Serial murder by healthcare professionals

Canada's Medical Assistance in Dying System can Enable Healthcare Serial Killing

The Canadian approach to assisted dying, Medical Assistance in Dying (MAiD), as of early 2024, is assessed for its ability to protect patients from criminal healthcare serial killing (HSK) to evaluate the strength of its safeguards. MAiD occurs through euthanasia or self-administered assisted suicide (EAS) and is legal or considered in many countries and jurisdictions. Clinicians involved in HSK typically target patients with the same clinical features as MAiD-eligible patients. They may draw on similar rationales, e.g., to end perceived patient suffering and provide pleasure for the clinician. HSK can remain undetected or unconfirmed for considerable periods owing to a lack of staff background checks, poor surveillance and oversight, and a failure by authorities to act on concerns from colleagues, patients, or witnesses. The Canadian MAiD system, effectively euthanasia-based, has similar features with added opportunities for killing afforded by clinicians' exemption from criminal culpability for homicide and assisted suicide offences amid broad patient eligibility criteria. An assessment of the Canadian model offers insights for enhancing safeguards and detecting abuses in there and other jurisdictions with or considering legal EAS. Short of an unlikely recriminalization of EAS, better clinical safeguarding measures, standards, vetting and training of those involved in MAiD, and a radical restructuring of its oversight and delivery can help mitigate the possibility of abuses in a system mandated to accommodate homicidal clinicians.

Fourteen Deaths from Suspected Heparin Overdose in an Italian Primary-Level Hospital

Healthcare-related homicidal cases are not novel within the medical-legal landscape, but investigations are often made difficult with the scarcity of material evidence related to the crime. For this reason, it is necessary to carefully analyze the clinical documentation and employ ancillary forensic resources such as radiology, histopathology, and toxicology. In the presented scenario, the observation of 14 deaths from abnormal bleeding in a First-Level Italian Hospital revealed the administration of massive doses of heparin by a nurse. On behalf of the Judicial Authority, a multidisciplinary medical team investigated the case through the following steps: a thorough review of the clinical documentation, exhumation of the bodies belonging to the deceased patients, performing PMCT and autopsy, and collecting tissue samples for histopathological, immunohistochemical, and toxicological investigations. All the analyzed cases have been characterized by the observation of fatal hemorrhagic episodes not explained with the clinical conditions of the patients, confirmed using autopsy observations and the histological demonstration of the vitality of the lesions. However, due to the limited availability of biological material for the toxicological analysis, the indirect evidence from hematological analyses in hospitalized patients was crucial in demonstrating heparin overdose and its link to the recorded deaths. The present scenario demonstrates the fundamental importance of a multidisciplinary approach to cases of judicial interest related to the healthcare context. Therefore, the illustrated methodologies can be interpreted as an operational framework for similar future cases.

Brave Clarice-healthcare serial killers, patterns, motives, and solutions

Healthcare serial killing involves the intentional killing of multiple patients by a healthcare professional. It is a formidable challenge to identify in the medical context, and a daunting legal task to prove beyond reasonable doubt. What can be done or remains to be done to intercept these serial killing events and help serve justice, while at the same time not risk dismantling public trust in the healthcare system? In light of several recent modern charges of murder against healthcare practitioners across the world, this review aims to report the themes, patterns, and motives of medical serial killers as well as highlight areas of work on both medical and legal fronts to help identify these events, and to most importantly protect the vulnerable patient community.

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.

An Accessible Yarn-Based Sensor for In-Field Detection of Succinylcholine Poisoning

Succinylcholine (SUX) is a clinical anesthetic that induces temporary paralysis and is degraded by endogenous enzymes within the body. In high doses and without respiratory support, it results in rapid and untraceable death by asphyxiation. A potentiometric thread-based method was developed for the in-field and rapid detection of SUX for forensic use. We fabricated the first solid-contact SUX ion-selective electrodes from cotton yarn, a carbon black ink, and a polymeric ion-selective membrane. The electrodes could selectively measure SUX in a linear range of 1 mM to 4.3 μM in urine, with a Nernstian slope of 27.6 mV/decade. Our compact and portable yarn-based SUX sensors achieved 94.1% recovery at low concentrations, demonstrating feasibility in real-world applications. While other challenges remain, the development of a thread-based ion-selective electrode for SUX detection shows that it is possible to detect this poison in urine and paves the way for other low-cost, rapid forensic diagnostic devices.

Serial murder in medical clinics and care homes

BACKGROUND

Serial murder in clinics and care homes have gained attention more than once in recent years. The strong yet quickly fading public outrage has not yet led to well-founded professional and health-political engagement with the topic. With few systematic studies conducted, knowledge about perpetrator-related and environment-related risk factors in the day-to-day context of healthcare is sparse.

METHODS

Court cases of serial murder in clinics and care homes in Germany, Austria, and Switzerland that were concluded with a final verdict by February 2022 were investigated. Research materials consisted of court documents and observations made during the trials. The cases were evaluated with regard to the victims, crime scenes, methods of killing, perpetrators, and perpetrator motives. 12 serial murders involving 17 perpetrators were included in this study.

RESULTS

Perpetrator-specific early warning signs included a pronounced insecurity in combination with a striving for prestige and power, which were accompanied by a loss of empathy. Reactions of the colleagues and supervisors of the perpetrators in the immediate professional environment included misjudgement, concern about one's own disadvantages, feared damage to the reputation of the institution, and insufficient willingness to clarify the situation. As a result, many initial murders went unsuspected and unreported so that the frequency of the criminal activity and the number of victims increased over time.

CONCLUSION

More information about serial murder in clinics and care homes is necessary. Research efforts are needed to better assess the prevalence of such crimes and to develop appropriate preventive measures. Circumstances that enable such acts, risk factors, perpetrator profiles, and early-stage countermeasures must be comprehensively addressed in the context of education, training and further education.

Safety Analysis of 13 Suspicious Deaths in Intensive Care: Ergonomics and Forensic Approach Compared

OBJECTIVES

Thirteen suspicious deaths occurred in an intensive care unit of Tuscany, Italy, in 2015. All patients developed sudden unexplained coagulopathy leading to severe bleeding. None of them had been prescribed heparin, but supertherapeutic concentrations of heparin were found. After a nurse was arrested on suspicion of murdering Human Factor and Ergonomics (HF/E) experts received a mandate to identify system failures. According to the judgment of the Court of First Instance on April 2019, the nurse was found guilty.

METHODS

The HF/E group used a two-pronged safety analysis: understanding the conditions in which the healthcare practitioners were working in the period when the suspicious deaths emerged and reviewing the clinical records.

RESULTS

Fourteen patients admitted to the intensive care unit in 2014 and 2015 were selected on the basis of markedly abnormal coagulation tests (n = 13) or a family member's complaint (n = 1). In 13 cases, a massive, abrupt hemorrhage in the presence of an unexpected abnormality of coagulation tests occurred, whereas the fourteenth patient had the only prolongation of coagulation markers without bleeding. All cases examined classified as adverse events related to a coagulation disorder. Human factor and ergonomics analysis identified a number of latent and active failures that contributed to the event and provided a set of important recommendations for safety improvement.

CONCLUSIONS

When presented with a manifest, albeit suspected, wrongdoing with lethal consequences for patients, forensic investigators and safety investigators have distinctly different goals and methods. We believe that a memorandum of understanding between HF/E and forensic investigative teams provides an operative framework for allowing co-existence and fosters collaboration. The pursuit of safe care as a new emerging right for patients and balancing the right to legal justice with the right to safer healthcare merit further investigation and discussion.

Homicidal poisoning series in a nursing home: retrospective toxicological investigations in bone marrow and hair

Homicidal poisonings remain rare and can be difficult to detect, especially in the elderly or in medical settings. In this atypical poisoning series, a young nursing assistant purposely poisoned thirteen residents of a nursing home and killed ten of them. The medications used were a mix of psychotropic medications (cyamemazine, loxapine, tiapride, risperidone, and mirtazapine), under liquid formulation, which were inducing malaise and coma. The forensic investigation included analysis of blood, urine, hair, and bone marrow and exhumations of seven corpses up to 3 years after the inhumation. Hair collected from a hairbrush of a cremated victim have been analyzed. Bone marrow sample preparation was based on a liquid/liquid triple extraction. Hair were incubated after decontamination overnight at 55 °C in methanol. Segmentation was possible for seven samples, except for delayed exhumation samples (n = 4) and hairbrush hair sample (n = 1). The extracts were then analyzed using gas chromatography coupled with mass spectrometry (GC-MS) for unknown screening and using liquid chromatography coupled with tandem mass spectrometry (LC-MS/MS) for a targeted screening and quantification. Screenings revealed the presence of the same mix of psychotropic medications. Cyamemazine, mirtazapine, loxapine, tiapride, and risperidone hair concentrations were 6-17,458 pg/mg, 74-1271 pg/mg, 9-1346 pg/mg, 13-148 pg/mg, and 3-5 pg/mg, respectively. Cyamemazine bone marrow concentrations were 229 and 681 ng/g and 152-717 ng/mL in blood. Patients' medications were also identified and quantified. This poisoning series provide analytical data that could support subsequent toxicological result interpretation in similar forensic cases.

Insulin and the law

Hypoglycaemia, if it can be proved, may be used as a defence against almost any criminal charge provided it can be established that the perpetrator was in a state of neuroglycopenic (hypoglycaemic) automatism at the time of the offence. Hypoglycaemia produced by exogenous insulin can also be used as a suicidal or homicidal weapon. This paper discusses some of the pitfalls confronting the investigator of suspected insulin misuse including problems arising from the increasing prevalence of insulin analogues and the unreliability of immunoassays for their detection and measurement in the forensic context.

Medical humanities and medical alterity in fiction and in life

A widely accepted component of any answer to the question 'What is it to do good medical ethics?' is the commitment to benefit people's health, in principlist terminology, 'beneficence'. This paper addresses deliberate maleficence and the cultural otherness with which it is associated, focusing on the activities of the serial killer Dr Harold Shipman. It finds an uncanny 'fit' between the normal operation of healthcare services and this sort of alterity which has attracted little attention from bioethicists but has been addressed by novelists. To the extent that the medical humanities offers useful insights into hard moral problems, its capacities rest on taking account of both the fictional and the real.

Poisoning: fact or fiction?

Analytical toxicology is a complex discipline. Simply detecting a poison in a biological sample does not necessarily mean that the individual from whom the sample was obtained had been poisoned. An analysis can prove exposure and perhaps give an indication of the magnitude of exposure, but the results have to be placed in proper context. Even if sampling was ante-mortem an analysis does not necessarily prove the effects that the drug or poison had on the victim immediately before or at the time of sampling. Tolerance is one big issue, the mechanism of exposure (how the drug got into the body) is another, and of course with post-mortem work there are always additional considerations such as site of sample collection and the possibility of post-mortem change in analyte concentration. There are also questions of quality and reliability, and whether a particular analysis and the interpretation placed upon the result are appropriate in a particular case.

Correlates of Perceived Care Comfort with an EMS Professional Having a Legal Conviction

Objectives

The first objective was to examine the outcome of how comfortable a potential EMS-caller would be receiving care from an out-of-hospital-care EMS professional who might have a legal conviction. A second objective was to test for correlates that would explain this outcome.

Methods

In the autumn of 2010, a structured phone survey was conducted. To maximize geographical representation across the contiguous United States, a clustered, stratified sampling strategy was used based upon US Postal Service zip codes.

Results

Of the 2,443 phone calls made, 1,051 (43%) full survey responses were obtained. Data cleaning efforts reduced the total to 929 in the final model regression analysis. Results revealed significant public discomfort in receiving care from EMS professionals who may have such a conviction. In addition, respondents who are less educated and older more strongly (1) agree that EMS professionals should have their licenses revoked for wrongdoing; (2) agree EMS professionals should be screened before being hired; (3) perceive EMS credentials to be important; (4) support a lawsuit for improper care; and (5) are collectively less comfortable with being cared for by an EMS professional who may have a legal conviction. Reliable scales were found for future research use.

Conclusion

There is significant public discomfort in receiving care from EMS professionals who may have a legal conviction. The results of this study provide increased impetus for the careful screening of EMS professionals before they are hired or allowed to be volunteers. Beyond this due diligence, the results serve as a reminder for increased EMS provider awareness of the importance of exhibiting professionalism when dealing with the public.

Blau G, Gibson G. Correlates of perceived care comfort with an EMS professional having a legal conviction. Prehosp Disaster Med. 2012;27(4):1-6.

Hypoglycemia in non-diabetic in-patients: clinical or criminal?

BACKGROUND AND AIM

We wished to establish the frequency of unexpected hypoglycemia observed in non diabetic patients outside the intensive care unit and to determine if they have a plausible clinical explanation.

METHODS

We analysed data for 2010 from three distinct sources to identify non diabetic hypoglycaemic patients: bedside and laboratory blood glucose measurements; medication records for those treatments (high-strength glucose solution and glucagon) commonly given to reverse hypoglycemia; and diagnostic codes for hypoglycemia. We excluded from the denominator admissions of patients with a diagnosis of diabetes or prescribed diabetic medication. Case notes of patients identified were reviewed. We used capture-recapture methods to establish the likely frequency of hypoglycemia in non-diabetic in-patients outside intensive care unit at different cut-off points for hypoglycemia. We also recorded co-morbidities that might have given rise to hypoglycemia.

RESULTS

Among the 37,898 admissions, the triggers identified 71 hypoglycaemic episodes at a cut-off of 3.3 mmol/l. Estimated frequency at 3.3 mmol/l was 50(CI 33-93), at 3.0 mmol/l, 36(CI 24-64), at 2.7 mmol/l, 13(CI 11-19), at 2.5 mmol/l, 11(CI 9-15) and at 2.2 mmol/l, 8(CI 7-11) per 10,000 admissions. Admissions of patients aged above 65 years were approximately 50% more likely to have an episode of hypoglycemia. Most were associated with important co-morbidities.

CONCLUSION

Significant non-diabetic hypoglycemia in hospital in-patients (at or below 2.7 mmol/l) outside critical care is rare. It is sufficiently rare for occurrences to merit case-note review and diagnostic blood tests, unless an obvious explanation is found.

Dr Harold Frederick Shipman: an enigma

Dr. Shipman was the worst known serial killer in British history, at least in terms of numbers of victims, and possibly the worst in world history, if politicians are excluded. He killed at least 215 patients and may have begun his murderous career at the age of 25, within a year of finishing his medical training. His case has had a profound impact on the practice of medicine in the United Kingdom. Was he a special case? What were the origins of this behaviour? Could the behaviour have been prevented? It is necessary to learn what we can from a few personal facts and largely circumstantial evidence. He withheld himself from any useful clinical investigation or treatment once he had been taken into custody. Could he have been treated at any stage?

Murder by insulin: suspected, purported and proven-a review

Murder by insulin-whether attempted, suspected or proven-is rare. Only 66 cases worldwide could be found for this review. A conviction was secured in 31 cases and additional weapon was employed in 11. Differentiation of attempted homicide from Munchausen syndrome by proxy in the young and from 'mercy killing' in the elderly was not attempted. Most perpetrators were close relatives and most victims were alive when discovered and responded to treatment. Hypoglycaemia is the first clue to homicidal insulin use in living subjects and requires the demonstration of a plasma insulin concentration of generally more than 1000 pmol/L and undetectable plasma C-peptide concentration to establish the diagnosis. Serum glucose measurements are valueless in victims found dead. The presence near the body of insulin vials, syringes or needles, loose talk by the suspected perpetrator or their ready access to insulin may be the only clue. The demonstration of insulin in tissue around an injection site by immunohistopathology or by measuring it in an extract clinches the diagnosis. Immunoassays suitable for clinical use to detect and measure insulin and C-peptide are subject to random errors and cannot be relied upon unless special precautions including separation by gel filtration or HPLC are undertaken prior to analysis. They do not detect or measure accurately a new generation of synthetic insulin analogues. Mass spectrometry will be required to do this and to validate clinical immunoassays, upon which convictions have always had to rely in the past.

Homicidal poisoning by injection of methidathion: The first ever report

We present the first ever case of homicidal poisoning due to injection of methidathion, an organophosphate insecticide. Case: A 4-month-old baby presented to the emergency department with chief complaints of unconsciousness and irregular respiration. A bitter odour and an injection site with a greenish blue colouration and two bullaous lesions were noticed by the emergency department physicians. Postmortem examinations revealed a wide shiny blue colouration of the antecubital region with oedematous muscular fascia and focal liquefaction necrosis. Blood and tissue levels were positive for methidathion. Our case report emphasizes the necessity of a detailed crime scene investigation and postmortem examination for the possibility of homicide in such cases. Although injection sites may be the expected results of medical treatment, dermal lesions also may be associated with injections of toxic substances.

Routine mortality monitoring for detecting mass murder in UK general practice: test of effectiveness using modelling

BACKGROUND

The Shipman Inquiry recommended mortality rate monitoring if it could be 'shown to be workable' in detecting a future mass murderer in general practice.

AIM

To examine the effectiveness of cumulative sum (CUSUM) charts, cross-sectional Shewhart charts, and exponentially-weighted, moving-average control charts in mortality monitoring at practice level.

DESIGN OF STUDY

Analysis of Scottish routine general practice data combined with estimation of control chart effectiveness in detecting a 'murderer' in a simulated dataset.

METHOD

Practice stability was calculated from routine data to determine feasible lengths of monitoring. A simulated dataset of 405,000 'patients' was created, registered with 75 'practices' whose underlying mortality rates varied with the same distribution as case-mix-adjusted mortality in all Scottish practices. The sensitivity of each chart to detect five and 10 excess deaths was examined in repeated simulations. The sensitivity of control charts to excess deaths in simulated data, and the number of alarm signals when control charts were applied to routine data were estimated.

RESULTS

Practice instability limited the length of monitoring and modelling was consequently restricted to a 3-year period. Monitoring mortality over 3 years, CUSUM charts were most sensitive but only reliably achieved >50% successful detection for 10 excess deaths per year and generated multiple false alarms (>15%).

CONCLUSION

At best, mortality monitoring can act as a backstop to detect a particularly prolific serial killer when other means of detection have failed. Policy should focus on changes likely to improve detection of individual murders, such as reform of death certification and the coroner system.