Serial murders in health care settings

The case of Charles Cullen is one of the most egregious cases of serial murder in health care settings, according to Beatrice Yorker, JD, RN, MS, FAAN, dean of the college of health and human services at California State University Los Angeles, who has researched and published in the field of forensic nursing. Cullen, formerly a nurse, murdered between 35 to 45 patients while working in 10 hospitals and ultimately received 11 life sentences.

Cullen's story was "just mind boggling. That really seemed to trigger a lot of response. But again, not enough response. They treated it as though he were the only one." That was the impetus of the article, "Serial Murder by Healthcare Professionals,"1 Yorker co-wrote with Ken Kizer, MD, MPH, consultant and founding president of the National Quality Forum. The two also recently published another article on the topic.2 (To see more stories on serial-type murders in health care, visit or

"That's what really prompted us to write our article, to say, 'Look, this is a huge problem.' The body count is probably larger than the garden-variety serial murder, like the Green River Killer, or the guys who go out and stalk women. They only get away with maybe eight to nine victims. Whereas the hospital serial killers, some of them have over 200."

The health care setting, she says, is a psychopath's dream. "First of all, you expect people to die. Second of all, you never treat it like a crime scene. Third of all, you don't do enough autopsies on death. The whole idea is when you're in a hospital, it is so normalized," she says. Often, nighttime or weekend shifts in hospitals, or in nursing homes that may have only one vocational nurse per unit for those shifts, are ripe for criminal action for these individuals because of less supervision and fewer personnel in-house, Yorker says.

Often these perpetrators go unnoticed, moving from one facility to another. Very few have a criminal background, so no one would be alerted when per usual protocol the human resource department conducts criminal background checks.

One of the only clues these types leave behind, Yorker says, is fabricating details about their lives — for instance, whether they were married or divorced or whether they were involved with any civil legal proceedings. The markers of the personality is they often are "crisis creators," and the problem with detecting an employee with psychopathic tendencies is "right now in health care you can't screen for whether you have a psychopath like you can in law enforcement and in the FBI and places like that. In health care, so far, that would violate people's civil rights. It's not done. But as soon as you have some hint that a health care provider has psychopathic tendencies, particularly as it comes to falsifying credentials, that should be a huge red flag," she says.

Many hospitals and their counsels provide references believing that they are allowed only to offer dates of service. The belief is "'If we give a bad reference we could be sued.' Well, true. But only if it's an untrue reference and only if there were damages, and the damages tend to be in the $30,000 range. But if you give a truthful reference that when this nurse worked in your hospital, adverse patient outcomes increased threefold or something like that, first of all, that's not libelous or slanderous. It's true. And second of all, if you don't give that, you're looking at damages in the $8-$20 million range," she says.

Hospital legal counsels need to balance the risks and the benefits, she says. There was a case of a hospital worker who had eight "fire/do not rehire" notes in his files, but only one hospital released that information. He worked at about 20 facilities and patients died in his care every time he was on a shift, Yorker says.

"There's now case law that supports or that shows that facilities can be at risk for civil penalties if they don't provide this information, although I think the preponderance of concern among the risk management folks is that if they do provide the information they will be sued for libel," Kizer says.

Kizer says serial murders in health care settings often occur in smaller communities. "And often, in some of these smaller communities, it's maybe even easier to get away with it."

Yorker favors video surveillance systems to uncover these types of events. Kizer says in most cases that are discovered, colleagues had suspicions.

So in the absence of a criminal background and full reports from resources, what are clues to look for? "The things that jump out are obviously deaths or codes. Some of those codes are going to be successfully resuscitated. So those are two clear types of events that should be monitored on a regular basis, and they really should be monitored on a unit-by-unit basis. And someone should be looking at that," Kizer says.

"The benefit of doing that is less to pick up criminal activity than a standard-of-care problem. It might be harder to justify it if you were just looking for criminal events. But the reality is, if you look for it you're going to find all kinds of things. So there's lots of benefit there," he says. "Now what's harder to pick up would be events that aren't fatal. Codes are kind of that transition. Assaults are often harder to access and track, and they aren't often as clear-cut."

Most cases are committed by woman, partly because the vast majority of hospital workers are women, Yorker says. "As a matter of fact, men are overrepresented in our data, especially when you look at the nursing because only 7% or 8% of nurses are male and yet 38% of the nurse murderers are male." She says society "has ignored or has not paid attention to feminine forms of violence and murder. We are very well versed and we're very opposed to male forms of violence. That's bludgeoning, that's gun shots, that's strangling, that's beating. What we are not as aware of, and much more tolerant of, is feminine forms of violence, which is poisoning, smothering, sort of killing in the context of caretaking."


  1. Yorker BC, Kizer KW, Lampe P, et al. Serial murder by healthcare professionals. J Forensic Sci. 2006 Nov;51(6):1362-71.
  2. Kizer KW, Yorker BC. Health care serial murder: a patient safety orphan. Jt Comm J Qual Patient Saf. 2010 Apr;36(4):186-91.