The worst nurse

Tens, possibly hundreds of patients were murdered by nurse Charles Cullen in the course of his 16-year career. Following the publication of The Good Nurse, a new book about Cullen’s murders and capture, HRMR asked author Charles Graeber what risk managers can learn from this nightmare scenario.

Charles Cullen may be the most prolific serial killer in history. In the course of a 16-year nursing career it is believed that he murdered around 300 patients, spiking their IV bags at random or administering lethal injections in person. The precise figure will never be known: Cullen is hazy about names and numbers, and crucial records have been lost or destroyed, but he has confessed to murdering 40 people, and is currently serving a 127-year prison sentence.

The Good Nurse, a remarkable new book by journalist Charles Graeber, documents Cullen’s murderous career and tells the gripping tale of the police investigation that eventually snared him. It also raises a question almost as chilling as the fact of Cullen’s murders: how was it that, while concerns were repeatedly raised about Cullen’s treatment of his patients, he was able to stay in employment, moving from hospital to hospital with neutral or positive references, for 16 years?

Even when the New Jersey Poison Information and Education System (NJPIES) urged the risk manager at his final place of employment to call in the police, it was several months before this actually happened—months in which Cullen was able to continue working and to murder at least six more patients.

OBSTRUCTED INVESTIGATIONS

When the police finally became involved, they felt that they were being obstructed by the hospital’s administration. During the course of their investigation they were given wrong information by the hospital’s risk manager regarding the hospital’s Pyxis automated medication dispensing machine, which Cullen had been using to obtain drugs to kill patients.

The risk manager told them that the machine kept dispensing records for only 30 days, whereas in fact Cullen’s full, incriminating dispensing history was recorded there. Only when one of the detectives telephoned the machine’s manufacturer did he discover the truth.

There were other hitches too: the lawyer who led the hospital’s internal investigations said he had not identified the person responsible and kept no notes of his interviews with staff; the hospital’s administration lawyers requested that the risk manager be present for interviews with the staff; and when the detectives finally found a staff member who could help them ensnare Cullen, that nurse received a call from the risk manager telling her that if the police contacted her again she should tell them to speak directly to the hospital’s attorneys.

Fortunately the nurse—who was Cullen’s best friend in the hospital but could see how the evidence stacked up against him—remained willing to help the police, even going as far as wearing a wire in order to record a confession from Cullen.

When tracing Cullen’s chequered nursing career—a career punctuated with suicide attempts and job moves—the police found that his previous employers were, in several cases, of little help. Two said that they had lost Cullen’s personnel file. Another gave them a file detailing how Cullen had resigned after being repeatedly reprimanded. “Would not consider for rehire—medication issue,” it said on his record.

Graeber writes: “It was easy to understand that the administrators did not have the sort of concrete evidence required to conclusively determine their nurse had definitely and intentionally administered an overdose to a specific patient. At the same time the detectives couldn’t help but notice that whether by design or accident, the hospital had consistently dealt with the Cullen problem in a manner that created the fewest possible legal ramifications for themselves and the slightest possible paper trail for others.”

AN IMPOSSIBLE DILEMMA

As the story progresses a picture emerges of risk managers put in an almost impossible situation, with patient safety on one side and the hospital’s reputation and legal position on the other. Talking exclusively to HRMR, Graeber says that part of the problem was the huge leap of imagination required to actually believe that Cullen was deliberately killing patients. Having spent hours interviewing Cullen in prison, Graeber paints a picture of a man who, while certainly odd, does not fit the stereotypical image of a serial killer.

“I don’t know what a serial killer should seem like except from how they’re portrayed in the movies, and that definitely wasn’t him,” he says.

“He was self-deprecating, he was very funny about his current situation, and was very aware that he had essentially exchanged a nurse’s uniform for another set of scrubs—the prisoner’s uniform.”

Asked what lessons risk managers can take from Cullen’s story, Graeber says it is important to keep an open mind as to what is truly happening and to be willing to ask yourself whether you are doing a good job by keeping the process internal or whether you need to ask for outside help.

“The risk manager has to ask him or herself what truly is best, not just for the hospital but also for patient outcomes,” he says. “I do not envy their position at all because I could see how time and time again concerns over good patient outcome may be in direct conflict with some of the understandable legal concerns of the institution for which they work. I think that’s an especially difficult role to have where to do your job well you may have to put your job at risk.”

Ultimately, Cullen was caught—but only after 16 years in which he used computerised patient charts on hospitals’ Cerner systems to browse for his next victim, or to monitor who had received his polluted IV bags. During that time, many saw him as a good nurse, always on hand when a patient coded, always calm in a crisis. What they didn’t know was that Cullen was causing the codes.

“Really the nurses and the risk managers are the heroes in this book—there is one bad actor and many good actors,” says Graeber. “I’m sure today those risk managers are asking themselves what they should have known, and whether they could have done more.

“That must be a very difficult thing to wrestle with, but of course hindsight is 20/20 and it’s so far beyond the imagination that most of us would never think that we were dealing with a serial murderer.”
The Good Nurse by Charles Graeber is published by Twelve. 

The background: Charles Cullen

Born in West Orange, New Jersey on February 22, 1960, Cullen was the youngest of nine siblings. He had an unhappy upbringing. Graeber writes: “He’d been a late-life mistake that his working-class Irish-Catholic parents could hardly afford.”

Cullen’s father died not long after he was born and his mother was killed in a car crash when he was in his senior year in high school. Distraught by the loss, Cullen tried to commit suicide—one of many attempts throughout his life—and then joined the Navy. After a short, unhappy naval career he was discharged on medical grounds and trained as a nurse. He was a star student, becoming president of his nursing school class, while also holding down several part-time jobs to pay his way.

In one of these jobs, at Roy Rogers, he met and became besotted with his manager, Adrianne Baum. The pair went on to marry and had two children, but the marriage gradually faltered due to Cullen’s alcoholism and increasingly strange behavior. Eventually they divorced.

In the meantime, Cullen had started killing patients. It is not known exactly when this began but the earliest murder Cullen has admitted to was a patient in the burns unit of St Barnabas Medical Center in New Jersey in 1998. His favorite method was tampering with IV bags, often injecting them with insulin or digoxin, but he also administered injections directly.

In 1998 he was fired from Liberty Nursing and Rehabilitation Center in Allentown, Pennsylvania, after he entering a patient’s room with syringes in his hand and drugs she had not been prescribed. A scuffle ensued and the patient ended up with a broken wrist—but amazingly Cullen had to wait only two days before a nursing agency found him nursing work.

This scenario was repeated many times throughout his career, as he moved through nine hospitals in New Jersey and Pennsylvania. A nursing shortage made it especially easy for him to be hired and Cullen’s previous employers tended to move him on with neutral or positive references.

In September 2002 Cullen took a job in the critical care unit at Somerset Medical Center in Somerville, New Jersey. His killing continued and by June 2003 staff had started to become suspicious about his behavior.
In July 2003 the executive director of the NJPIES warned Somerset Medical Center officials that they had a police matter on their hands, but the hospital delayed contacting the authorities until October 2003, by which time Cullen had killed at least another six patients.

Once the police became involved they quickly identified Cullen as their prime suspect. An investigation into his employment history revealed that other hospitals had been suspicious about his treatment of patients. Cullen was fired from Somerset Medical Center on October 31, 2003 and was arrested at a restaurant on December 12, 2003.

Why write The Good Nurse?

Charles Graeber first established contact with Charles Cullen when he hit the headlines in a bid to donate a kidney to the brother of an ex-girlfriend. The controversy of the ‘killer kidney’ was big news.

Graeber wrote to Cullen saying he would like to write an article on the subject and quickly became the one journalist Cullen would talk to. He visited the hospital to interview Cullen and the idea for a book started to take shape.

“The story was so much more complicated than I had understood from the newspaper coverage thus far; it was much more complicated than I was able to cover in a magazine story,” he says. “It had so many characters and there’s so much a person needed to know in order to have a proper understanding of what happened and what should have happened, especially for someone who was foreign to the medical field.
“That’s why it became a book. A large part of the mission of this book was to lay the facts out in a manner which was comprehensible and compelling enough that you would intentionally go through them all so that the readers could decide for themselves what should have been done and draw lessons.”

He adds that it was important to find the right tone for the book. “I had concern for my own ethical being, knowing that I was hooking an aspect of my career on someone else’s murders and I didn’t want to become compromised in some way by being part of the process, even though I thought it was an important story to tell.”

A statement from Somerset Medical Center

We gave Somerset Medical Center the opportunity to respond to some of the allegations contained in The Good Nurse. This is a statement from Somerset Medical Center:

“Nearly 10 years after Charles Cullen’s unthinkable crimes were brought to light, we remain shocked and saddened by these tragic events. Our deepest sympathies will always be with the families of all of Charles Cullen’s victims, and we hope that his being brought to justice has provided them with some sense of closure and peace.

“The recently released book, The Good Nurse, has obviously brought renewed attention and scrutiny to the topic of Charles Cullen and his crimes. The book highlights many of the flaws and inadequacies that existed in the healthcare industry and allowed Cullen to move from one hospital to the next over the course of more than 15 years.

“While we disagree strongly with the manner in which our institution and our employees are represented in the book, we believe that the best interests of Somerset Medical Center, its employees and our community are best served by maintaining our focus on continuing to provide the highest quality of care to our patients now and in the future, rather than publicly rehashing the details of this tragic chapter in our history.

“Somerset Medical Center was a leading advocate in efforts for legislative reforms to make needed changes to the hiring process for healthcare workers. These efforts led to significant industry changes, including passage of New Jersey’s Health Care Professional Responsibility and Reporting Enhancement Act. We sincerely hope that our efforts, and the reforms that they have helped to bring about, help prevent this type of tragedy from ever occurring again.”