Tuesday, July 24, 2012

Charles Cullen: Healthcare Serial Killer

Suspicious Death


Somerset Medical Center
Somerset Medical Center
A most astonishing case began after two people at Somerset Medical Center in Somerville, New Jersey were given the wrong medication. The ICU nurses who discovered this did not yet know that they were sharing in a disturbing experience with other healthcare workers in nearby institutions. They also did not know that their own institution was soon to be warned, and that SMC would break the case. All they knew was that one man had died and another woman had just barely been saved from an overdose of digoxin. Newspapers from the affected areas, the Newark Star Ledger and the Morning Call, along with national and other local publications, followed the story as it unfolded, with one of the Star-Ledger reporters leading the way.
The state-of-the-art computerized care system at SMC, called Cerner, allowed nurses to check patients' medical history at a terminal, according to Max Alexander, in the Reader's Digest. Another system tracked all drugs that were used and opened a drawer that allowed workers to get them. So the procedure for accessing and dispensing meds had become much easier.
On the night shift of June 15, 2003, someone ordered digoxin, a heart medication, for a patient, although it had not been prescribed and nothing in the patient's history indicated a need for it. Then it was canceled on the computer, but the drug itself disappeared from the stock. Around the same time, someone accessed the records of Jin Kyung Han, a forty-year-old cancer patient. She'd been battling the disease for a while, and the next morning she went into a cardiac seizure. When blood work was done, her doctor was surprised to find a high level of digoxin in her system. She'd been given this earlier but had been taken off when she reacted badly. An antidote was administered and she stabilized.�� But the drug's presence puzzled the staff.

Reverend Florian Gall
Reverend Florian Gall
Less than two weeks later, a sixty-eight-year-old Roman Catholic priest, Reverend Florian Gall, died. After the autopsy, high levels of digoxin were found in his system as well, but he was a heart patient, so the drug was not unexpected. Yet at that dose, it looked suspicious. Such levels seemed more sinister than could be dismissed as someone's error.
The hospital administration sent records and samples to the New Jersey poison control center and initiated an internal investigation. With their sophisticated computer system, they were able to see who might have taken digoxin from the system. It didn't take long to see the beginning of a pattern.

Warnings


Charles Cullen
Charles Cullen
On the nights prior to both patients suddenly going into critical conditions, a forty-three-year-old male nurse named Charles Cullen had ordered digoxin. Yet he'd requested it for patients under his own care, not for either of the victims. And he'd canceled the orders. There was no evidence with which to confront him, although the drug was clearly missing, and the administration had no indication that Cullen, a nurse with sixteen years of experience, had ever been negligent or sloppy...or worse. They looked through other records in their search for answers.
No one was fired or laid off pending the investigation results. Yet other patients suffered from having high levels of drugs in their systems, and Steven Marcus, a toxicologist and executive director of New Jersey Poison Information and Education System, warned SMC that July that they had a poisoner on their staff. He had spotted a cluster of at least four cases. Hospital officials resisted his analysis, reports the Star-Ledger, and had even complained about Marcus to the state's health department, saying he had rushed to judgment and was pressuring them unduly. Yet he insisted that someone had to go to the police and get a forensic investigation underway.

Steven Marcus, executive director of New Jersey Poison Information and Education System
Steven Marcus, executive director of New Jersey Poison Information and Education System
Administrators were not trying to save face so much as hoping to prevent the facility from erupting into chaos. They continued to look into the situation internally. Still, they couldn't ignore the obvious: Cullen was the common factor in these four cases, each with either a high level of insulin or digoxin, and one more of whom had died. He'd even accessed Reverend Gall's records after his death. Had he been checking something? Yet Cullen continued to work.
Then two more patients suffered similar overdoses and on October 31, after thirteen months on the job, Cullen was fired. Somerset County Prosecutor Wayne Forrest had initiated his own investigation, starting with Cullen's work history. He found the man to have worked at an alarming number of healthcare organizations, including four in New Jersey, and from some he'd been fired. Forrest could only hope they weren't faced with a serial killer.

Somerset County Prosecutor Wayne Forrest
Somerset County Prosecutor Wayne Forrest
Rick Hepp, a reporter from the Newark Star-Ledger did some quick sleuthing and went to Cullen's bungalow-style home in Bethlehem, PA, and knocked on the door. Cullen answered. A seemingly quiet man, thin and pale, he had sadness in his dark eyes and looked weary. Hepp told Cullen that someone at the Center was being investigated. Cullen admitted that he was the nurse in question.
"They've been asking a lot of questions about me at Somerset Medical Center," he stated. But he wouldn't say why he'd been fired.
Hepp discovered that, despite the investigation, Cullen was still licensed and technically able to find another job. It didn't take Hepp long to also learn that Cullen had been the subject of probes at other hospitals, including one there in his home town. It was a potentially explosive story, not just about the possible murders of patients but about continuous cover-up by healthcare agencies. Hepp was on to something.
Even so, it was over a month from the date he was fired that Cullen was finally arrested. Among serial murder investigations, those that must trail a healthcare serial killer have among the most difficult jobs.

Shocking Revelation

On December 12, 2003, Cullen was arrested as he left a restaurant and soon charged with the murder of Reverend Florian Gall and the attempted murder of Jin Kyung Han, saved from the June overdose but who had died that September from unrelated causes. With both cases, Cullen was suspected of injecting a lethal dose of digoxin, which he had procured via deceptive computer manipulation from hospital supplies. But he'd been ignorant about computer tracking: canceling the order doesn't delete the transaction. He'd left a record.
Cullen did not resist arrest. In court at his arraignment, he pled guilty to the charges and said he had no intention of fighting. "I don't intend to contest the charges," he uttered in a quiet voice. "I plan to plead guilty."

Charles Cullen in court
Charles Cullen in court
The judge did not want him to enter a plea at that time. Cullen's response was to rescind his request for a public defender. "I don't plan to fight this," he reiterated. His bail was set at $1 million and he was taken to Somerset County jail.
But he had already dropped a bombshell to detectives a few days earlier that went well beyond the current charges and would open up the largest murder investigation in that county's history. Many more charges would follow, in this and six other counties, covering two states.
Over the past sixteen years in ten different institutions, Cullen had admitted, he'd intentionally overdosed thirty, possibly forty patients. He didn't have an exact count, but he was clearly a serial killer of major proportions. To that date among healthcare killers, only Donald Harvey, another male nurse, had come close to a number like that.

Donald Harvey
Donald Harvey
In 1987, Harvey pled guilty in Indiana, Kentucky and Ohio to 37 counts of murder and several counts of attempted murder, mostly by poisoning or smothering. A psychiatrist who examined him said that he was a compulsive killer, murdering to relieve tension. When all was said and done, he had the most confirmed victims of any healthcare serial killer in America, and he'd actually confessed to more than twice this number.
Cullen now stood to pass the record. Hepp was on the story before anyone else, and he quickly learned about the phenomenon of healthcare serial killers, or HCSKs. Just a month before Cullen's revelations, Kelly Pyrek had organized the data in Forensic Nurse magazine, and had quoted some shocking statistics from Beatrice Yorker, Director of the School of Nursing at San Francisco State University: male nurses are disproportionately represented among caretakers who harm patients. While there are many more actual cases of females who indulge in this behavior, the 146,000 male registered nurses represent 5-7% of nurses but are responsible for about 1/3 of the healthcare serial murder cases in the U.S.
National papers and television programs jumped into the fray to learn more about both Cullen and HCSKs. Nurses who kill, it seemed, perceive how to exploit the atmosphere of trust in the hospital community and to hasten deaths that may go unnoticed. In the past thirty years, the Philadelphia Inquirer reported, there had been at least three dozen such cases in civilized societies, but it turned out they had underestimated by nearly half.
Yorker indicated that, worldwide, there had actually been 72 such cases since 1970, with escalations from one decade to the next, but Paula Lampe in the Netherlands had counted 81 (and 31 were male). Among them, they had over 2,000 fatalities (and that was before the final inquiry in England had decided that physician Harold Shipman had killed as many as 250 patients.)

Harold Shipman
Harold Shipman
Some had entered the profession as "angels of death," while others transformed into killers on the job. "Many experts speculate," says Pyrek, "that healthcare has contributed more serial killers than all other professions combined and that the field attracts a disproportionately high number of people with a pathological interest in life and death."
People watched to see what Cullen would say next. For a long time, it seemed, he'd been hiding in plain sight, but now he was exposed.

Suspicions in PA

Cullen fully expected to get the death penalty, but in a quick turnabout less than a week after his arraignment, he accepted a public defender, Johnnie Mask, who subsequently said Cullen might offer names in exchange for taking the death penalty off the table. Both PA and NJ had to agree to the terms all or nothing. He bartered for his client's life with information for families needing closure about their loved ones who had been under Cullen's care.

Public defender Johnnie Mask
Public defender Johnnie Mask
Yet before Mask stepped in, Cullen had already spent seven hours telling the New Jersey State police about his methods and motives. The Star-Ledger eventually acquired the transcript and printed it. Even as Cullen was talking that day, other detectives were busy putting his record together and contacting institutions in Pennsylvania, such as Lehigh Valley Hospital in Allentown and St. Luke's in Bethlehem, to ask what they knew about their former employee.

Lehigh Valley Hospital
Lehigh Valley Hospital
And as the story got out to the public, for some it sparked a note of horrified recognition.
In 1999, the Northampton County coroner, Zachary Lysek, had told several officials that he believed there might be an "angel of death" operating at Easton Hospital. He had examined the death circumstances of a 78-year-old patient, Ottomar Schramm, and he'd been fairly certain the man had been murdered. Schramm had succumbed to a fatal dose of digoxin, but his condition had not warranted getting the drug. While Lysek could not prove where Schramm had received the medication, since he'd come to the hospital from a nursing home, he was certain that someone had administered it with evil intent. He requested an internal investigation at the hospital, based on reports from one of Schramm's relatives about who had been near the patient (Cullen, with a needle), and it was conducted, but it was inconclusive. Lysek was frustrated. In his gut, he knew that something was amiss. But Cullen was already gone. He'd moved on to St. Luke's, in nearby Bethlehem.
Then in 2002, Lysek heard from a nurse at St. Luke's about suspicious behavior by one of her fellow nurses, Charles Cullen, and he'd contacted that county's DA. It turned out that seven St. Luke's nurses had done their own detective work and were now collectively prepared to warn hospital administrators and the state police about Cullen. They believed he was killing patients, because in June 2002 they had found opened and unopened packages of drugs improperly placed in a bin, and had seen Cullen leaving the rooms of patients who then expired. There had also been spikes in Code Blues on his shifts.
Cullen was pressured about this so he resigned and moved on. The state hired a pathologist, Dr. Isadore Mihalakis, to make a comprehensive investigation, but in March 2003, says the Morning Call, he issued a report indicating that after reviewing 67 cases, he had no proof of criminal activity "in which prosecution was the appropriate course of action." The hospital administrators did notify the PA Board of Nursing about Cullen's unprofessional conduct, with no identifiable result. Still, no bodies had been exhumed for an exhaustive analysis, few autopsies had been performed for the records, and no one had interviewed Cullen. By then, he was already at work at Somerset Medical Center (having lasted only 18 days at another institution near Allentown).
He eventually admitted his part in the death of the Easton Hospital patient, Omar Schramm, as well as patients at St. Luke's.
Another man who had suspected Cullen and had tried years earlier to get investigators interested was Larry Dean, the son of Helen Dean. But he didn't hear the story as it grew into national news in 2003. By that time, he'd died.

"He Stuck Me!"

Over the border from Easton in Phillipsburg, New Jersey, Helen Dean, 91, was recovering from surgery at Warren Hospital for colon cancer. That was August 1993. This story was featured in detail in the Easton Express-Times and the Reader's Digest.�� Larry recalled a thin male nurse entering the room and ordering him to leave. He did so, and then returned. The nurse left the room and Larry's mother seemed angry. "He stuck me!" she exclaimed.
But Larry knew that she was not supposed to receive any medication that morning. She pointed out the injection mark on her inner thigh and he used a magnifying glass attached to his knife to inspect it. There was no mistaking the puncture wound. He and his mother reported this incident to some nurses, but no one seemed concerned. And no one bothered to look up Helen's records to see if she was supposed to have received any medication.

Helen Dean
Helen Dean
The next day, she grew ill and began to vomit. She'd been scheduled to go to a nursing home for physical therapy that morning, but they were unable to release her for several hours. By afternoon, her heart failed and she died.
Larry was shocked. Then he was outraged. He felt certain that his mother had been murdered by the nurse in her room the day before, and he tried to get authorities to pay attention, but an investigation turned up no evidence. It was learned that Cullen had been fired in 1992 from the nursing agency that had gotten him his previous job before coming to Warren Hospital, but it wasn't clear why. He agreed to take a lie detector test, but the results were inconclusive (Alexander indicates that he passed). An autopsy on Helen showed nothing provable, either, in terms of criminal conduct.
Cullen soon resigned, but Larry did not give up. He attempted to find out whatever he could to prove that his mother had been the victim of a nurse who was killing patients. In the end, however, he died before seeing justice done.
An exhumation in 2004 proved the case, and Cullen admitted to it: Helen Dean was among the victims whom he eventually listed.
But from there, he'd started hopping from one institution to another. During a nine-year period, he worked at eight more healthcare agencies, and many more people died unnecessarily. Not surprisingly, Cullen generally preferred the night shift.

Early Alert

He was on that shift at the Liberty Nursing Home and Rehabilitation Center in Allentown, PA, when another incident occurred. This time, someone took the fall, but it wasn't Cullen.
On May 7, 1998, writes Alexander, Francis Henry was in the hospital suffering from the repercussions of a serious car accident. He was in a great deal of pain. Nurse Kimberly Pepe was in charge of his case, and when he died, it was found that he'd received an unauthorized dose of insulin. They confronted Pepe and she denied that she'd given him any insulin. She had not checked his blood, she said, as reported in the Express-Times, because he had no history of diabetes. His medical history had indicated Parkinson's disease. Authorities instigated an investigation, which was ultimately inconclusive. Nevertheless, Pepe was fired.
Angry, she filed a discrimination claim with the Equal Employment Opportunity Commission, pointing out in her suit against the hospital that Cullen had been in the room as well: he had a patient there. In addition, he was suspected of stealing drugs. She insisted that she had been wrongly dismissed and discriminated against as a woman.
While the hospital later claimed that it had not been investigating Cullen at the time, he was in fact fired that same year for an issue related to medication delivery schedules. He went from there to Easton Hospital, while Pepe was left to stew over what she perceived as unfair handling of her case. In October 2001, her case was finally settled, which included a confidentiality agreement to prevent her from discussing it.
Liberty did notify the PA Department of Health about the medication error, but had no power to discipline Cullen. They didn't pass along their concerns (were not required to), and no one contacted authorities beyond the initial report.

Charles Cullen, mugshot
Charles Cullen, mugshot
With Cullen's arrest in 2003, Pepe was vindicated.

Inside Scoop


Detectives Timothy Braun and Daniel Baldwin
Detectives Timothy Braun and Daniel Baldwin
To his interrogators, Detectives Timothy Braun and Daniel Baldwin, Cullen admitted that he had intended the deaths of the patients he'd killed. He told them how easy it had been to go from one place to the next, moving on as soon as suspicions were voiced. Basically, he blamed others for letting him get away with what he'd done. He said that some of his bosses had known the errors that he made that harmed patients, but they'd overlooked them.
Cullen claimed that he had killed patients to end their suffering, which at first blush seemed viable, since he'd often been around critical-care and burn-ward patients, but as the cases were opened and people were named, it would become clear that a number of patients were not suffering and some were even on the mend when he decided to take their lives.
In addition, he'd put insulin into IV bags stored in a closet, apparently just to see what would happen (although the hospital in question later said they'd found no evidence for this claim). He doesn't even know if the contaminated IVs brought anyone harm, but clearly this had nothing to do with mercy. It was malicious mischief, pure and simple.
Cullen also said he'd wanted to quit but had bills to pay and children to support. Yet he made no mention of attempting to look for another line of work. Even his counselor thought he should stop nursing, he said, because he wasn't dealing with his depression very well. He felt he had no choice but to keep doing what he was doing.
He mentioned that he thought that patients were being treated as nonhumans, and that was so difficult for him to watch that he decided to end their suffering. "I couldn't stop myself," he said. "I just couldn't stop."

Anne Klein Forensic Center
Anne Klein Forensic Center
Cullen was transferred from Somerset County jail to Anne Klein Forensic Center in Trenton, NJ, where he was examined by a panel of professionals. He surrendered his NJ and PA nursing licenses as each state suspended them. That he could have been fired from half of the facilities where he had worked was a serious red flag for the system, and officials moved toward discussions about what could be done to prevent something like this from happening again. Families who believed Cullen was responsible for their loved one's demise began procedures to sue those hospitals that had not reported Cullen for damages. Every hospital that had ever employed Cullen looked over its records, examined its procedures, and prepared to defend itself.
In the meantime, Cullen's background was pieced together.

The Making of a Killer

Reporters were quick to learn what they could about the man, and friends, relatives, and former associates were helpful in supplying details.
Cullen was the youngest of nine brothers and sisters who grew up in West Orange, New Jersey. The New York Times reported that their father was a bus driver, their mother a home-maker. Born in 1960, Cullen grew up in a working-class neighborhood, in a strongly religious Roman Catholic family. His father died when he was seven months old and his mother was in a fatal car accident while he was in high school. Two of his siblings had also died young, and he cared for one of them during the process.
In 1978, he dropped out of high school and enlisted in the Navy, serving on a nuclear submarine. (According to Alexander, he liked to help the ship's doctor give vaccinations and don surgical gowns.) When he was discharged in 1984 after two stints, he attended the Mountainside Hospital School of Nursing. By 1988, he was working at the first of many hospitals where he would stay only a short while. He got married and had two daughters, but soon was divorced over his workaholism and negligence. In 1998, says the Morning Call, he filed for bankruptcy and had a pile of debts and back payments due in child support to the tune of over $66,000. He lost his dog to the animal protection agency, and though some colleagues said he was inconsiderate of others, he claimed he felt picked on.

Mountainside Hospital logo
Mountainside Hospital logo
In 1997, signs of a troubled mind surfaced. Cullen was taken to a hospital in New Jersey because he suffered from depression. He refused to provide a blood sample and afterward filed a police report against the doctor who had insisted he have one. He ended up in serious debt to this hospital. Just over two years later, he lit coals in a bathtub, sealed off his apartment, put his dog outside, and disabled smoke detectors, to make a suicide attempt. A neighbor smelled the smoke and alerted police. When they took him in, they learned that this was not his first attempt. (Cullen was to claim during his interrogation that he'd tried killing himself some twenty times.)
An A&E broadcast in 2004 indicated that Cullen had threatened another nurse around this time whom he had dated once. Apparently after they'd gone out, he offered her an engagement ring and she turned him down. He broke into her home, ostensibly because he was concerned about her, but more likely to let her know how vulnerable she was should he decide to do something. He was arrested, and then tried to kill himself. For this incident, he drew a year's probation. He insisted that he had not intended to distress the woman.
Rick Hepp from the Star-Ledger located one of Cullen's sisters, who declined to be named, but who told him that her brother was a private man, especially regarding his mental health. "He didn't want to discuss it," she said.
Colleagues recalled him as a gentle person willing to put in extra hours. He was always ready to medicate people in pain.
As his debt mounted, he moved from one hospital to another, and at St. Luke's in Bethlehem, PA, he left in 2002 to avoid that investigation. Yet despite his spotty work record, Cullen never had trouble getting another job, probably due to the shortage of nurses.
The Morning Call wanted to know more. Reporters were aware of legal papers about Cullen during his most troublesome year, and they set about to have these released.

The Hospital Dilemma

The Somerset Medical Center said they did not know that Cullen had been investigated elsewhere. When they'd checked his credentials, they learned nothing that would have made them hesitate to hire him. All they'd received, reports USA Today, were his dates of employment. It was at this facility where Cullen may have done his deadliest work, admitting to killing between 12-15 patients in only 13 months. Had concerns been passed along from previous institutions, things would have been different, and that upsets hospital officials. They were faced with a massive investigation, damage to their reputation, and civil lawsuits.
The Pennsylvania hospitals had additional concerns. During the 1980s, employers had learned that they could be sued for passing along negative evaluations or a refusal to recommend, which is tantamount to saying that someone is guilty before they've been fairly tried. They were understandably gun-shy about putting themselves on the line. To say nothing at all seemed the best course.
Still, there had been indicators about Cullen that could figure into damages. Nurses at St. Luke's had warned anyone they could find that Cullen could be a killer. By their count, Cullen had worked just over 20% of the total hours available in critical care but was present for over 56% of the deaths there. Nurses at two nearby facilities had also demanded that Cullen be dismissed and investigated. However, hospital administrators had declined to pass the word along.
Yet they found themselves in a Catch-22: If they didn't warn, they could be sued, and if they did, they could be sued. Even worse, Cullen's confession made the incidents clearly murder, and the insurance companies had indicated that they would not cover intentional killings. While the cases have not yet been settled, and St. Luke's in particular is legally challenging the threat of lawsuits, it's clear that this is a significant dilemma for healthcare institutions around the country, because Cullen will surely not be the last such killer.

Dr. Michael Welner
Dr. Michael Welner
Dr. Michael Welner, a New York-based psychiatrist and founder of the Forensic Panel, wrote an editorial at this time for the Philadelphia Inquirer, criticizing the current climate of managed care. He points to the assembly-line type of illness management that allows a predator to hone his skills, along with the difficulty of detection in a hospital setting as primary factors in the dilemma: No one had cried for help, there were no wounds, and the suspect had no criminal record. The solution rests in training clinicians and in refashioning personality testing for employment purposes to skew toward compassionate types. "Such professionals," he says," will nurture the rest of us rather than their own need for omnipotence."

Motives

Cullen told law enforcement officers that he had given patients lethal doses of drugs as a way to be merciful. Yet he told them a number of other things as well that countered this claim.
Johnnie Mask hired several psychologists to do a formal assessment of Cullen. There was no need to decide on his mental state at the time of the offense for a trial, but there were other issues, such as where Cullen would spend the rest of his life. In addition, people wanted answers. Why had he done what he did? Dr. Frank Datillio from Allentown spoke to reporters at the Morning Call, indicating that he believed that Cullen had identified with the pain of his patients and had killed them as a way to relieve his own pain and depression.

Cullen with Johnny mask in court
Cullen with Johnny mask in court
Yet people with experience in the psychology of healthcare serial killers would hesitate to accept such statements at face value. There's usually much more between the lines. Many HCSKs have taken the easiest path and said their motives were about mercy, but few cases have supported that claim. Very few. It appeared more likely that, similar to others in his position, Cullen killed because he derived something from it that satisfied him. Not all of the patients were dying or in pain. Some were recovering or in no danger at all. Where was the mercy in those acts?
In the Reader's Digest, Beatrice Yorker was quoted as saying, "These people are sociopaths mostly interested in getting their own needs met. I liken them to firefighters who set fires. Often what they need is power and control or excitement and attention."
While arguments have flown back and forth over the Cullen case in terms of ultimate responsibility, it's clear that patients must depend on hospitals and clinics to spot the red flags and do something about them. Too often, these killers have been allowed to drift from one hospital to another, fired under a cloud of suspicion but rarely brought to justice until after incriminating evidence has reached shocking levels. While there's no distinct psychological type to look for, there are red flags: secretive behavior, missing medications, a preference for the night shift, spikes in unexpected deaths on a certain person's shift, and spotty past work records can be troublesome signals. Cullen had all of these. It appears to be the case that he looked for ways to kill.

The Case Continues

Late in April 2004, Cullen pleaded guilty to murdering thirteen patients in New Jersey and one in Pennsylvania, as well as to the attempted murder of two more patients in his care. It turns out that he tended to kill in clumps, and once there were two victims on a single day. His last murder took place just ten days before he was fired while he was under investigation by several agencies. These were only the first admissions, and relatives of other potential victims (as well as their lawyers) wondered how many more he would add.

Charles Cullen
Charles Cullen
In May, Cullen added three more murders to his list, all of them elderly women in New Jersey. Helen Dean was among them.
Prosecutors from seven counties had to get together and agree on the details of the plea deal, which is why it took so long for Cullen to make his actions public. Cullen will not be eligible for parole for 127 years, and his admissions set in motion a number of lawsuits that had been poised, pending what he would say.
In the meantime, the Morning Call newspaper in Allentown, Pennsylvania, had sued to make legal papers available that described the details of a year of full of problems in Cullen's sordid life. Once they had the information, it became clear just how Cullen's state of mind affected his decision to kill. Clearly, he was acting out during times of stress and failure.
According to The Morning Call, Cullen was "a suicidal alcoholic whose life was spiraling out of control in the weeks before he gave lethal doses of heart medicine to his first known victim."
 

Lethal Time Line

In 1993, his wife had filed for a restraining order against him, based on her fear that he might endanger her and their two children. She said he had spiked people's drinks with lighter fluid, burned his daughters' books, forgotten his daughters at a babysitters' for a week, asked a funeral home about their rates, and showed extreme cruelty to the family pets. Cullen's response was that his wife was exaggerating, but she insisted that he was mentally ill. He apparently racked up a number of moving violations during this time as well.
In these unsealed domestic violence documents, Cullen was revealed as a man steadily losing ground. On January 22, 1993, he was served with divorce papers, and a few weeks later he was when he was arrested for stalking another nurse. After breaking into her home, Cullen admitted himself into a psychiatric facility. On two occasions that same year, he was accused of domestic violence, and he also tried to kill himselfa problem that his wife claimed had dogged him much of his life. That's when he'd killed the three elderly female patients in New Jersey.
Just days after his wife sent inspectors to Cullen's apartment to examine it for fire hazards she claimed were present (but weren't), Cullen killed 90-year-old Lucy Mugavero.
In June, he agreed to submit to a polygraph (and passed) to show that he had not neglected his children or abused alcohol in their presence. In July, he killed 85-year-old Mary Natoli.
In August, a caseworker reported the Cullen had not addressed his alcohol addiction or depression, so he recommended that all visits with the children be supervisedsomething Cullen had vehemently resisted. During this time, he had committed the misdemeanor against the nurse and was convicted. Within weeks, he'd killed Helen Dean.
In 1994, he wrote a note in court papers to the effect that his wife was still suspicious of him. He went to another facility in New Jersey, and then received his license to work in Pennsylvania. That allowed him to move around to several facilities over the next nine years, still fighting for unsupervised custody arrangements with his children even as he killed more people.
The record for this one-year period clearly shows that when things went wrong, Cullen reacted with aggression toward those who could not protect themselves. He may have done so to find some sense of power or control in his desperate life.

Lehigh County District Attorney James B. Martin
Lehigh County District Attorney James B. Martin
Lehigh County District Attorney James B. Martin had two meetings with Cullen during the initial admissions, telling reporters that he believed that Cullen was telling the truth, and that he was remorseful. With detectives, Cullen went through files of possibly suspicious deaths and rejected most of them as originating with him. More interviews were scheduled to go over other cases.
"It all comes down to how much he can remember," one prosecutor commented. They even looked through files going back to Cullen's days in nursing school in 1984, and the potential was there for him to be declared the worst healthcare serial killer in the nation's history.
 

A Killer's Assistance

In June 2005, several newspapers published the results of a long meeting with Cullen in which he offered advice for healthcare institutions in how to make it more difficult for people like him to do what he did. In short, he said, there should be protocols for accountability for staff and for drug-handling procedures. Among them would be installing surveillance cameras, the use of swipe cards and bar codes, and a daily count of lethal medications. He also said there should be a national database for updating employment history of healthcare workers. Institutions should pass information along to one another, Cullen advised, and hospitals should pay attention to the mental health of their employees. Poor performance such as his should be reported to the state board of nursing. The best deterrent, one of his listeners interpreted him to mean, is the certainty of detection.
In his various responses, Cullen's personality is clear: He blames others. He holds hospital administrators responsible for not stopping him or reporting him. He blames the way hospitals operate, which is to say, he exploited the trust factor present in places where employees have patient wellbeing as a goal: it was their fault, not his, for being so gullible.
One of his MOs was to get medications by opening patients' drawers or closets, because no one tracked the drugs. When electronic drug tracking was put into place, he simply learned how to manipulate computer records. He left "tracks," but no one noticed until he made a mistake. There was no system in place for making people who got the drugs accountable for them. In another place, he recalled, a storage room for drugs was never locked and it was easy for him to pilfer them. He claimed he threw away thousands of dollars worth of pharmaceuticals, but no one seemed to notice.
Officials in both states were already busy getting policies and procedures into place. State regulators in NJ strengthened nursing standards, with new rules and harsher penalties. They also introduced the Safe Health Care Reporting Act, which would expand the current National Practitioner Data Bank to include all licensed healthcare workers, not just physicians. And legislation was considered in both PA and NJ to protect hospitals from lawsuits should they have reason to offer a negative evaluation to a former employee's new employer. In April 2004, writes Alexander, New Jersey Governor James McGreevey signed a law that requires all healthcare facilities in the state to document and report serious medical errors, and some PA hospitals will tell prospective employees before hiring that they will pass along whatever negative information they have.

New Jersey Governor James McGreevey
New Jersey Governor James McGreevey
 

Acting Out

As of this writing, Cullen has admitted to 29 murders and six attempted murders, without apology. He hoped to escape his sentencing hearing in New Jersey (he can waive his right to be there), where families give their impact statements, but the state had a card to play: Cullen had requested to donate a kidney to a friend of his former girlfriend, and he was allowed this on condition that he attend the hearing. The families wanted closure; they insisted he be forced to hear from them just how much damage he had done. Although it's expected that these are the last cases to which he will admit, there are still open cases pending investigation. Some families still believe, despite his denials, that he was instrumental in their loved one's death.

Michael Strenko's mother holds a portrait of him outside court
Michael Strenko's mother holds a portrait of him outside court
He went to court in Somerville, New Jersey on March 2, 2006 to receive eleven life sentences, while about twenty relatives of his victims battered him with name-calling and descriptions of the emotional aftermath of his crimes. His thin hair had turned gray in the two years since he was arrested, writes Geoff Mulvihill for Newsday, and he sat throughout the ordeal with his eyes closed.

Somerville New Jersery Courthouse
Somerville New Jersery Courthouse
Then on March 10, he went to Allentown, Pennsylvania, and there he made a scene. The Morning Call showed a photo of him muzzled as the result of his failure to abide by the judge's instruction. Judge William Platt had apparently made a comment to the press about Cullen that Cullen's attorney said Cullen did not like, so he started the proceedings by saying, "Your honor, you need to step down."
Judge Platt said that he was unbiased and intended to preside over the hearing. Cullen continued to insist that he step down, turning this phrase it into a repetitive chant, "Your honor, you need to step down." The judge insisted that Cullen quiet down, but Cullen continued. Platt ordered that he be gagged, so a cloth was placed over his face with a mesh hood to hold it over his mouth, but he continued his chant in a muffled manner. Victims' relatives were frustrated in their attempts to be heard, but they addressed him anyway. They also told reporters what they'd said, but in some ways, Cullen had one-upped them, robbing them of their satisfaction in confronting him. At the end of the hearing, he received seven more life sentences.

Somerset County Jail
Somerset County Jail
In mid-March, Cullen was moved from the Somerset County Jail to New Jersey State prison in Trenton, where security is reportedly the tightest in the state, to serve his eighteen consecutive life sentences. His health and mental state will be checked there. His request to donate a kidney was granted, allowing him one trip away from the prison to an unspecified place in New Jersey. Cullen is still required to assist in other investigations, even after his sentencing, according to his plea deal, so there may yet be future revelations. He remained unrepentant and refused to say why he had killed people who were not in need of his so-called merciful action.

Analysis

While people argue over whether Cullen murdered from "pure" motives like compassion, there are indicators that support the likelihood that he gained something for himself from killing patients. People may sometimes reveal things about themselves despite that they may be saying. Let's look at some of his behaviors.
  1. Cullen's agreement to be interviewed by detectives without an attorney, coupled with his quick and shocking confession, suggest that he wants the full extent of what he did to be known: it may be that, having been caught, he wants to show how clever he was (similar to the home break-in when he called the victim to let her know what he could do). The length of the initial interview seven hours also affirms this, as does how much often repeats information about his state of mind and his circumstances. He betrays a "poor me" attitude.
  2. His claim, "I didn't intend for these people to suffer," may well be true, but he fails to actually view them as people. He never asked, never considered what they might have wanted. They were instrumental to his ends. Abusers often have been abused. It may be safe to say that his idea that he wanted to spare them from being "dehumanized" indicates that he has felt some significant dehumanizing forces in his own life. And they probably made him angry or frustrated.
  3. Cullen was advised to step away from nursing, yet he didn't. He knew what he was doing, yet he did not stop. Even so, it was not compulsive in the sense that something came over him and he surrendered to it (as Ted Bundy described). While someone like Bundy prepared a "murder kit," and was thus considered an organized killer, he generally prepared for opportunities rather than specific individuals. Cullen knew who he wanted to kill and then learned and manipulated the system to make this occur.A lot of preplanning is involved with that. It can then become compulsive, but probably did not start out that way.
  4. He claimed that walking away was not an option. Of course it was. There are other jobs. He offered no indication that he even looked for options. That's just an excuse. His elaborate explanation about finances and child payments is another way of blaming an external force. Lots of people have that situation but don't act out in the ways he did. If he knew it was wrong and he had some insight about it, then he could have stepped away. Could he really believe that not keeping up with child support payments was worse than killing people? If so, then he has an elaborate rationale in place. The experience may have become addictive for him, in terms of the rush of anticipation and the ultimate feeling of having this power over others. How can anyone say "I had no choice but to do a job that put me in a situation where I would have to kill people"?
  5. Then he blamed stress that made him want to work more hours. It's always something outside him that gets the blame. The fact that he didn't have someone in his life, the fact that he was in debt, his depression. He takes no responsibility for making some rather dramatic decisions on behalf of people who did not seek his help.
  6. Cullen knew exactly how to kill people with medication, and yet his own suicide attempts are inevitably inept. That's inconsistent. He could have gotten legal prescriptions for the right types of drugs. He knew what to do.
  7. The question he dances around is why he feels "driven to end people's suffering." It's easy to say that he was projecting his own pain and then trying to eradicate it that way, but there's probably a better explanation that pinpoints his way of dealing with things throughout his life. You don't kill just because you hurt or we'd all be out there killing people. There's a reason that he chose that particular way of dealing with his own life issues, as well as why he not only continued to do that but eventually felt driven to do it. I think he became addicted to the rush of anticipation, the energy of finding a way to do it, and the exhilaration of those moments when one realizes one has gotten away with such an act. This pattern has been true of many serial killers. The victims matter less and less (Cullen says they're all in a fog now, he can barely remember them), and the experience becomes increasingly more gratifying, so that the activity tends to escalate into more intensity and more frequency.
  8. "It was not something I was ever wanting to tell people about," he says, but then he confessed it right away once he was caught. He did want to tell. It would have been a simple thing to have said, "Yes, I did some things to those two people in New Jersey" and left it at that. Instead, he confessed to everything.
The compartmentalizing evident here is similar to many serial killers. They are able to live on "levels." On one level, they can act and think this way, on another level, that way. And the two (or more) can be in complete conflict. They can dissociate themselves from the morality of their killing but still dictate morality to others about other types of behavior. They can lie about what they're doing but still value the truth. They can treat family well but see victims as less than human. It's a type of logic that works when one can step in and out of various identities. It becomes a way of life, not necessarily something they actively calculate in every situation. In an environment where medical mistakes do get made and people do die as a result, it's not hard to mimic that and get away with it, especially since the healthcare industry relies on an atmosphere of trust and concern for others.

Healthcare Serial Killers: Ramifications


Dr. Gregory Moffatt
Dr. Gregory Moffatt
Dr. Gregory Moffatt, a therapist and expert in risk assessment, discusses the more general phenomenon, in Blind-Sided, of murders that occur where they are not expected. That is, many murders are committed by people who seem nonviolent. Moffatt argues that there are certain predictors of a predisposition toward violence that are generally overlooked by people acquainted with the killer. There is a way to identify the person who may become violent, and he offers a list of warnings to take seriously. While he does not directly address the population of nurses and physicians who may become killers, his warning signs are nevertheless applicable.

Blind-Sided, by Gregory Moffatt
Blind-Sided, by Gregory Moffatt
Among the signals for potential violence are:
A past history of violence
  • Threats
  • Social isolation
  • Substance abuse
  • Job instability
  • Poor self-image
  • Anger/depression
  • Poverty
  • Severe situational stress
  • Feelings of being wronged
  • Weak support system
Cullen fit a number of these, although his social isolation made it difficult for people around him to know what he might have been going through. It should have been clear that he had issues with anger and depression, and that he had little money and few (if any) friends. But he was a quiet, reclusive man who did not let others know him. Nevertheless, some coworkers did suspect him, and they were correct.
Among those warning signs that Moffatt does not include that are more specific to healthcare serial killers are the fact that Cullen would often predict who was going to die, he was often seen coming from rooms where patients soon died, and he jumped from one institution to another, often being fired or leaving under suspicion.
People acquainted with someone with the potential to kill, says Moffatt, should:
  • Take threats or statements of intent seriously
  • Seek assistance or resist violence when it occurs
  • Have a plan in place before violence occurs
  • Call for help immediately
  • Don't panic
With Cullen, some of the patients were certain that he had done something to them that ought not to have happened, such as giving them an injection. Had they demanded to know what he was doing, or been more assertive about reporting him, the chances are better that he'd have been caught and more thoroughly investigated.
Perhaps the wake-up call from this case and the new legislation will deter some potential angels of death of killing. It remains to be seen. We know that more HCSKs have been convicted in the past fifteen years than in decades before, so it's clear that we're either catching more of them or more of them are developing. In either case, hospitals must acknowledge their existence and train their personnel to spot them, document their movements, and take action. All of us who will become patients depend on this.

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