I’ve been meaning to contact you all, but things have been a zoo here (as you can imagine). Your call to Eddy and me in June seems to be the grain of sand in the oyster that brought this situation to light. [Your] ability to spot the trend and get the hospital focused on pursuing this issue proved quite valuable. Clearly your instincts were right on target! Thanks.
Dr. Bresnitz e-mailed Dr. Marcus two years later regarding the calls, telling him, “Ironic that Somerset portrays themselves as doing the right thing by notifying us when clearly it was in response to your informing them that if they wouldn’t do it, you would.”
9 At 4:23 p.m. on July 10, 2003, several hours after Dr. Marcus had called and e-mailed the DOH.
10 Those patients were Joseph P. Lehman, who suffered unexplained hypoglycemia on May 28, 2003, and Francis Kane, who had a similar incident on June 4, 2003.
11 They’d hired an RN from an inspection agency, who spent two days interviewing leadership and checking the machines before submitting a report.
12 According to documents from the police investigation, an internal memo on the interview (written July 25, 2003, and included in police investigative reports), by Fleming, indicates conflicting impulses and information, including that he had not interviewed any nurses other than Cullen, that he had some suspicion that the unexplained overdose incidents at Somerset were both connected, and that such incidents might not yet be finished:
Ms. Lund and I discussed a variety of issues and planned some further investigation,” Fleming wrote. “Some of the blood taken from patients in the CCE/ICU in recent days is going to be tested and the ICU/CCU blood taken from patients now and in the immediate future is being saved. In addition, we are going to speak to the nurses caring for Reverend Gall on the 27th and 28th of June. The billing records are going to be checked to see if Digoxin was billed to any of these three patients, even though the record doesn’t show that it was given. Lastly, Ms. Lund is going to send me the Han medical chart and the Maurer medical chart. (Maurer was another, unknown patient who was also apparently within the scope of Fleming’s investigation.)
The penultimate paragraph suggests that while police involvement was not warranted, Lund and Fleming already suspected Cullen as a subject to be watched: “We agreed that there was nothing so overtly suspicious at this point in time (either from the records or Mr. Cullen’s demeanor itself) that would necessitate a call to the authorities. However all the patients in ICU/CCU are being carefully monitored and red flags are going up for any Digoxin orders of medication administration…. Incidentally, the records also show a number of viles [sic] of Digoxin not being accounted for last month.”
CHAPTER 27
1 Pasquale Napolitano, killed on July 13.
2 Dr. Max Fink, the head of the insulin coma unit at the Hillside Hospital in Glen Oaks, Queens, New York, from 1952 to 1958, described some of the effects of insulin for PBS’s The American Experience:
Stages of Coma
0630–0715: Pre-comatose.
Patient went gradually to sleep and then to coma. Two forms of coma were recognized, a “wet” and a “dry.” In the “wet” form, sweating was profuse and was accompanied by “goose-bumps” in the skin. Salivation increased, so much so that nurses sopped it up with gauze sponges. In the “dry” form, the skin was hot and dry, muscles twitched, in a sequence that began in the face, arms, and then in the legs. These were often small twitches, but from time to time, patients would move and jerk an arm or a leg. Occasionally, a grand mal seizure supervened.
3 Götz Aly et al., Cleansing the Fatherland (Baltimore: Johns Hopkins University Press, 1994). The Eichberg Station was designed to accommodate experiments with intentional IV overdoses; see Henry Friedland, The Origins of Nazi Genocide (Chapel Hill: University of North Carolina Press, 1995), 131.
CHAPTER 28
1 Details of this horrifying incident, and all patient deaths, are drawn from police investigation documents.
2 September 23, 2003.
CHAPTER 29
1 Tim got the call that he’d made the grade in Essex the same day that he got the call that his father had passed away. He didn’t know if that was what changed it for him, but something shifted in the way he saw his role in life.
2 Fifteen years later, in January 2010, Essex County investigators finally made their knowledge of Duryea’s killer’s gun public. The Newark Star-Ledger would report “Robert Reeves, 44, used the same .32-caliber revolver involved in the Duryea slaying to fire five bullets into a Newark minister. When asked about Reeves, Anthony Ambrose, the prosecutor’s chief of investigators, [confirmed] in an interview that Reeves is ‘a person of interest’ in the Duryea case.” Philip Read, “More Details Emerge in the Killing of Glen Ridge Grandmothers,” Star-Ledger, January 10, 2010, http://www.nj.com/news/index.ssf/2010/01/new_details_emerge_in_1995_kil.html.
CHAPTER 30
1 Dennis Miller at Somerset Medical Center contacted the office of Prosecutor Wayne Forrest on this date.
2 Details of the detectives’ actions and interactions with the individuals at the hospitals are drawn from the police investigative reports and detailed by personal interviews.
3 In fact, the Department of Health and Senior Services had reached out to the New Jersey Attorney General’s office before Somerset Medical Center administrators contacted the Somerset Prosecutor’s Office.
The full story of how these incidents were reported is a bit more complicated, and suggests that the process of reporting, investigating, and ultimately acting upon the incidents at Somerset Medical Center in a timely manner had been stalled or sidetracked at several junctures, both within Somerset Medical Center and at the highest level of the DOH itself.
The DOH sent an investigator named Edward Harbet, an RN and a complaints Investigator from Health Care Systems Analysis. He visited SMC on July 11 and 14, reviewing the medical records of the patients involved and the summary of the SMC internal investigation, and interviewing several administrators. Harbet was unable to identify any specific findings that would explain the relevant lab values in the patient incidents. He told SMC administrators that the charts would be reviewed by others in his department.
The sitting commissioner of Health and Senior Services at the time was Cliff Lacey. According to e-mails from the senior assistant commissioner, Marilyn Dahl, the incidents at Somerset Medical Center had been discussed with Commissioner Lacey following the reporting of both Steven Marcus and then Somerset Medical Center administrators. “Based on his experience with the drugs in question, and as the senior medical officer of a large hospital, the commissioner thought it was extremely premature to start suspecting foul play. I had, at that time, raised the issue of a referral to the AG, and the commissioner declined,” Dahl wrote. “He was able to hypothesize several likely scenarios not involving foul play that could have resulted in the outcomes reported.” (Emphasis mine.)
Then, on September 26, 2003, some members of the DOH became increasingly concerned about what was unfolding at Somerset.
A senior DOH staffer named Maureen F. Miller sent an e-mail to Marilyn Dahl. “While the Dept was aware that three unexplained incidents had occurred and was working with Somerset’s administration who was investigating the incidents,” Miller wrote, “Somerset reported to us today that a fourth incident occurred one month ago,” despite being explicitly warned of the necessity of reporting any additional patients.
Dahl was deeply concerned. She reported that she had met with Alison Gibson, director of Inspections, Compliance and Complaints at the DOH, and Amie Thornton, assistant commissioner of Health Care Facility Quality:
We all agreed that there may be sufficient reason to suspect foul play. The disturbing part of this picture is that Somerset had made us aware of the 3 previous occurrences, yet chose to wait an entire month before reporting the 4th. We believe that this was irresponsible at best, and would like permission to seek counsel’s opinion from OLRA [the DOH office for Legal and Regulatory Affairs] for
referral to the AG’s [Attorney General’s] office. [Emphasis mine.]
That day, the Department of Health reached out to the Attorney General’s office regarding the issue at Somerset. Amie Thornton wrote Ms. Miller and others at the DOH later on September 26 to report that “I believe at this point the hospital actually suspects foul play as they have retained private investigators/attorneys to investigate this situation.” Seven days later, Somerset Medical Center contacted the Somerset County Prosecutor’s Office (SCPO).
CHAPTER 31
1 Sachs, Maitlin, Fleming, Greene, Marotte and Mullen.
2 This conversation is reconstructed from SCPO investigation documents detailing the meeting and the information Lund provided, aided by extensive interviews with Detective Baldwin.
3 Somerset hadn’t called the police for a half-dozen patients who had been poisoned—then, months later, called to report the death of a man who hadn’t.
CHAPTER 32
1 This call was part of an investigation at Easton Hospital, just underway at this time but already stalled.
CHAPTER 33
1 The info to this date (October 8, 2003) comes from various databases and contacted agencies, including the South Carolina State Police, the Summerville (South Carolina) Police Department, the Palmer Township (Pennsylvania) Police Department, the Phillipsburg (New Jersey) Police Department, and the New Jersey Board of Nursing.
CHAPTER 34
1 Those investigations were closed in late December 1991, with no conclusion. Charles Cullen was fired the first week of January 1992, and the insulin spikes stopped. Saint Barnabas has since maintained that these facts are unrelated, and that the administration did not have reason at that time to believe Charles Cullen was a risk to patients.
2 Fragments of this investigation would later be recovered after Cullen’s arrest.
3 Several incident reports described the MO of the crimes almost exactly. For example, Charlie had been written up for checking the insulin levels of a patient repeatedly and at inexplicable and inappropriate intervals, and for leaving an unprescribed and unlabeled IV hanging for a patient after his shift, rather than the prescribed KCL solution. Afterward, when his supervisor contacted him at home by phone, Cullen seemed apathetic, and he claimed that if it was hanging there, it must have been the prescribed KCL. It wasn’t, but exactly what was in the bag, and whether this was one of the saline IVs which Cullen would later admit to having randomly spiked with insulin, would never be known.
4 Cullen had signed up with MCHCS halfway through his years at Saint Barnabas in order to have more flexibility in the hours and units in which he worked. This was the reason that Cullen’s Saint Barnabas file covered only the final two years of his five-year tenure; technically, a different corporate entity had hired him.
5 In fact, what was meant by “dual medication error” is somewhat more damning of the nurse. What was referred to here is a situation in which Cullen had (1) withheld medication the patient was prescribed; (2) in its place hung an unlabeled bag that, strangely, he had (3) pinched off so that the next nurse would be the one to start the drip. It is, in fact, a triple error; exponentially less likely, and rather more troubling than a single dosage error, as it cannot so easily be written off as a simple mistake. The supervisor’s reaction reflects this.
Ostensibly the IV bag in question contained only saline, though we cannot know for sure, as Cullen’s practice at the time was to use such bags, spiked with insulin, to sicken patients; and he often covered his tracks by ensuring that the spiked bags were infused by other nurses when he was not present.
6 According to the DOH investigation and police investigation documents, SMC’s legal counsel prepared a time line in “anticipation of potential litigation,” in which “DBR, Paul G Nittoly, (PGN), [was] asked to participate in investigation of abnormal lab values with help of private Investigator, Rocco E. Fushetto (REF).”
7 This conversation is drawn from the notes and recollections of Detectives Braun and Baldwin and detailed in police investigation documents. The only liberty taken with the statements reported by the police investigation documents is the use of quotes to create the scene.
CHAPTER 35
1 Bruchak, Egan, and their commander, Cpl. Gerald Walsh, all participated in the briefing, but Egan was Detective Baldwin’s main point of contact.
2 The details of this case could constitute a book in themselves. The following details were provided in the course of the civil suits brought by five families of former patients against Saint Luke’s Hospital. Saint Luke’s argued that the cases should be thrown out because they were older than the two-year statue of limitations; Lehigh County Judge Edward D. Reibman ruled that they were still relevant. Ultimately, Saint Luke’s settled with the families out of court. While the specifics of the settlements are sealed, some details may be gleaned from court records (Case law: Superior Court of Pennsylvania, Krapf v. St. Luke Hospital, Lehigh County Judge Edward D. Reibman, Nos. 2958 EDA 2009, 2959 ED 2009, 2960 EDA 2009, 2961 EDA 2009, 2962 EDA 2009. Before: Gantman, Shogan, and Mundy, J. J.): much of the issue facing the court was whether Saint Luke’s had reason to believe that Cullen had been involved in patient deaths.
Attorney Paul Laughlin recalled that he suggested patient charts be reviewed to ascertain whether the diverted vecuronium bromide had been improperly administered, thereby resulting in patient harm (Pl.Ex. VVV at 40–44); however, the question of what precisely Attorney Laughlin learned during, and concluded from, his investigation is not clear. And in that respect, the deposition testimony of the various witnesses diverges considerably. Laughlin indicated that particularized suspicion of Cullen harming patients was never brought to his attention. (See ibid. at 127–135.) However, notes from his interviews in combination with testimony of Nurse Patricia Medellin leave it within the purview of the finder of fact to draw a different inference.
Specifically, Nurse Medellin stated she met with Attorney Laughlin on the night he confronted Cullen and that he had instructed her to call him if she “had any additional thoughts.” (Pl.Ex. III, at 72.) After learning that opened containers of vecuronium bromide had been found in the receptacles and that other nurses had concerns that patients may have been harmed, she telephoned Laughlin on or about June 7, 2002. (Pl.Ex., at 76–78.) She informed him that the unauthorized administration of vecuronium would be consistent with unexplained slowing down of patient heart rates, leading to codes when their hearts stopped. (Ibid. at 79.) She also told Laughlin that no one in the CCU at that time should have been receiving vecuronium. (Ibid.)
In response Attorney Laughlin informed Nurse Medellin that “the investigation was closed” and that he was “confident that Cullen was not in any way harming patients.” (Ibid. at 80.) Medellin pressed Laughlin about how he could be so sure, especially when Laughlin had admitted to her that he had not compared the medications sent from the pharmacy versus those actually used on patients and had not compared the number of patient codes on day versus night shifts when Cullen was on duty. (Ibid. at 81–82.) Laughlin allegedly responded that based on his experience as a prosecutor in Philadelphia for eight years, he was confident in his investigation and was “certain” that Cullen “was not hurting anyone.” (Ibid.) He then informed her once again that the investigation was “closed and not open [[001]] for further review.” (Ibid. at 82.)
Nurse Medellin also testified at deposition that she voiced her concerns to her supervisors, but that she was met with an equally inhospitable response. (Ibid. at 96.) In particular, she stated that after Attorney Laughlin dismissed her concerns, she spoke to Thelma Moyer, the clinical coordinator at Saint Luke’s, and Ellen Amedeo, the CCU nurse manager at the hospital, both of whom dismissed her concerns and informed her that the investigation was closed. (Ibid.) She also testified that after speaking with Attorney Laughlin, she compiled a list of the patients who died in the CCU, compared it to Cullen’s shifts, and determined that a disproportionate number of patients died while he was on duty. (I
bid. at 91–93.) However, because of the lack of receptivity and “almost anger” expressed by Clinical Coordinator Moyer and CCU Nurse Manager Amedeo to her previous entreaties, Nurse Medellin did not present the list she compiled for fear of “repercussions.” (Ibid. at 97.) After he returned from leave in July 2002, the hospital’s general counsel, Seymour Traub, directed Attorney Laughlin to prepare a report and ordered additional chart reviews to be performed by Saint Luke’s staff. (See Pl.Ex. BBBB at 30.) Risk Manager Rader and Nursing Manager Supervisor Koller were charged with reviewing charts of all of the patients who had died over the course of the weekend in which the diverted medications were found. (See Pl.Ex. UUU at 21.) However, Nursing Supervisor Koller testified at deposition that she had never before performed any similar such chart review and, in fact, was not even aware of the purpose of her review when Risk Manager Rader asked her to review the patient charts. (Pl.Ex. AAAA at 46–50.) For her part, Rader testified at deposition that Attorney Laughlin indicated to her at that point that he could not find “a scintilla of evidence that there was any foul play involved.” (Pl.Ex. UUU at 114.) Risk Manager Rader and Nursing Supervisor Koller identified neither any suspicious administration of vecuronium nor any suspicious deaths. (Pl.Ex. UUU at 138.) Accordingly, the additional inquiries ordered by General Counsel Sy Traub failed to unearth Cullen’s involvement in patient deaths; afterward, the hospital’s chief executive officer concluded this part of the investigation by referring Cullen to the State Board of Nursing for follow-up as it saw fit. (Pl.Ex. III.)
After notification by the district attorney that the matter had been referred to law enforcement, the hospital undertook further investigations, including patient-chart review by an outside physician; however, this, too, failed to lead Saint Luke’s to conclude Cullen had harmed any patients. (See Pl.Ex. NNN at 51–55, 125–127.) Cullen ultimately confessed to killing, among others, the five decedents at Saint Luke’s at issue in these cases. (See Pl.Ex. B; Ex. C.) In total, seven patients have been specifically identified as having been killed by Cullen at Saint Luke’s.
The Good Nurse: A True Story of Medicine, Madness, and Murder Page 32