Background
Healthcare serial killing involves the intentional killing of multiple patients by a healthcare professional. Ultimately, the practitioner-patient relationship is a trust-based one, where the patient places trust in doctors, nurses, and the healthcare system [
1]. This opens a vulnerability to those with ulterior motives.
Healthcare practitioners have intimate knowledge of the process of human life and death. This, paired with the facilities that hospitals provide and the tools such as paralytics and lethal doses of medications, as well as the general anticipation of death as a patient outcome (thus garnering little suspicion), maybe the attractants of those opportunistic killers.
In this explorative review, we analyze in depth the topic of the healthcare serial killer and summarize the commonalities and themes among cases in the literature, as well as the challenges faced across both healthcare and legal systems, and the potential safeguards that can be implemented across several systems to protect the patient community. The insights derived in this review are scoped from a variety of cases and studies in the literature from different countries and systems.
Medical murder is a two-pronged modern problem that requires simultaneous and synergistic efforts from the medical and legal perspectives, as well as swift interception in order not to weaken the trust between the general public and their healthcare systems.
Patterns to ponder
Some characteristics of the healthcare serial killer include a history of substance abuse, craving attention about his or her skills, a diagnosis of a personality disorder, a record of incidents at another hospital, and fabrication of credentials.
Characteristics that may be noticed by colleagues or staff members include suspicions or anxiousness when covering patients when they are on duty, noticing that the healthcare serial killer can always tell beforehand which patients are going to die and when (as well as inappropriate behavior like betting on which patient is going to die), and a higher incidence of death occurs when they are on shift (although statistics alone cannot prove guilt, they can help paint a general picture or initiate investigations). The healthcare serial killer may also have particular nicknames, i.e., Angel of Death [
30].
A cluster of common themes in the serial murder of patients includes the following:
Yorker et al. have detailed the findings in 90 prosecutions involving caregiver-associated serial killing. Their findings suggest that the prosecutions were highest in areas with more advanced healthcare systems such as the USA and Germany [
31]. The majority of those convicted were nurses. Gender wise, 49% of those convicted were female, and there appears to be a gender discrepancy involving male nurses which account for 6% of registered nurses but account for 44% of nurses prosecuted for murder. The vast majority of healthcare murders occur in hospital setting—and are not limited to only one area in the hospital (i.e., killing in the ICU and the outpatient clinic) [
31]. It might be that countries like the USA and Germany have more cases of medical serial killing, as such advanced healthcare systems may have the means to intercept and address this problem.
A variety of methods may be employed by the killer with injections of insulin and potassium, or tampering with respiratory equipment (i.e., lowering the flow rate) being common choices [
31]. Insulin injections will lead to hypoglycemia and coma and eventual death if not treated abruptly. These cases may be further compounded by a patient who is already diabetic where this malicious dose of insulin may be misattributed as an overdose by the patient themself. In a quarter of the cases, the method was unknown [
31].
Toxicology is a staple in placing convictions and prosecuting cases of healthcare murders where poisons or paralytics were used [
32]. Nonetheless, most of the calls to examine toxicology are post-mortem or post-exhumation where a high index of suspicion is present. This is a problem where rapidly degrading compounds are being used, an example being the use of potassium to induce cardiac arrest, where upon death, there is already an elevated level of potassium in the body [
32,
33]. A high index of suspicion should be present where any substance is found to be elevated in a patient that
was not previously prescribed to them and the presence of high concentrations of a substance in syringes, as well as fingerprint of the perpetrator on the syringe may all count as compelling evidence for serious medical error or a crime (see Table
4).
Table 4
An unusual hospital orderly and his observations
Finally, the primary alarm call for any investigation typically comes from
coworkers who have noticed unusual statistics revolving around the accused healthcare provider’s shifts or their direct eye-witness reports, rather than from concerns voiced by patient family or even medical examiners [
25].
What can be done?
Medical murder can be often missed—a point of recent focus in countries like Belgium and the Netherlands where modern trends in euthanasia policies have rung appropriate alarms for potential abuse [
34,
35]. Furthermore, the true incidence of medical homicide “is impossible to determine,” as each healthcare system presents its own opportunities for malice. What is needed are the tools for early detection and confident (and potentially anonymous initial) reporting in order to prevent covert retaliation occurring to the reporter. All attempts to reconcile this issue with the Law and Public must also address the need to not undermine public trust in the healthcare system. This may be addressed by timely, honest, and transparent recognition of when suspicions arise.
Morbidity and Mortality (M&M) meetings are “a critical component of clinical governance” [
36]. This is a meeting forum where patient deaths and poor outcomes are discussed in order to improve patient safety. In the USA, they are
mandatory to attend. M&M meetings typically host an array of healthcare practitioners including doctors, nurses, medical students, and management. Ultimately, they provide the necessary assurances that poor patient outcomes are being addressed. These meetings may alert to any unusual outcomes or patterns and necessitate the need for disciplinary action.
One of the hindrances of such meetings is the many hurdles to open discussion, where one study detailed issues such as (1) an open investigation is occurring regarding the case, (2) fears of being judged for a mistake even though their specialty is associated with high mortality rates (such as emergency medicine), (3) meetings being used as personal vendettas, (4) meetings being rushed too soon after the event without enough relevant information or evidence, (5) presence of dominant personalities who would criticize or show off their own decisions, and (6) the presence of management/the desire for it to be a doctors only meeting [
36,
37].
Overall, despite the threat of criminal prosecution, physicians are open to discussing adverse outcomes of their patients, but there remains considerable room for improvement in order to conduct these meetings in the most effective way possible [
37]. These include keeping a goal-oriented approach to the meetings and a clear definition of outcome measures in order to determine and make a distinction between what may be deemed as a learning experience and what may progress into further investigations. Meetings should be properly timed when all the relevant information is ready, should be attended by a variety of persons, and perhaps should be delivered in a blinded fashion in order to avoid narcissistic displays by other doctors such as “criticism or showing off.” M&M meetings maybe a useful tool to triage cases of mortality and should be utilized in other healthcare systems worldwide and attended routinely [
37,
38].
A systemic change is called for on healthcare systems to shift from denial of employment lawsuits, or wrongful discharge charges, to the absolute prioritization of patient safety, and recognizing that if a successful conviction is made, this will lead to more damaging wrongful death lawsuits.
There needs to be serious consideration of the intentional harm of a patient as part of training healthcare workers in patient safety. Hiring and screening processes need to be more robust—calls for background checks where there are gaps in employment history and questions into previous terminations should be made. Serious control over insulin supply is needed as it is a notorious drug of choice for perpetrators which draws little suspicion [
16] (some countries have employed a 2-signature system needed for the prescription of potassium and insulin).
Evidence to the discrepancies and errors found in death certificates calls for standardization and appraisal of doctors’ abilities in this area [
38,
39]. With regard to the exhumations, a recent attempt by the German Crown Prosecutor was conducted to identify missed homicides, where they found alarming differences between the true cause of death and that which was noted in the death certificate [
38]. Thirty-nine out of the 155 exhumations were classified as possible medical malpractice with 7 death certificates labeled as totally erroneous causes of death [
38].
The results of the exhumations have shed light on 2 primary issues. Firstly, if the initial death certificate indicated nothing worthy of suspicion by the doctor, then police investigation remained
superficial, and no autopsy was ordered [
38]. This is critical in that previous cases involving doctor serial killers have conducted their own death certificates to cover their crimes. It is also unusual that in the case of the exhumations, some of those suspected of medical malpractice showed extreme discordance with the true cause of death—even when the cause of death was
obvious. The second point is that it was a “lucky coincidence” that inspired a re-evaluation of the case, typically another murder attempt by a suspect [
38].
There appears to be a pattern of falsifications of documents or credentials—and these were often missed during hiring, and
if they were identified, it
was not a deterrent for hiring. Hospitals need to enforce stricter measures for determining the authenticity of the credentials of their workers and consider the practice of falsifying credentials as
a high-risk factor for future criminal activity (even in cases of no previous criminal record) [
40]. Countries such as the UK employ rigorous checks/certification process and revalidation which is aimed to promote a governed practice which can be used as an exemplar [
41‐
43].
Legal issues
A successful criminal prosecution in a case of healthcare serial killing relies on an array of evidence, including eyewitnesses, toxicology reports, confessions, and statements made by patient family and colleagues. A finding that a patient is more likely to die at the hands of an accused physician is insufficient to prove guilt of murder in a criminal court but may be exceptional in a civil suit. In the case of Micheal Beckelik, there was not enough evidence to prove guilt beyond reasonable doubt, but a civil suit charged him successfully for 27 million dollars [
44].
The burden is on the prosecution to prove to 2 critical points: (1) the patient’s death was
unnatural—and this can be a challenge given a predilection for victims of extremes of age or those with chronic illness and high morbidity—where death may be anticipated, and (2) that it is the actions of
this particular healthcare provider that led to the patient’s demise [
44]. Reasonableness is another challenge, as human error is deemed unreasonable, but in the context of a medical setting, the question becomes whether or not an action taken towards a patient would have been taken by a reasonable person under similar circumstances [
44] with come consideration of the
ability to provide a standard of care. Establishing the presence of implied malice maybe a determining factor in a murder charge versus a manslaughter charge against a practitioner.
Healthcare serial killers use a variety of defenses when intercepted and accused in court, the two most common being insanity and euthanasia defense. In the euthanasia defense, the killer may claim that they administered a lethal dose of medication at the request of the patient (the capacity of the patient and their explicit consent becomes the topic of argument in this case, as well as whether or not there are established laws or policies in place for physician-assisted dying, and if other palliative options were considered).
Hospital administrators are often uncooperative with prosecutors and may even obstruct the investigation with reasons being fear of negative publicity, civil suits, and poor record keeping. On the other hand, cases where the hospital was cooperative with
discreet investigations resulted in the collection of evidence and successful convictions, and served as a deterrence for future suspicious activity [
31].
According to the US Department of Justice, healthcare serial killing is a class of crimes considered to be the most difficult to detect and prosecute. Even in the rare scenario where it can be detected, proving guilt requires extensive medical knowledge and expert input [
13].
With regard to the serial killer versus the treatment killer, we wish to highlight an important distinction. The treatment serial killer, whose arrogance and narcissism fueled by their lack of introspection or admittance of their own limitations, may typically be charged with manslaughter because a motive or intent remains unclear (if anything, it appears superficially that they are hopeful that their risky choice saves the patient life to increase their acclaim or reaffirm their self-confidence). The distinction with the serial killer remains in setting the precedent that there
is a history of patients that are in fact treated well by them, within the guidelines of sound clinical reasoning and decision-making skills. If one can establish this, then the choice to resort to a different or deviant choice with another patient should be questioned. The treatment killer would have an all-around poor performance as a practitioner, with tales of their mishaps or negligence across the board. It should become quite unusual if one who is skilled enough to make the best decision opts instead under no particular stressor or change of setting, to make a poor decision that would lead to the patient’s demise. The decision to do harm in this exclusionary scenario would itself be the motive or the implied malice. This can only be done with an extremely thorough analysis and examination of all the patients that have ever entered their care—a task of determination that may set the foundations for which future healthcare serial killers may be addressed by the criminal law, and where charges of first-degree murder may be laid. To reiterate in making a case against a suspected medical
serial killer, we recommend that one should not shy away from utilizing the fact that
there are successfully treated patients by the accused of similar demographics or qualities or disease characteristics as those patients that are their victims. This makes sense in that running a successful practice serves the needs of the serial killer as this can build trust within the medical community, whereas tales of the treatment killers’ outcomes and negligence may precede them and even deter patients from them [
45]. This observation maybe specialty specific—and may also explain the unusual longevity of the serial killer’s career as their “mishaps” or “outcomes” might never be addressed as anything more than that and may never see the light of a formal investigation.
Conclusions
Healthcare professionals are already at a level above suspicion, as well as the advocacy of the medical community for a “no blame culture” towards addressing incidents where an adverse patient event may have taken place. Given the sheer number of victims of healthcare serial killers that can span into hundreds or thousands of patients, and the longevity into which they conduct their careers which can span decades, it is sufficient to say that the efforts of the medical community to prioritize patient safety in this regard has failed as medical serial killing is still a modern and ongoing problem.
This review serves as a call to action on the part of all international healthcare systems to face the harsh and unpalatable reality that the medical field is an opportunistic one in the hands of those with criminal intentions. There is a real need for the implementation of systems that can intercept these persons—all the way from critical hiring practices to M&M meetings, where patient outcomes can be triaged as learning opportunities to those which require further investigations, to standardizations and quality assurance of death certificates that are often the gatekeepers of further investigations by the police. This is also a call on those members of law enforcement to facilitate cooperative interactions with staff and hospitals—rather than a “witch hunt” style of investigations.
Law and Medicine are professions that often collide and conflict—but we wish to reiterate that Law and Medicine are a symbiotic relationship [
46,
47]. The Law allows Medicine to conduct itself with great privilege through which physicians may care for with due consideration of all of the morals and ethics and thought that went into such allowances. However, we cannot turn a blind eye when such provisions may be turned on their own head and allow an event, such as the murder of a patient to take place, and moreover turn back doubly on the Law itself which is left with the daunting task to prove guilt beyond a reasonable doubt. There is an area where our true symbiosis maybe seen, and it lies in the root philosophy of Medicine itself—
Primum non Nocere (Do No Harm). Here is an area of mutual concern which sets the scene for a more collaborative and integrative scenario dedicated to rooting out the most grotesque of outcomes—the murder of a patient.
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