Serial Killings and Attempted Serial Killings in Hospitals, Nursing Homes, and Nursing Care

Background: Serial killing by doctors or nurses is rare. When it occurs, it is generally only detected after multiple homicides by the same perpetrator have escaped detection in the past. The persons at greatest risk are multimorbid elderly patients whose sudden death for natural reasons would not come as a surprise. However, patients’ risk of falling victim to homicide is increased only if such vulnerable patients are exposed to perpetrators with certain personality traits. In this situation, homicides can be committed in which little or no evidence of the crime is left behind. In this review, we address the frequency, nature, and circumstances of serial killings and attempted serial killings in hospitals, nursing homes, and nursing care.

Methods: This review is based on publications retrieved by a selective review of the literature in monographs, medical databases, specialty journals, general-interest media, and the Internet.

Results: An evaluation of searchable, published case descriptions of serial killings and attempted serial killings in hospitals, nursing homes, and nursing care, mainly from Europe and the English-speaking countries, enables identification of the type of patients at risk, the modes of homicide, and the personality traits of the perpetrators. Multimorbid, care-dependent and nursing-dependent persons are the main victims. The perpetrators (men and women) generally act alone and have often been working in patient care for many years. The most common method of homicide is by drug injection; violent physical homicide is rarer. In many cases, irregularities in drug stocks, erratic behavior of a staff member, and/or a cluster of sudden deaths are indeed noticed, but are too slowly acted upon.

Conclusion: Irregularities in drug stocks, inexplicably empty drug packages and used syringes, erratic behavior of a staff member before and after a patient’s death, or a cluster of unexpected deaths mainly involving elderly, multimorbid patients (detectable from internal mortality statistics) should always lead to further questioning and investigation.

Serial killings in which the crime scene is the workplace and the perpetrators belong to a specific occupational group happen most commonly in healthcare facilities (1). These are places where death occurs on a regular basis and is sometimes expected imminently. Staff members routinely care for patients and handle medications. Homicide can be carried out inconspicuously, e.g., by injection into a vascular access port. Moreover, hospital patients and nursing home residents expect to be helped and do not harbor suspicions against the very persons who are going to provide assistance. In the case of such serial killings, external examination of the corpse generally reveals no sign of unnatural death. Death is certified as being from natural causes because the victims had diseases which can often—though not always—explain sudden death. The homicides often remain undiscovered for a long time; only retrospectively do relevant signs, barriers to detection, and the fact of killing emerge. Serial killings and attempted serial killings are baffling, because the background and motives remain unclear. The following questions present themselves: What are the characteristic features of serial killings in hospitals, nursing homes, and nursing care? What grounds for suspicion and preventive measures emerge?

On the basis of published case descriptions, this article surveys the circumstances of homicide; the means used to bring about death; the occupation, age, and sex of the perpetrators; the number of victims; and the outcome of legal proceedings. The characteristics of the killings are analyzed. The restriction of the data to case reports and the inadequate documentation of such events hampers research and limits generalization. A total of 43 instances of serial killing were reported worldwide between 1970 and 2006, with 305 confirmed victims (2) and more than 2079 suspicious cases (3).

Methods

Monographs and specialist journals in medical and general databases (PubMed, JUSTfind, Google, Google Scholar) were surveyed selectively with the aid of search terms, and articles in generally accessible publications such as newspapers and magazines were searched on the Internet (for references to homicides, hospitals, clinics, nursing homes, homes, serial killings, healthcare systems). Analysis followed in cases where there had been attempted or successful killing of at least two persons and the following basic data were, broadly speaking, available: site of crime, sex, occupation, and age of perpetrator, modus operandi, number and age of victims, details of sentencing. Data published later than 1945 were considered for inclusion. We excluded, for example, cases published in the respective national language by local media across the world.

Results

Altogether we found evaluable sources of data on 70 serial homicides (eBox 1). Twenty-three of these were serial killings or attempted serial killings in the German-speaking countries (Germany, Austria, Switzerland; Table 1), 26 took place in the USA (eTable), and 21 were in other countries (Belgium, Brazil, Canada, Czech Republic, Finland, France, Great Britain, Hungary, Ireland, Netherlands, Norway; Table 2). We excluded patient homicide scenarios (4, 5, 6, 7, 8, 9) that could not be viewed as serial killings. These included inappropriate treatment ending in death, killing by severely mentally ill fellow patients, and altruistically motivated acts in the sense of euthanasia or mercy killing. Frequently the minimum number of judicially accepted victims of serial killing is reported. Alongside these confirmed homicides there are further cases that are either not brought to court or could not be proved at trial. Hospitals were most often the scene of the crime (n = 57), followed by nursing homes (n = 11) and outpatient or domestic care (n = 3). At a conservative estimate, there were at least 616 judicially determined homicides and 1879 suspected attempts.

Table 1

Serial killings and attempted serial killings in hospitals, nursing homes, and nursing care: verdicts and reports from German-speaking countries

Table 2

Serial killings and attempted serial killings in hospitals, nursing homes, and nursing care: cases outside the German-speaking countries and the USA

eBox 1

Serial killings: the data, as far as available, from 72 reports

eTable

Serial killings and attempted serial killings in hospitals, nursing homes, and nursing care: verdicts and reports in the USA

The majority of the perpetrators had been working in the healthcare system for a long time. The victims were often frail elderly patients with pre-existing illness and limited resilience who were unable to defend themselves. Only in four instances were neonates or children among the victims.

Hospitals, nursing homes, and nursing care locations as crime sites

It is unlikely that all serial killings and attempted serial killings were captured; in a few cases merely a newspaper article without detailed information was found. A tendency towards higher totals of victims than reported can be assumed, because the numbers are derived partly from statements by the perpetrators, who have no interest in voluntarily revealing greater numbers of victims.

The serial killers from the medical professions in the healthcare system include physicians (e.g., Harold Shipman [Table 2, no. 21]) (7, 10). Killings have also been committed by physicians with falsified qualifications, as shown by the case of a supposed anesthetist (Kassel District Court, verdict of 25 May 2022; ref. no. 6 Ks–1622 Js 24089/19; 3 murders, 10 attempted murders). Not infrequently, the killings carried out by physicians are so-called mercy killings or medically assisted suicide. In April 2022 a jury in the USA found a physician (Dr. Husel, Ohio) not guilty of murdering at least 14 severely ill patients with high doses of opioids.

Although death is a not infrequent occurrence in healthcare facilities and existing illnesses may seem to plausibly explain the patient’s passing at the time concerned, the sudden nature of decease may occasion suspicion and prompt verification of the cause of death by means of autopsy. Several factors often coincide:

• Severe (pre-existing) illness of the patients
• High pressure of work
• A difficult working atmosphere
• Assumption of heavy professional responsibility.

The perpetrators are part of a hierarchy, have to follow instructions, but at the same time bear responsibility. This may be perceived as stressful. In addition, they have a need for appreciation of their worth or seek to underline their importance.

Mode of homicide

The majority of the persons who became serial killers had—apart from their role in emergency resuscitation—very little influence on the treatment. However, serial homicides are not a documented treatment variant with intended (“slow euthanasia”) or unintended advancement of the time of death. Rather, they represent deliberate action when circumstances permit, e.g., an unobtrusive injection, coupled with knowledge of the effect of medications (antidiabetics, electrolytes, muscle relaxants, heart drugs, sedatives). The patient’s death is often not intended, e.g., when a midwife injects an anticoagulant or a pediatric nurse injects medications (Table 1, nos. 16 and 22). Intention is present, however, as in case 17 in Table 1, when a dramatic emergency is brought about so that the perpetrator can demonstrate their own competence and gain appreciation.

Besides killing by means of injections, serial homicides by asphyxiation (covering of the mouth and nose) have been described, and also by pouring water into the respiratory tract (Table 1, no. 8). Furthermore, in 10 cases mechanical asphyxiation was reported (Table 1, Table 2, eTable).

Problems of proof

At best, a serial killer’s final victim can be autopsied soon after death; the number of victims frequently remains unknown. Death from natural causes is often certified. In the absence of a plausible reason for death, not uncommonly a “diagnosis” such as heart failure, cardiac arrest, or fatal cardiac arrhythmia is given. This also happens because the sudden nature of death is not critically questioned and suspicions are not reported: either from fear of personal detriment or due to concern for the institution’s reputation.

Estimation of the true total number of victims in cases of serial killing is problematic for a number of reasons. It is conceivable that perpetrators desist from further killings after two or three undetected homicides. Moreover, in the past suspicion was probably aroused even less often than in recent years.

The processes of autolysis and putrescence that begin after death may mean that indubitable proof of fatal manipulation, be it administration of medication or violent asphyxiation, is no longer possible.

Homicide by physicians also occurs, but is not the focus of this article. Demarcation from the condonement of death due to high dosage in the context of palliative care is not easy, and detection is difficult when physicians are simultaneously the agents and the persons responsible for determination of the cause of death. However, it is not our intention to trivialize this problem.

Exhumations after serial killings

A long post-mortem interval considerably reduces the likelihood of establishing the cause of death, although toxicological analyses may be helpful depending on the drug or toxin used (11, 12, 13). Problems arise, for instance, in the postmortal detection of medications whose active substance is not only administered intravenously but is also contained in active sprays and gels that are employed in catheterization or bronchoscopy. The detection of frequently administered drugs is less conclusive than the demonstration of an antiarrhythmic agent not commonly used during the period concerned.

Proof of homicide is hindered by unclear or missing data on the dosage of therapeutically indicated medication. Toxicological analyses can often demonstrate the presence of drugs in an exhumed body, but quantification, if possible at all, requires interpretation, because postmortal processes of redistribution, elimination, decomposition, and changes in concentration due to water loss in tissues and bodily fluids may lead to significant alteration in levels (14, 15). Assessment of whether overdosing took place may be achieved by means of analysis of the total amount of substance still present in the specimen (e.g., stomach contents or tissue sample).

Personality and motives of the perpetrators

A typical example of an major mode of serial killing is provided by the case of the nurse N.H., who in two different hospitals gave patients cardiovascular drugs to put them in a state requiring resuscitation, with the aim of distinguishing himself when the resuscitation attempt then took place (eBox 2).

eBox 2

The case of the nurse N.H.

The perpetrators’ personality patterns embrace various intentions and profiles, but some characteristic traits stand out from the literature (16, 17). Also in the case of N.H., prominent features noted during his detention included the desire for respect, thoughts of grandeur, manipulative tendencies, a pronounced need for attention, and even behavioral abnormalities such as Münchhausen syndrome. These observations led to the diagnosis of a combined personality disorder with narcissistic, histrionic, and dissocial elements. Given the nature of the attacks, characterized by planning, caution, and successful concealment, there can be no doubt of his culpability according to §§ 20, 21 of the German Criminal Code.

The personality traits mentioned above are important when considering how the serial killings could come about. In the case of N.H., the hypotheses of euthanasia, i.e., that he wanted to end the patients’ excruciating suffering (18), and homicidal lust, in other words that he took sadistic pleasure in tormenting and killing them, were rejected.

The desire for attention and approval may be decisive. In the case of N.H., “display” behavior was noted. Also important is the need for excitement and “thrills.” The person concerned often has narcissistic ideas of grandeur, importance, and power, together with self-aggrandizement to the point of feeling like the lord of life and death (19). N.H. stated that he wanted to command admiration: it would have to be something grandiose. The accounts show that the actions also served to provide relief in narcissistic crises. They helped to improve the perpetrators’ mood and stabilize their self-esteem. Feelings of apathy, dissatisfaction, stress, and internal unease could thus be repressed.

A further motivational factor is an underlying rivalry with physicians, the intertwining of the roles of doctors and nurses. For instance, N.H. complained of the physicians’ incompetence and arrogance, seeing no significant difference between their duties and his own. In the emergency rescue team he stood out as coming to work dressed completely in white, in contrast to the other paramedics.

Finally, another important element is depersonalization and objectification of the patients: in the course of the exploration, N.H. said that they “no longer possessed any human attributes.” It disturbed him when they spoke. According to him, the only good patient was one covered with a green sheet. He no longer perceived victims as individuals but dehumanized them. This was made easier by the fact that they were being ventilated and could no longer communicate.

Such perpetrators do not have alternative conceptions or feelings of remorse that are strong enough to oppose the increasingly embedded behavior patterns. This points to a lack of stabilizing influences such as conscience, empathy, and a value system. One expert witness characterized this as ethical dereliction and moral brutalization. From the viewpoint of forensic psychiatry and criminal prognosis, it can be assumed that in such cases, especially those with an extensive history of relevant crimes, a propensity towards comparable deeds is deeply embedded in the personality and the risk of reoffending correspondingly great.

Cases of serial killing mostly display a specific interplay of social, institutional, and individual factors. The leading motive is the individual pursuit of prestige and increased self-esteem. Extension of a series of crimes over a period of years is favored by positive reinforcement, routine, and habituation, supplemented by clinical deficits in organization, risk management, and quality control (4, 5).

Reasons for suspicion in the workplace and preventive measures

The analysis of documented cases reveals that the following circumstances may constitute reasons for suspicion:

• No evaluation of whether death was plausible on the basis of the underlying illnesses
• Ad hoc, no convincing natural cause of death
• Specification of the mechanism of death on the death certificate, such as heart failure or cardiac arrhythmia
• Irregularities in drug stocks
• Inexplicable discovery of used syringes
• A disproportionate accumulation of fatalities
• “Concealed hints” by a member of staff
• Overzealous involvement in emergency situations with a discernable need for praise and approval
• Access to drugs
• Rumours around fatalities
• Handling of drugs unconnected with the concrete patient care tasks

Preventive measures:

• General measures to counter a culture of “looking the other way”
• A system for anonymous reporting of suspicious cases
• Staff training to improve awareness of the problem
• Addition of the topic of (serial) homicide to the advanced training curricula of physicians and nurses.

Implementation of precautionary measures

First suspicions should not be discounted. If there is a death register, fatalities can be compared with staff duty rosters. However, statistical peculiarities alone should not be overrated (35). There should be regular, thorough audits of the drug stocks, with additional checks whenever indicated. Blood samples for toxicological analysis can be taken from patients who survive an event. An inexplicable cluster of non-fatal incidents, e.g., cardiac arrhythmia—all the way to successful resuscitation—should prompt investigation and an attempt to identify a natural explanation against the background of the affected patients’ illnesses (20).

In the event of suspicious circumstances or inconsistencies, death should be followed by autopsy with toxicological tests. Autopsies also serve to exonerate persons under suspicion and clear up unanswered questions (21). A higher rate of autopsy may increase the risk of discovery and have a deterrent effect. State prosecutors have suggested setting up dedicated prosecutors’ offices and centralized inquiry teams for crimes in the care and medical sectors. In the German federal state of Lower Saxony, the Burial Act has been amended to replace the classification of death (into natural, unnatural, and unexplained) by nine defined circumstances of death with mandatory reporting to the police. The public health authorities in Lower Saxony can order autopsies. Amendments to the Lower Saxony Hospital Act affect ward pharmacies, internal hospital drug committees, and mortality and morbidity conferences and introduce an anonymous error-reporting system. To date there has been no move to have external post-mortem examinations in hospital and care homes conducted exclusively by external physicians who were not involved in the deceased patients’ treatment.

Conclusion

Awareness of the circumstances and risk constellations in serial killings and attempted serial killings in hospitals, nursing homes, and nursing care may help staff members to recognize suspicious situations. Failure to follow up suspicions can lead to accusations against the responsible physicians at a later date (36). Pointers to homicide include the circumstances of death, unusual behavior by a person on duty at the time of death, a cluster of fatalities, irregularities in the drug stocks, suspicion on the part of staff members, unexpected sudden death, and absence of a plausible natural explanation for death. Any suspicions should prompt a swift internal review including autopsy, and if indicated the state prosecutor should be informed at a early point. In the case that homicide is confirmed, earlier fatalities should be re-examined. With or without a confession, the bodies of patients whose deaths were unexplained should be exhumed and autopsies conducted whenever possible. A higher autopsy rate and the expectation of autopsy may have a deterrent effect.

Conflict of interest statement
The authors declare that no conflict of interest exists.

Manuscript submitted on 24 November 2021, revised version accepted on 12 May 2023

Translated from the original German by David Roseveare

Corresponding author

Prof. Dr. med. Dr. jur. Reinhard Dettmeyer
Institut für Rechtsmedizin, Justus-Liebig-Universität
Frankfurter Str. 58, 35392 Gießen, Germany

Cite this as:
Dettmeyer R, Saß H, Malolepszy L, Mousa M, Teske J, Vennemann B: Serial killings and attempted serial killings in hospitals, nursing homes, and nursing care. Dtsch Arztebl Int 2023; 120: 526–33. DOI: 10.3238/arztebl.m2023.0128

►Supplementary material

eBoxes, eTable:
www.aerzteblatt-international.de/m2023.0128

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