Nurses Who Kill

Even now, before the investigative dust settles, there are two sides to the Charles Cullen case. Police arrested Cullen, an RN, in December 2003 for the murder and attempted murder of two patients at Somerset Medical Center in Somerville, N.J.

According to his claims, Cullen killed between 30 and 40 patients during his 14-year nursing career. That is one story. The second story, perhaps not as dramatic, is his employment record. Ten times he was hired, five times he was fired, four times he was questioned about patient deaths, and twice he was accused of improper administration of medications. The second story is about the decisions made along the way, the decisions that allowed Cullen to move from one healthcare facility to another, without suspicion, without alarm, without raising an eyebrow.

In a written statement, New Jersey senators Frank Lautenberg and Jon Corzine said, “The confessed killing spree ripped open shocking flaws in the nation’s system of screening healthcare professionals.” Lawmakers were among the first to react to the story as calls went out for better systems and comprehensive databases that would mandate more inclusive reporting of healthcare professionals.

“We need to look at how we can strengthen the reporting requirements,” says Cheryl Peterson, RN, of the American Nurses Association, “We need to bring all healthcare practitioners up to the standard of physicians.”

Physician data is currently compiled within two systems, the National Practitioner Data Base (NPBD), created by Congress in 1990, and the Federation of State Medical Boards (FSMB). “The FSMB is a centralized database that compiles reports from each of the individual state medical boards,” says Robert Wise, MD, vice president of the Division of Standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). “The NPDB vides information to hospitals and other healthcare facilities on disciplinary action, malpractice payments, and hospital punishments of physicians. These currently are our best systems for monitoring reported problems with healthcare practitioners.”

“There have been instances where hospitals have faced costly lawsuits after taking away a physician’s privileges,” Wise adds. “Instead, the physician is asked to leave, no report is generated and the physician is free to practice somewhere else.”

A recent story in a New Jersey newspaper reported on an anesthesiologist who was convicted of manslaughter in England in February 2001, after failing to monitor a patient under his care. Unable to practice in England, the physician came back to the states and renewed his New Jersey license by checking “no” when asked if he had been convicted of a crime and whether his license had been suspended or revoked. Since he was a foreigner, the conviction was not recorded on the NPDB. Even when he was reported to the state board, it took 11 months for the board to file a complaint. He was allowed to practice while he was under investigation and during the appeal process.

In 2002, the New Jersey Board of Nursing disciplined 56 nurses; another 68 had their licenses revoked or voluntarily surrendered them. State nursing boards want to raise awareness of what should be reported, and the National Council of State Boards of Nursing (NCSBN) is coordinating the boards in a national system, the Nursys Data Bank, to allow better access to complaints and records across state lines. Twenty-seven nursing boards now participate.

“We are very interested in coordinating the boards so information can be shared from state to state,” says Kristen Hellquist, associate director for policy and external relations at the NCSBN. Hellquist knows that no reporting system is foolproof. “All the databases in the world wouldn’t have stopped Cullen,” she adds, “if no one reported the problems.” The Nursys DataBank would not have stopped Cullen, since no state board ever took action against his license until December 2003.

By the time he started working at Somerset Medical Center, Cullen had been investigated in two cases of patient deaths and fired from several hospitals, but no complaints were filed in New Jersey. In June 2003, the hospital conducted an internal investigation because of test abnormalities in lab results. When possible explanations such as faulty equipment or operator error were ruled out, the New Jersey Department of Health was called in to conduct its own investigation; however, the second investigation proved to be inconclusive. Still looking for answers, the hospital called in the county prosecutor’s office. The hospital fired Cullen and reported him to state authorities on Oct. 31, 2003. Cullen was charged with murder and attempted murder of two patients on Dec. 15, 2003. Dennis Miller, CEO of Somerset Medical Center, praises his staff for their efforts in putting the pieces together.

“We didn’t choose this,” Miller says, “but I am proud of our staff, our NPs, ICU nurses, pharmacists, and lab techs, who all worked to find the answers. It must be mandatory for any licensed healthcare facility that has suspicion of potential criminal activity to report this to the licensing boards as well as the local prosecutor office.”

Bruce Sackman, special agent in charge of the Office of the Inspector General, Northeast Field Office, U.S. Department of Veterans Affairs (VA), has a great respect for the role that nurses can play in the investigation of suspicious deaths. Sackman worked on investigations of two notable healthcare serial killers. Dr. Michael Swango was convicted of killing three patients at a Long Island VA hospital in 2000, and was suspected of killing between 35 and 60 patients throughout his career; Kristen Gilbert, a nurse, was convicted of killing four patients and attempted murder of three others in the VA Medical Center in Springfield, Mass., in 2001.

“Healthcare facilities need to develop policies and procedures regarding suspicious deaths,” Sackman says. “Management has to establish a standing operating procedure, so staff knows what to do when they have suspicions. Just as facilities have disaster drills, suspicious-death drills must be incorporated into their regular training. They must know how to secure evidence and protect the crime scene.”

Sackman says whistleblowers must be protected, and there must be immunity for facilities that report suspicious activity. Every licensed healthcare provider should have the ability to declare a suspicious death and know how to call for an investigation. And every hospital should have a forensic nurse on staff.

“I think that every hospital should have a forensic nurse, a trained staff person who can work with police to conduct suspicious death investigations,” Sackman says. “The nurse is able to bridge the gap, translating all of that medical information and hospital routine for law enforcement investigators.”

Sackman reports that he worked with a team of VA nurses during the Swango investigation, and again during the Gilbert case. “I would not do a healthcare investigation without a nurse on my team.”

Carol N. Dunbar, APRN, has worked as a staff nurse, patient educator and nursing supervisor, and is currently a patient-relations representative at The Valley Hospital in Ridgewood, N.J. She was a special agent with the FBI from 1983 to 1984.

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