Healthcare Serial Killers: Patterns and Policies

In a sordid, widely followed case that had repercussions beyond the borders of Canada, the Ontario-based nurse Elizabeth Wettlaufer was recently convicted of killing eight elderly patients and causing harm to a further six people in her care.^[1] The case was eerily reminiscent of those of two British serial killer nurses, Beverley Allitt^[2] and Benjamin Green,^[3] who were convicted in 1993 and 2006, respectively.

Has the medical profession produced a disproportionate share of serial killers relative to other professions? Yes, according to the psychiatrist Dr Herbert Kinnell, who wrote in the BMJ that those with a "pathological interest in the power of life and death" may gravitate toward patient care.^[4] Clearly, the trust inherent to care can be abused. The ready access to vulnerable people, combined with the medical knowledge to commit (and cover up) murder, can present the ideal circumstances for those with ill intentions to act on them.

Healthcare serial killers, usually defined as "any type of employee in the healthcare system who use their position to murder at least two patients in two separate incidents, with the psychological capacity for more killing,"^[3,5] represent one of the most monstrous abuses of trust. We review some of the worst perpetrators, while seeking explanations for their actions, identifiable patterns of behavior, and possible means to prevent future occurrences.

The First American Serial Killer

The man considered to be one of the first American serial killers and the inspiration for the book The Devil in the White City had set his sights on becoming a physician, but Herman Mudgett was reportedly expelled from medical school at the University of Michigan for insurance fraud relating to stolen corpses. He reappeared in Chicago in the 1880s as the pharmacist Dr H.H. Holmes.^[6,7] With the city basking in the limelight of the 1893 World's Expo, Dr Holmes built a mansion close to the fairground, to which the "reputable" druggist lured young women and men.

After his arrest for insurance fraud in 1894, the routine search of Dr Holmes' residence revealed a "murder castle"—recounted in gripping newspaper reports—replete with bolted chambers, hidden chutes, butcher's table, crematory, and mutilated body remains.^[8,9] Holmes is thought to have killed up to 200 people.^[9] He admitted to 27 counts of murder and was hanged in 1896.^[6,7,8,9]

Such red flags as medical school expulsions, dismissals from employment, and even revocation of medical licenses are a common theme among the rogues' gallery of medical murderers.

Peripatetic Perpetrators

The late-19th-century serial killer Dr Thomas Neill Cream was first caught in 1881 in Chicago, where he was convicted of murdering the husband of a mistress.^[10,11] Freed 10 years later, with his medical license revoked,^[11] Dr Cream moved on to London where in 1892, as the "Lambeth Poisoner," he was sentenced to hang for having poisoned six women with strychnine.^[12,13]

Shortly before his death, Dr Cream claimed to be Jack the Ripper.^[10,11] The true identity of that killer of five women in 1888 London has never been proven, but medical doctors—including Sir William Gull, "physician in ordinary" to Queen Victoria—are among the touted suspects.^[4]

Dr Cream's international carnage goes against the typical pattern of serial killers to operate in defined geographical areas.^[14] Extenuating circumstances, such as being convicted in one locale, can lead the killer to travel further afield to continue their murderous ways.

Such was the case with Dr Michael Swango, who is suspected of murdering up to 60 patients over a period spanning 20 years.^[15,16,17] He admitted to poisoning three patients while in Long Island and subsequently confessed to the murder in 1984 of Cynthia McGee, a patient during his brief time at Ohio State University Hospitals.^[15,17]

Dr Swango spent time in jail, changed his name (and then changed it back), and had his medical license revoked in two states,^[16] before practicing medicine in Zimbabwe and Zambia.^[17] He was arrested in 1997 as he prepared to board a flight for a new medical career in Saudi Arabia.^[15]

Early in his career, a student nurse witnessed Dr Swango inject a patient's intravenous line with something that trigged respiratory distress. She reported the incident to her supervisor, but no one followed up.^[18]

Unqualified Practitioners

Of note, female healthcare killers are caught more quickly than their male counterparts, whereas the opposite is true for nonmedical serial killers.^[19] Social scientists speculate that this is a reflection of "the hierarchy or privilege system within a hospital setting: male doctors occupy the top of the status hierarchy, whereas female nurses or nurse's aides are relegated to the bottom."^[19] Healthcare serial killers are more likely than non-healthcare serial killers to be women.

Ironically, a case involving an unqualified nurse became a rallying cry for the cause of state registration of nursing in Massachusetts. A one-time pupil in the nurse-training program at the Massachusetts General Hospital in Boston,^[20] Jane Toppan was indicted in Barnstable, Massachusetts, for the murder of three patients and found not guilty due to insanity. She was committed to an asylum.^[22,23,24]

According to an editorial in the American Journal of Nursing, Jane Toppan had merely posed as a nurse; she had been "discharged for cause" from her nursing studies in 1891 and was not a graduate. The writers described it as an "instance of the disloyalty of medical men to the graduate nurse."^[20]

Similarly unqualified, the appropriately named Dr Linda Hazzard apparently benefited from a grandfather clause that granted her the title of "doctor" on the basis of her (limited) experience as an osteopathic nurse^[25] and little other formal medical schooling.^[25,26,27]

Hazzard, who considered herself a wellness pioneer,^[27] was responsible for—and seems to have benefited financially from—the deaths through starvation of between 12 and 40 victims.^[26,27] Her sanatorium was designated "Starvation Heights" by locals.

Dr Hazzard seemingly practiced what she preached: She died, apparently of self-inflicted starvation, in 1935.^[26]

Angel of Death

A review of murderers in medicine would be incomplete without Nazi Germany's physician and physical anthropologist Josef Mengele. He was one of approximately 30 physicians, led by SS captain Dr Eduard Wirths, at Auschwitz concentration camp.^[28]

Mengele was known as the "Angel of Death" for his particular brutality and cold-bloodedness^[28]; this moniker is often applied to healthcare killers of any gender.^[3]

Would Mengele have been a serial murderer if Auschwitz had not provided him with the opportunity? "In ordinary times, Mengele could have been a slightly sadistic German professor," or so one physician claimed to the author of The Nazi Doctors: Medical Killing and the Psychology of Genocide.^[29]

After being wounded in combat, Mengele reportedly asked to be sent to Auschwitz because of the research opportunities. In the hospital block, Dr Mengele's sadistic experiments—often conducted on children—sought "to illustrate the lack of resistance among Jews or Roma to various diseases"^[28] and to explore his various theories on twins and heterochromia, among other subjects.^[28,30] Those who did not die during Mengele's torturous experiments were frequently murdered shortly thereafter for further examination during autopsy.^[28]

Another healthcare killer who took advantage of war and earned a salacious sobriquet was France's Dr Marcel Petiot, or "Dr Satan." He was convicted of murdering more than 20 people, whose remains were discovered in his basement furnace.^[31,32,33] In Paris, during the Nazi occupation, Dr Petiot earned the trust of Jewish people in hiding with fabricated stories of a network of smugglers who could ensure their safe passage out of France. He then killed them to steal their possessions.^[31,33]

A Troubled Past, and Other Warning Signs

Marcel Petiot seems to have left a complicated trail of deceit, erratic behavior, and criminality in his wake. He nevertheless managed to complete his studies in medicine, work as a physician, and become elected to political offices in several municipalities.^[32]

The aforementioned Dr Michael Swango may have been voted "most likely person to succeed" by his graduating class of 1972, but from his medical training through to his conviction for murder, he was followed by a cloud of suspicious, illegal, and often murderous activities—including a conviction in 1985 for poisoning the coffee and donuts of his fellow paramedics.^[16]

Are these patterns of behavior common to healthcare serial killers? Despite the apparent heterogeneity of offenders, Yardley and Wilson^[3]—writing specifically about nurses—build on a previously published 22-point checklist to present the following characteristics and circumstances that, when grouped together, should raise grave concern about a healthcare professional and prompt appropriate investigation:

• A comparatively high incidence of death on their shifts;

• A history of depression and/or mental instability;

• Behavior that makes their colleagues anxious;

• Possession of drugs (eg, in the workplace or at home); and

• Seems to have a personality disorder.

The case of Dr John Bodkin Adams appears to check all boxes, despite his acquittal in 1957 of the murder of patients Edith Morrell and Gertrude Hullett, These wealthy widows both left money and valuables to the physician in their wills.^[34] Bodkin Adams, who had been previously convicted of fraud, was subsequently found guilty of manipulating prescriptions for which his medical license was revoked (and reinstated 4 years later).^[35]

Shortly after joining a medical practice in the wealthy retirement location of Eastbourne on the British south coast, Dr Bodkin Adams became the subject of persistent rumors that focused on the suspicious deaths of his wealthy elderly patients; his use of dangerous drugs, such as heroin and morphine; and his sizeable wealth.^{[18,34,35,36]}

Dr Bodkin Adams died a free man in 1983. He was never convicted of murder, despite being suspected in the deaths of up to 132 patients.^[18] After his acquittal, the presiding judge, Lord Justice Patrick Devlin, remarked, "The rigorous standards of the law sometimes allow that the guilty walk free."^[36]

The Most Notorious of Them All

One of the most notorious cases in recent history is that of Dr Harold Shipman, which gained coverage in the medical journals as well as the lay press. On January 31, 2000, the seemingly congenial^[37] Dr Shipman—a general practitioner with a year-long patient waiting list^[38]—was convicted of murdering 15 of his patients and of falsifying one patient's will.^[37,39] He was sentenced to 15 consecutive life sentences and committed suicide in prison on January 13, 2004.^[40] He never admitted to nor spoke of the murders.^[38,40]

A public enquiry chaired by a senior high-court judge, Dame Janet Smith, was initiated in early 2001, becoming the largest forensic investigation in the history of the United Kingdom—involving over 1000 cases and 4 years of work.^[39,40] Dr Shipman, a graduate of Leeds School of Medicine who had practiced in West Yorkshire and in Ryde, Greater Manchester, was found responsible for killing at least 215 patients.^[39] The enquiry voiced serious concerns, but lacked conclusive proof, in a further 62 suspicious deaths.^[40]

In 1998, when he was charged with the death of Kathleen Grundy and of falsifying her will, it is estimated that Dr Shipman was killing at a rate of one patient per week.^[39,40] His victims were mostly women, tended to live alone, and were frequently killed using diamorphine.^[38] Shipman, who also stole from his victims, was 25 times more likely than comparable GPs to be present at the time of a patient's death.^[37,38]

The unusual rate of death of his patients fueled the suspicions of fellow GPs, a local undertaker, and a taxi driver who had an elderly clientele.^[37,38] The cabbie relayed that "My list of regulars was being cut back all the time...it began to feel wrong, and about 3 or 4 years ago I noticed all those who were dying went to the same doctor."^[38]

Some argued that Dr Shipman was a serial killer who just happened to be a doctor, but Dr Aneez Esmail, writing in the New England Journal of Medicine, countered that "it was the very fact that Shipman was a doctor that enabled him to kill and remain undiscovered" and called for more oversight and questioning of physicians.^[40]

The Cullen Law

The "Cullen Law" (officially the Health Care Professional Responsibility and Reporting Enhancement Act) "requires health care facilities to notify the state Division of Consumer Affairs with any information regarding impairment, incompetence or negligence by a health care worker that could endanger patients." It was passed in New Jersey in 2005 after the case of nurse Charles Cullen, who was convicted of killing 29 patients (and is suspected in other cases of suspicious death) in New Jersey and Pennsylvania.^[3,41,42]

Cullen led an erratic, troubled early life, characterized by unpredictable, cruel, or aggressive behavior and several suicide attempts.^[3,41,42] Nevertheless, he worked in nine hospitals and a nursing home over a span of 16 years.^[41] Throughout his medical career, Cullen was frequently dismissed or left employment under dubious circumstances. After his trial, the medical system was found at fault for its ultimate inability to stop Cullen from becoming one of the most prolific serial killers in US history.^[3]

The exact number of Cullen's victims is unknown. However, his pattern of behavior was consistent: He preyed on vulnerable patients, in such circumstances as night shifts that provided him with relative "freedom," during which he injected them with lethal doses of drugs, including digoxin.^[41,42]

Vulnerable Victims

An analysis of 58 healthcare serial killers by Canadian researchers found that many investigations were initiated because of concerns expressed by coworkers.^[19] The authors explain that like con men (or women), these murderers prey on the most vulnerable patients, often getting to know their victims to earn their confidence while cleverly deflecting suspicion to prolong their murderous activities over potentially long periods.^[19]

Victims of healthcare killers tend to be extremely young (infants); elderly; or otherwise vulnerable, such as the very ill, in contrast to the runaways, drug addicts, or sex workers that sexual serial killers prey upon.^[19] In the Canadian analysis, the victims were overwhelmingly elderly, but access can determine victim selection—as occurred in the cases of nurses working the children's ward.

Genene Jones is currently serving two concurrent jail terms: 99 years for the fatal injection with a muscle relaxant of 15-month-old Chelsea McClellan in 1982, and 60 years for the injection with an anticoagulant of a 4-year-old boy who survived.^[43,44,45] During her trial, an expert witness testified that Jones appeared to be "driven by a desire to be seen as the heroic nurse who rescued dying children" and was "intoxicated with the power of life and death she wielded over children."^[44] Such variations of Munchausen syndrome by proxy—where parents or caregivers induce illness in their children in order to gain medical attention—have been cited as motivation for others, including the child-killing nurse Beverly Allitt.^[3]

During the 1970s and early 1980s, Jones practiced as a pediatric nurse in numerous clinics, doctors' offices, and hospitals in Texas.^[44] She had been considered "a deeply divisive figure"^[45] and "overbearing and foul-mouthed yet exceedingly confident of her medical knowledge and nursing skills."^[45]

An investigation by the Centers for Disease Control and Prevention found that between April 1981 and June 1982, when Jones worked at the pediatric intensive care unit at Bexar County Hospital, a child was over 25 times more likely to undergo a medical emergency and over 10 times more likely to die when Jones was on duty.^[45]

Friendly Persona

Whereas revenge, sexual excitement, power and control, and sexual access have motivated traditional serial killers, these factors seem less applicable to healthcare serial murder.^[19] Although some perpetrators, such as Cullen, claimed to be mercy killers, the evidence doesn't back them up, and many sick or elderly victims were not in danger of dying without their interference.^[3]

Healthcare serial killers put on a convincing front of affability and concern for their patients.^[19] Donald Harvey, a nurse's aide, was described by the wife of one of his victims as "so nice, so cheerful, always helping" and by Dr Emmanuel Tanay, a psychiatrist and expert on serial killers, as "very much in control of his actions," a person who "must gratify an inner need, a tension, by killing."^[46] In 1987, Harvey confessed to killing 37 people, mostly by poisoning them with cyanide, rat poison, arsenic, or petroleum, which he mixed into drinks and food.^[47,48,49]

Family members often have a positive impression of the perpetrator, and such cultivation of relatives helps the killers remain above suspicion. Nurse Beverly Allitt gave twins Katie and Becky Philips an overdose of insulin but only succeeded in killing one, leaving the other brain damaged. The parents were so grateful to Allitt for seemingly saving Becky that they made her the surviving twin's godmother.^[19]

The offspring of one of Harold Shipman's victims said, "He was a marvellous GP apart from the fact that he killed my father."^[38]

Insulin overdose and poisoning in general appears to be the preferred modus operandi for healthcare killers.^[3,19] The rarity of autopsy after the death of a sick or elderly patient facilitates evasion of capture among healthcare professionals who have ill intent.^[19] Harold Shipman persuaded relatives that he could certify the cause of death in cases where the sudden death of previously nonterminal patients should have prompted a coroner's investigation.^[38]

Gallows Humor and Risk-Taking

Mirroring the way in which other serial killers taunt the police and the media via letters, healthcare serial killers use gallows humor to flaunt their accomplishments without necessarily arousing suspicion.^[14] They often take pride in the monikers they have earned through their deeds or coworkers' suspicions. The globetrotting poisoner Michael Swango reveled in the nickname "Double-O Swango—licensed to kill," bestowed on him by colleagues after a spate of his patients died.^[17,19] Donald Harvey similarly joked with coworkers about the number of patients who died while he was on duty. "He'd say, 'I got another one today,'" the prosecutor told the court at his trial.^[47]

Such joking can allow the murderers to relive their killing experience, as can fostering and continuing close relationships with victims' relatives.

Traditionally, serial killers escalate their behavior in the pursuit of bigger thrills.^[14] For healthcare killers, this may take the form of injecting victims in front of an audience (other healthcare professionals or relatives of the victim) to satisfy a need for more excitement as their killing career progresses.^[19]

According to the Federal Bureau of Investigation (FBI), these risky behaviors and provocations should not be interpreted as a desire to be caught: "It is not that serial killers want to get caught; they feel that they can't get caught," as their confidence grows with each offense.^[14]

Ways to Protect Society

Lubaszka and colleagues^[19] contend that healthcare serial killers should be easier to catch than traditional serial killers because the location and means of their crimes are predictable. They propose the following four policies:

1. A system of national-level communication among hospitals to report and share matters of discipline and misconduct of healthcare professionals.

2. Better systems for accounting for medicines (such as fingerprinting and weighing).

3. Better means for hospital administrations to encourage patients and staff to report inappropriate behavior, which should be investigated. Along the same lines, families of patients should be encouraged to listen and act on the concerns of their loved ones.

4. Revamped in-service ethics training to reinforce the moral and legal obligations of all healthcare employees.

Serial murder may garner headlines and our macabre fascination, but it is thankfully extremely rare. The FBI estimate that < 1% of all murders committed in any given year are the act of serial killers; medical murderers are a subset of these.^[14] Regarding the Shipman case, the UK's chief medical officer, Liam Donaldson, concluded that "Everything points to the fact that a doctor with the sinister and macabre motivations of Harold Shipman is a once-in-a-lifetime occurrence."^[37]

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Cite this: Steven Rourke, Tricia Ward. Healthcare Serial Killers: Patterns and Policies - Medscape - Aug 14, 2017.