that collection and preservation of
potential evidence be done consistently and timely, and how can this evidence be
protected?
A: "Whenever a death occurs during a code, anything associated with
that code should be viewed as potential evidence of a possible crime. There
should be procedures-which there are-in place to preserve and protect the
integrity of that potential evidence. Specific nurses should be assigned to
preserve that evidence. No one else should be allowed to touch it. To me, it's
not only about procedure and policy, but adhering to these principles. Is
everything considered to be potential evidence? Absolutely. Consider this.
Gilbert was falsifying medical records and cutting out sections of EKG strips to
cover up her crimes, yet, at the same time, leaving spent and broken ampoules of
epinephrine out in the open. She knew that epi wasn't controlled or accounted
for; and she knew which parts of the a patient's medical record would go under
the most scrutiny and which wouldn't. Gilbert used the system that was already
in place to her advantage. So, everything, from discarded surgical gloves to the
packaging medications come in, should be regarded as evidence. A dead patient's
room should be taped off and considered off limits to anyone until it has been
disproved that a crime did not take place. Is this too extreme? It very well may
be. But it's been proven that the system in place now is not working."
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