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Homicidal Poisoning: Angels of Death

Most people who die from poisoning, do so accidentally. As a mode of criminal homicide, poisoning is, compared to guns, knives, blunt objects, and ligatures, rare. According to FBI statistics, out of the 187,000 criminal homicides committed from 1990 to 2000, only 346 involved poison. But forensic toxicologists, the people educated and trained to detect and identify substances harmful to the human body, believe that homicidal poisoning is more common than crime statistics suggest. In 2002, 26,435 people died of poisoning. While only sixty-three of these deaths were ruled as criminal homicide, 3,336 were listed, under manner of death, as “undetermined.” In other words, forensic pathologists considered these poisoning deaths suspicious.

Nobody knows how many people are being murdered by poison because most of these deaths are classified as natural. In most of these cases there are no outward signs of the poison. There are no bullet holes, stab wounds, cuts, bruises, or marks around the neck that signify that this death was not natural. People are poisoned, get sick, and die. In most instances, because the deaths were not outwardly suspicious, there is no autopsy. The victims are embalmed, buried, or cremated. End of story. Suspicions may be raised when, say, a surviving, estranged spouse receives a large life insurance payment, and a week later, remarries. Money and sex are common motives for murder, but motive is not evidence. The evidence of a homicidal poisoning is the poison. If the toxic substance is not detected and identified in the course of an autopsy, the killer, in almost all of these cases, has gotten away with his or her crime. Exhumations are rare.

Poisons are rarely detected in cases where clinical autopsies are performed by hospital pathologists. This is because the pathologist is not thinking homicide, or looking for poison. Unless a specific poison is suspected, the chance of random discovery is unlikely. Arsenic, because it is readily available, tasteless, and can be administered in a series of small doses that cause a period of illness before death, is the weapon of choice among those who murder by poison. Within twenty-four hours of ingestion, arsenic moves from the blood into the victim’s liver, kidneys, spleen, lungs, and GI tract. In two to four weeks, traces can be found in the victim’s hair, nails, and skin. From there, traces of the poison settle in the bone. Thirty minutes after ingesting a small dose of arsenic, the victim will experience a metallic taste, garlic smelling breath, headaches, muscle cramping, vertigo, vomiting, abdominal pain, and diarrhea. Larger does can cause convulsions. If the victim doesn’t die within a few hours from shock, the poisoned person my die a few days later from kidney problems. If the victim survives two to four weeks, in addition to the horrible suffering, he or she will start losing their hair. When death finally comes, the likely cause will be identified as renal failure. Other common poisons used in the commission of homicide include strychnine (rat poison), morphine, and Demerol. Antifreeze (ethyzene glycol) has become popular in recent years among poison killers.

Deaths by homicidal poisoning that do not raise suspicions, and therefore are almost always misdiagnosed as natural, involve hospital patients who are elderly, or already ill. The death of an old or gravely ill hospital patient is, almost by definition, a natural death. This is why physicians, nurses, and other health-care workers who kill—so-called “angels of death”—have gotten away with killing so many people.

Normally, homicide by poison is not an impulsive, opportunistic crime. But in the hospital, or in a home for the elderly, it is a crime of opportunity. The angel of death has easy access to the poison and the victim. There is no need for preparation and planning. Moreover, there is no apparent or obvious motive for the homicide because these killers do not receive any direct personal gain out of the crime. The homicidal motives of angels of death are therefore pathological and hidden. This type of serial killer is difficult to spot because angels of death are not manifestly insane. They possess personality disorders that compel them, out of generalized rage, boredom, or the impulse to play God, to kill and kill often. As killers they are cold-blooded, careful, and vain, making them hard to catch. Quite often, in their work histories, they have been terminated from pervious health-care jobs. When too many patients have died on their watch, and the come under suspicion, they are either terminated, or quit on their own. The tendency, among health-care administrators, is to deny the obvious, and pass the problem on to someone else. Over the years, dozens of angels of death have been caught, but only after large numbers of patients have been murdered. Given the nature of the crime, and the limited role forensic science plays in these cases, it is reasonable to assume that these angel of death convictions represent the mere tip of a rather large homicidal iceberg. 

Donald Harvey Case

In 1975, after working briefly as a hospital orderly in London, Kentucky, twenty-three-year-old Donald Harvey took a job with the Veteran’s Hospital in Cincinnati, Ohio. As the years passed, a pattern emerged. When Harvey was on duty, patients died. Finally, after ten years and the deaths of more than one-hundred patients on his watch, the orderly was fired. He was terminated because several hospital workers suspected he was poisoning his patients. After he left, the death rate at the VA hospital plummeted. Terminating Donald Harvey turned out to be good medicine, at least at that hospital.

Shortly after his firing, Harvey was hired across town at Drake Memorial Hospital where the death rate began to soar. As he had done at the VA facility, Harvey was murdering patients by either lacing their food with arsenic, or injecting cyanide into their gastric tubes. The deaths at Drake, like the fatalities at the VA hospital, were ruled as natural. While suspicions were aroused, it was hard to imagine that this friendly, helpful little man who was so charming and popular with members of his victims’ families, could be a stone-cold serial killer.

As clever and careful as Harvey was, he made a mistake when he poisoned John Powell, a patient recovering from a motorcycle accident. Under Ohio law, victims of fatal traffic accidents must be autopsied. At Powell’s autopsy, an assistant detected the odor of almonds, the telltale sign of cyanide. This was fortunate because most people are unable to detect this scent. The forensic pathologist ordered toxicological tests that revealed that John Powell had died of a lethal dose of cyanide. Finally, this became the beginning of the end for Donald Harvey. He had been the last person to see Mr. Powell alive, and John Powell would be the last person Harvey would kill.

The Cincinnati police arrested Harvey and searched his apartment where they found jars filled with arsenic and cyanide, and books on poisoning. However, the Hamilton County prosecutor believed that without a confession, there might not be enough evidence to convince a jury of Harvey’s guilt. Harvey, on the other hand, was worried that if convicted, he would be sentenced to death. So a deal was struck. In return for a life sentence, Donald Harvey would confess to all of the murders he could remember. Over a period of several days, Harvey confessed to killing, in Kentucky and Ohio, 130 patients. When asked why he had killed all of these helpless victims, the best answer Harvey could muster was that he must have a “screw loose.” Forensic psychologists familiar with the case speculated that the murders had given Harvey, an otherwise ordinary and insignificant person, a sense of power over the lives of others.

Michael Swango Case

In 1978, three years after Donald Harvey started killing hospital patients, Michael Swango began his first year of medical school at Southern Illinois University in Springfield. For a time, during his freshman year, Swango moonlighted as a paramedic, but he was so morbidly obsessed with violence and murder, he was fired. The people he worked with at the emergency service had called him “Double-O-Swango” after the James Bond character who had a license to kill. At medical school, Swango was so weird, and menacing, several of his classmates, convinced he was psychologically unsuited for a career in medicine, wrote letters of complaint to school administrators. Swango was also, as a student, academically border-line. At the hearing to determine if he should be expelled, Swango was retained when one administrator voted in his favor. There is no way to know how many people would be adversely affected by that decision.

Michael Swango graduated from medical school in April 1983, and the following January, began an internship in neurosurgery at Ohio State University Medical Center in Columbus. A month into his internship, a student nurse saw Dr. Swango inject something into an IV line that immediately turned the patient blue. The victim recovered, and although the nurse reported what she had seen to hospital security, nothing came of this eyewitness’s information. Following the deaths of five of his patients, Dr. Swango’s superiors transferred him to the children’s hospital. After five of his co-workers at the children’s hospital got sick after eating fast-food brought to them by Swango, the hospital conducted an internal investigation that cleared the intern of wrongdoing. He was, however, kicked out of the internship program, ending his medical education.

After washing out of Ohio State’s residency program, Swango returned home to Quincy, Illinois where he was hired as a paramedic. Not long after he joined the emergency service, he poisoned, but did not kill, six of his co-workers. He was caught, convicted, and sentenced to five years in prison. This conviction did not prompt the authorities at Ohio State University to re-open their investigation of the poisoning of the five hospital employees who had worked with Swango in Columbus. Had he been convicted in Ohio as well, he might have spent another five years behind bars. After serving three years of the Illinois sentence, Swango was free to poison again.

Because Michael Swango was a convicted felon, one would assume that he would never have access to patients or health-care workers again. He might continue to poison people, but not as a physician or paramedic. However, during the eleven years following his release from prison, Swango would work as a hospital physician in Virginia, South Dakota, and New York state. He would acquire these positions with forged documents, phony resumes, and his gift for lying. He would leave, from 1987 to 1998, a long trail of dead patients and sick hospital employees. He murdered his patients by injecting a variety of paralyzing drugs into their IVs, deaths that were recorded as natural. He became an efficient killing machine, moving easily from one hospital to the next.

In 1988, the killing stopped when FBI agents arrested Swango for forging documents that had led to his employment at a VA hospital in Long Island. He was convicted and sentenced to four years in federal prison. Unless someone made a homicide case against Swango, he would, in a few years, be out of prison and free to resume his deadly pleasures. As it turned out, the person who saved the day was not a hospital administrator, or a homicide detective, or a prosecutor. It was James B. Stewart, a Pulitzer prize winning journalist who, in researching his book, Blind Eye, connected Swango to twenty non-fatal poisonings, and to the suspicious deaths of thirty-five hospital patients. The book came out in 1999 and led to the exhumation of three of Swango’s patients at the Long Island VA hospital. In September 2000, Swango pleaded guilty to the poisoning deaths of three of these patients. A judge sentenced him to life without parole.

Over a period of sixteen years, Michael Swango may have murdered as many as fifty people. All of the deaths had been diagnosed as natural. Swango’s license to kill had been revoked by a journalist whose book tells the story of how easy it is, within certain circles, to get away with murder. The old saying “murder will out” does not apply when the weapon of choice is poison.

Efren Saldivar

In March 1997, about a year before Michael Swango was arrested on federal charges pertaining to his forged medical credentials, a hospital worker at the Glendale Adventist Medical Center in Glendale, California, told a supervisor that a respiratory therapist named Efren Saldivar had killed an elderly patient by injecting a muscle relaxing drug called Pavulon into the patient’s I.V. Although this was a serious criminal accusation, hospital administrators decided not to bring it to the attention of the police. Instead, they conducted an internal inquiry. The hospital investigation consisted of a statistical analysis of the patients who had died on Saldivar’s watch, usually the night shift, spanning a period of eight years. The matter was dropped after the investigators reported that the numbers did not reveal a pattern that incriminated the twenty-seven-year-old therapist. It wasn’t much of an investigation, though. The suspected poisoning victim had not been tested for traces of the poison, and Saldivar was not questioned or asked to take a polygraph test.

Another Glendale Adventist employee came forward, a year later, with an even more disturbing accusation. According to this whistleblower, Elfren Saldivar, during his tenure at the 450-bed hospital, had poisoned to death several patients. This time, instead of running the numbers, hospital administrators called the Glendale Police Department. The exhumation and toxicological analysis of the patient seen poisoned by the first hospital witness would have been a good way to start the investigation. Instead, detectives jumped right in by asking Saldivar to come to the police station for a talk. He wasn’t under arrest because there wasn’t probable cause to believe he had committed a crime. The respiratory therapist could have halted the investigation by refusing to be interrogated, or insisting upon seeing a lawyer first. The police got lucky, however. Saldivar not only agreed to be questioned, he confessed to murdering at least fifty patients at three hospitals. Most of his victims had died at Glendale Adventist. Referring to himself as an Angel of Death, Saldivar said he had poisoned these patients to end their suffering. However, when detectives asked Saldivar to identify some of his victims by name, he froze-up, then informed his interrogators that he had just confessed to something he really hadn’t done. (It is very possible that when Saldivar realized the police had not done an investigation and had no idea who he had killed, that they were just fishing around, he decided not to do their work for them.) Saldivar said he was tired, and depressed, and had simply told them what he knew they wanted to hear. He said he hadn’t killed anyone.

Because they had not done their homework prior to the interrogation, the detectives had missed an opportunity. They now found themselves in the absurd position of either arresting Saldivar without probable cause, or releasing a man who had just admitted killing fifty people. They let him go. The hospital fired Saldivar, and he lost his therabpy license. The story got out, and the local media, referring to Saldivar as the “Angel of Death,” had a journalistic field day. The affair turned into a terrible embarrassment for the hospital, and for the police who now had no choice but to conduct a proper investigation.

During Saldivar’s employment at Glendale Adventist, 1,050 patients had passed away, all believed, at the time, to have died from natural causes. In the last two years of Saldivar’s tenure, 171 patients had died out of which 117 had not been cremated. From this group, twenty bodies were randomly selected for exhumation, autopsy, and toxicological analysis. The tissue samples were sent to the Lawrence Livermore National Laboratory in Livermore, California. Toxicologists at the lab found traces of the muscle relaxant Pavulon in six of the samples from patients who had died on Saldivar’s shift.

Glendale detectives questioned a Saldivar co-worker who admitted providing him with Pavulon knowing that Saldivar was using the drug to poison patients. Two other hospital workers said they knew what was going on, but had kept silent. No one likes a snitch. On January 10, 2001, thirty-four months from the day Saldivar walked out of the Glendale police station after confessing to multiple murder, he was arrested. Detectives pulled him over as he drove to work. Saldivar had been working as an apprentice electrician.

Saldivar confessed again, and this time it stuck. He said that after his sixtieth victim, he had stopped counting. If he had to guess, he figured he had murdered more than a hundred patients. He pleaded guilty, and a judge sentenced him to life without parole. The hospital worker who had provided the Pavulon had been granted immunity in return for his testimony, and the health-care workers who had failed to come forward with knowledge of serial murder, were disciplined on the job.

The detectives who interrogated the flabby, 250-pound serial killer were understandably interested in why he had committed these murders. In his first confession, Saldivar had said he had killed out of compassion, but the second time around, his statements regarding this aspect of his thinking were mixed and contradictory. “It was a gradual thing,” he said. “I did it without thinking. I don’t kow if you ever shoplifted a piece of gum or something. You don’t plan it. After that moment, you don’t think about it for the rest of the day, or ever.” While hospital poisonings are crimes of opportunity, it’s had to believe that Saldivar was so detached mentally and emotionally from the killings. He may have felt that people considered him a harmless, rolly-polly person of little significance in the world, and this was his secret way of making himself powerful, and important. Doctors make life and death decisions, and so could he. Saldivar, the second time around, said he had not killed to relieve suffering, but to reduce his workload at the understaffed hospital. “It was not something that gave me joy. Only I was at my wits’ end on the staffing. I’d look on the [assignment] board. Who do we gotta get rid of?” This statement doesn’t ring true, either. To avoid death row, hospital killers just have to admit committing the murders. They generally keep their true motives to themselves.

The Saldivar case, like most angel of death murders, did not make a big splash with the national news media. There was no trial, and no intriguing mystery. There was no sex, no money, no blood, and no glamour. The victims were either old and/or sick. They were about to die anyway. The fact that a health-care worker could kill so many patients without getting caught was not, by itself, a big enough story. People like Donald Harvey and Efren Saldivar were not very interesting people, and although they were serial killers, not very frightening. To be frightened by these people one had to be sick, or old, and under their care. These are inside crimes. The slogan, “whatever happens in Las Vegas stays in Las Vegas” could be applied to hospitals.

In the 1980s Donald Harvey became the best-known, but not the only serial killer of his kind. Between 1982 and 1987, Genene Ann Jones, a nurse from Kerrville, Texas, murdered forty-seven children by injecting them with muscle relaxant medicine. In 1989, Richard Angelo, a nurse at Good Samaritan Hospital in West Islip, Long Island, killed thirty-five patients by administering drugs that paralyzed them. One can only guess how many angel of deaths during this period went undetected.

Charles Cullen

On December 29, 1998, eight months after Efren Saldivar took back his first confession, paramedics in Easton, Pennsylvania rushed seventy-eight-year-old Ottomar Schramm to the hospital after he had suffered a grand mal seizure. Mr. Schramm, a resident of a Nazareth, Pennsylvania nursing home, died twenty-four hours later. A body fluid analysis revealed that Mr. Schramm had three times the therapeutic level of the heart medicine Digoxin in his system. Because Mr. Schramm had not been diagnosed with a heart problem, and had not been prescribed the drug, Zachary Lysek, the coroner of Northampton County, suspected foul play.

Coroner Lysek determined that the Digoxin had not been administered at the nursing home, and the forensic pathologist who performed the autopsy found that the heart drug had contributed to Mr. Schramm’s death. According to medical records, no one at the hospital had prescribed the medicine, either. Although he suspected that Mr. Schramm had been poisoned, the coroner had no solid evidence of a crime, as a result he ruled the death accidental.

Two months after Coroner Lysek’s investigation into Mr. Schramm’s death came to a halt, the deceased’s daughter came to him with information that breathed new life into the case. As her father was being wheeled out of the emergency room for tests, she had noticed that one of the male nurses was holding a syringe.  She asked the nurse what the syringe was for, and he replied that if the need arose, he’d use it to re-start her father’s heart. This same nurse, after the death, informed the daughter that Mr. Schramm had signed a living will which indicated he didn’t want his internal organs destroyed by autopsy. The daughter, suspecting that this man had injected her father with the heart drug, had reported al of this to a hospital administrator. When it appeared as though hospital officials were not going to act on her information, the daughter sought out Mr. Lysek.

The coroner followed up the daughter’s report by asking hospital administrators if they had identified the nurse with the syringe. They hadn’t. The coroner asked if there had been any kind of inquiry into the matter at all. There had, but the results had been “inconclusive.” The coroner must have wondered how hard it would have been to identify the male nurse with the syringe. It seemed that if there had been foul play in Mr. Schramm’s death, the hospital didn’t want to know about it.

The man with the syringe, the one who had discouraged the autopsy, was Charles Cullen, a thirty-eight-year-old registered nurse who, after Mr. Schramm’s death, left Easton for a job at Lehigh Valley Hospital in nearby Allentown. Cullen, over the past eleven years, had worked at six hospitals in eastern, Pennsylvania and western New Jersey, a highly unusual employment pattern for a registered nurse. Since graduating from nursing school in 1987, Cullen had attempted suicide several times, and had been treated for depression. Wherever he went, death followed. Virtually every patient he had worked on, regardless of age or medical condition, had died shortly thereafter. Being cared for by Charles Cullen had been a sentence of death.

Keeping to his habit of going from one job to the next, Cullen, after a short stint at Lehigh Valley, moved to St. Luke’s Hospital in Bethlehem, Pennsylvania. In August, 2000, a co-worker at St Luke’s caught Cullen hiding medication in bins used for needles. The hospital reported Cullen to the Pennsylvania State Police who closed the case following an incomplete investigation. Feeling the heat at St. Luke’s, Cullen accepted a position at Sacred Heart in Allentown. This was his ninth nursing job in fifteen years. In the meantime, patients were being poisoned to death.

In December 2003, Cullen’s career as a serial killer came to an end in Somerset, New Jersey where detectives arrested him for murdering a patient at the Somerset Medical Center. Cullen was also charged with the attempted murder of a patient who had been injected with Digoxin. Two days after his arrest, during the course of a six-hour police interrogation, Cullen confessed to killing, over a sixteen year period, more than thirty patients. This number, in all probability, reflected less than half of his victims. The following spring he pleaded guilty to twenty-nine murders and six attempted killings in New Jersey.

Back in Northampton County, Pennsylvania, in October 2004, Charles Cullen pleaded guilty to poisoning Mr. Schramm with the heart drug Digoxin. Following that conviction, Coroner Lysek changed the manner of Mr. Schramm’s death from accidental to homicide.

In March 2006, Cullen was in Somerville, New Jersey for another sentencing. The forty-one-year-old former nurse remained stoic as family members of some of his victims called him a “monster,” a “savage,” and “satan’s son.” The Somerset County judge sentenced Cullen to eleven consecutive life terms totaling 397 years for the murders of thirteen patients at the Somerset Medical Center, five at the Hunterdon Medical Center, three at Warren Hospital, and one for an ill person he had cared for in Essex County. By pleading guilty, Cullen avoided the death penalty. As part of his plea agreement, Cullen had been assisting the authorities in identifying as many of his victims as he could remember. A week later, he was sentenced to life in Pennsylvania for seven murders and three attempted killings in that state.

There have been, since 1970, at least fifty American Angel of Death convictions involving defendants who were physicians, orderlies, nurses, and hospital and nursing home therapists of one kind or another. The death toll, in just these known cases, runs in the hundreds. The actual number of poisoning deaths during this period could run into thousands. And it’s just not an American problem. In England, a general practitioner named Dr. Herald Shipman poisoned to death 250 of his patients between 1979 and 1999. In 2004 he hanged himself in his prison cell. In Lucerne, Switzerland, Roger Andermott, a nurse, was convicted in 2005 of poisoning or suffocating twenty-two nursing home patients. There have been similar cases in Germany as well.

Angels of death murder because they are either mad at the world, bored, or afraid if they didn’t kill others, they’d kill themselves. The more they kill, the more confident and reckless they become. Many of them have been treated for depression, and have attempted suicide. Some, like Dr. Michael Swango, were fascinated with poison and violent death. All of them would have been caught a lot sooner had health-care administrators and the police shown more interest. And almost all of them, when confronted with the toxicological evidence of their poisonings, confessed to avoid the death sentence.

Serial poisoning is a crime that can be detected through forensic science. The technology is there, but until these cases are more aggressively pursued within the health-care community, and by the police, patients will be murdered and their deaths will be registered as natural.

This page was last updated on: Wednesday, January 16, 2008

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A. James Fisher
Dept. of Political Science & Criminal Justice, 146 Hendricks Hall
Edinboro University of Pennsylvania, Edinboro, PA 16444
e-mail: jfisher@edinboro.edu blog: http://jimfishertruecrime.blogspot.com