The Role of the Forensic Nurse as an Integral Part of the Criminal Investigative Team
By Bruce Sackman

Editor's note: The views expressed in this article are the exclusive opinions of the author and not the U.S. Department of Veterans Affairs, OIG.

"It was a cold chilly day. On Ward C of the U.S. Department of Veterans Affairs Medical Center there was a different kind of chill that penetrated the floor. It was a deep eerie feeling; patients were dying unexpectedly from sudden cardiac arrest. Three nurses came together and voiced their suspicions. It was every hospital's nightmare. There was a killer among them, one who coldly and callously killed four men and attempted to kill three others by injecting them with the heart stimulant epinephrine."

These were the words of Assistant U.S. Attorney William Welch in his opening remarks at the trial of nurse Kristen Gilbert in U.S. District Court in Springfield, Mass. in November . Almost identical words could have been utilized in other recent healthcare murder cases.

On Sept. 7, the headlines in Newsday read, "He Liked to Kill: Dr. Swango Admits Murdering 3 at Northport Hospital, Faces Life Without Parole." On June 4, the Columbia Missouri Daily Tribune's headlines read, "VA Suspect Charged, Former Nurse Faces 10 Murder Counts." The latest case comes from Nocona, Texas. CNN reported on July 17, , "Texas nurse Vickie Dawn Jackson is in custody after being arrested on two charges of capital murder in an investigation into as many as 20 deaths over a two-month period at a hospital. Several vials of mivacurium chloride, a muscle relaxant that can be deadly in large amounts, were discovered missing around the time of the patients' deaths."

Few criminal investigators have experience working suspicious death cases at medical centers because very few of them are ever reported to the police. I am not referring to the confrontational violent crime committed by using a gun or other weapon. The majority of healthcare workers are dedicated professionals. I am referring to the insidious acts of a few who take the lives of others by poisoning. Highly trained medical professionals who have taken an oath to help heal the sick have a difficult time accepting the premise that a fellow medical professional would intentionally kill a patient. They are not alone. Patients rarely question the drugs they receive from doctors and nurses. So high is the confidence level in hospital staff that family members refuse to believe the cordial nurse or doctor who frequently visited their mom or dad at the hospital may have intentionally caused their death.

Hospital administrators aren't eager to support an inquiry into allegations about staff members committing murder. Their thoughts are, 'Can you imagine what damage will be done to our fine medical institution if word leaked out that one of our doctors or nurses were intentionally killing patients?' Rather than conduct a forensic inquiry, hospital administrators rely on peer reviews to determine that the cause of death was probably related to some underlying medical problem in the patient's history. Autopsies conducted by the hospital are not forensic autopsies, but are conducted to confirm the patient could have died from an underlying medical problem.

The police have little or no medical expertise. They rely on medical professionals to determine cause of death. If a team of physicians has already determined through peer review that the patient's death could have resulted from existing medical conditions, why pursue the matter further?

In what institutions other than healthcare facilities is death such a common occurrence? Deaths are reported all the time at hospitals and nursing homes. A certain percentage of patients in these facilities are expected to die while residing there. In large facilities deaths are daily occurrences. Who is going to question one more death of a very ill patient?

Given these facts, if I were inclined to commit a series of murders, I would be well advised to choose a healthcare facility. And what better profession to choose than that of a healthcare professional, one that virtually gives me the legal power of life and death over a person? Working alone on a night shift, I am virtually guaranteed that there will be no witnesses to my crime. My choice of weapons is formidable. There are a number of "sudden death" chemicals readily available on the ward, including many that are considered "non-detectable" or generally not tested for at autopsy. (During the course of one recent investigation it was determined 40 sudden-death injectibles existed on a single ward.)

Enter the forensic nurse. Nurses are not trained to be law enforcement technicians, they are trained to save lives. Forensic nursing represents the opportunity to combine both skills; the need for this discipline cannot be understated. Nurses usually know when a patient will shortly expire. Most hospital deaths are predicted not only by the staff but by the family. But in cases involving serial killers, patient deaths were unexpected by staff and family. What happens to crucial evidence when the staff becomes puzzled by the manner and timing in which a patient died?

The scene of the suspicious death is usually the patient's hospital room. A code is called and medical professionals rush in to save a life. Syringes, IV lines and feeding tubes are the most likely portals of entry if poison has been used. In the case of sudden unexpected death, what happens to these crucial pieces of evidence? Are they discarded as a matter of routine? The first assignment of a forensic nurse should be to ensure all physical evidence is retained for possible future forensic examination. The forensic nurse should ensure all pertinent medical records are secured in a safe location.

In the case of suspicious hospital deaths, very rarely are the police called to the scene immediately. Often days, weeks or even months go by until a decision is made to contact outside authorities. If suspicion only arises as a result of a pattern of untimely deaths, then it can be years before law enforcement is contacted. A review of the case(s) early on by a forensic nurse will help ensure that a timely and correct decision regarding outside referral will be made.

The overwhelming majority of suspicious deaths in medical facilities is not the result of criminal activity; however, it is imperative that someone with the training of a forensic nurse participate in the decision to refer the matter to the police. If a decision is made to contact law enforcement officials, the forensic nurse will act as the liaison between the healthcare facility and the police. It is important the forensic nurse begins a review of the patient's treatment records. This nurse must have access to all medical records including those of the pharmacy service, any correspondence between the patient, patient's family and the medical center and its personnel. Lastly, the forensic nurse may be required to review the charts of other patients that were treated in the same ward or by the same treating nurse or physician.

Most criminal investigators have little or no medical background. Most have no idea how a medical center operates, what data is recorded in a patient's chart, how a pharmacy dispenses drugs, how a hospital peer review process works or what a DNR order is. The investigator faces a considerable learning curve when first confronted with a medical suspicious death. In the early stages of the investigation, police depend on physicians and others to explain these processes. Unfortunately, police can become confused when inundated too much information regarding a world with which they are unfamiliar. Cops and prosecutors need a competent guide and interpreter to assist them in their journey through this maze of science and protocol. There is simply no one better suited for this task then the forensic nurse.

This journey begins with an understanding of hospital regulations and quality-of-care issues that must be thoroughly explained. It shortly evolves into the skill of explaining medical procedures and medical terminology to non-medical people, a trait often lacking in medical managers. The forensic nurse also has the important skill of evaluating the quality of care given a patient from a nursing perspective. This service cannot be understated. Nurses often reflect upon patient care from a different perspective than physicians or technicians, noting improprieties and spotting errors that other medical professionals miss. Forensic nurses are knowledgeable about drug interactions and the evaluation of prescriptions. All these skills are essential to the investigative team.

Staff nurses more often than not uncover the criminal activities of medical professionals who kill patients. The criminal activities of several recent hospital serial killers were actually discovered by nurses who suspected wrongdoing on the part of a coworker and alerted management. Unfortunately, management's initial medical review, absent training in forensics, usually found insufficient evidence to pursue the case.

Forensic nursing is still a relatively new and underutilized discipline. Healthcare facilities should waste no time in establishing this practice. It is simply what is most needed today to forge the link between medicine and investigation. fn

Bruce T. Sackman serves as the special agent in charge, Northeast Field Office, Criminal Investigation Division, U.S. Department of Veterans Affairs Office of Inspector General in New York City.

mailbag

To the editor:

I am a forensic nurse working in a busy Level 1 trauma in Kansas City, Mo. and am branching out to my own consultant practice. I am really excited about forensic nurse magazine and am waiting with bated breath for the next issue.

I have a comment about one of the articles. In "Clinical Forensic Nursing: A Higher Standard of Care," (forensic nurse premiere issue) the author, Mary Sullivan, makes a rather upsetting (to me) statement. The victim was being prepared in the OR for exploratory surgery of her abdomen and extremity injuries when the author wrote: "As a nurse was preparing to insert a Foley, she noticed that the woman had extensive tissue trauma in the perennial and perianal areas ... at this moment the patient's body became a crime scene."

I disagree with this. The moment the woman was found alone at the roadside, unconscious with extensive injuries, was the moment she was the crime scene. Ms. Sullivan may have intended the discovery of the perennial and perianal injuries to be an additional crime scene needing investigating, but the article is definitely misleading. I wonder (if in fact, the probable sexual assault was the first point of evidence collection and chain of custody) how much evidence was lost or discarded by the EMS crew and the emergency department staff, allowing the perpetrators to escape with only a sexual assault charge when in fact, based on the 'story' presented, he would have faced attempted manslaughter charges (since they deliberately left her on the road side to die).

I am so very thankful for our SANE nurses, however, the overlooking of and the misunderstanding of our clientele leads us, the medical professionals, to miss upward of 50 percent to 60 percent of our in-hospital populations, and 80 percent of the emergency department patients, as victims of some crime (and we certainly miss the perpetrators). We, as nurses and medical professionals, are "missing the boat." I see much work ahead of us, the forensic nursing division of nursing practice, in preparing our fellow nurses, residents, physicians and all healthcare providers in the arts and sciences of keeping our human rights intact, despite the well-meaning and misguided policies that attempt to preserve personal rights and confidentiality for our co-workers, patients, clients and ourselves.

Thank you again for the educational articles, the communication and sounding board and for bringing a new field of nursing into the limelight.

Collista Zook, RN, BSN, MS
community health and forensic nurse specialist

Click here to Subscribe

More News