Murder and the ICU.

The Intensive Care Unit (ICU) is a place of technology, unusual drug formularies and rapid decisionmaking, all designed to help critically ill patients get better. However, these same factors can create an environment where a healthcare worker might systematically harm a patient without fear of detection or punishment. Such allegations are difficult to substantiate because evidence is so difficult to obtain and thus criminal prosecutions are rare. In addition, the damage that ongoing investigations can have on staff morale and interprofessional relationships is often underestimated. In light of recent well-publicized cases, these issues will come under increasing public scrutiny. Many have argued that the most notorious case in which healthcare workers have systematically harmed patients in their care was that of Genene Jones [1]. She trained as a licensed vocational nurse (LVN) in Texas, USA, in the late 1970s. She was dismissed from two posts as a nurse. Her third post began in 1978 at a paediatric ICU in Texas. During the first year of her employment, a number of criticisms were levelled at Jones by her superiors. These included errors in drug administration, equipment use and emotional overinvolvement. However, it was noted that she would often volunteer to work extra shifts and care for the unit’s sickest patients. By 1981, 3 years after the beginning of her tenure, an unusual pattern of deaths was noted in the unit. The unexpected deaths were occurring in children whose condition was not necessarily considered as critical, during the evening shift. The deaths also occurred with greater than expected frequency in those being cared for by Jones. Her nursing colleagues dismissed these initial concerns. However, the medical staff requested increasing numbers of laboratory investigations after unexpected deterioration in children’s health. The nursing staff were also asked by the unit’s medical director to take extra precautions with drug administration and equipment settings. Despite this vigilance, excessive doses of heparin were given to one child on 2 consecutive days in direct breach of unit protocols. Subsequently, the death of a child following ‘routine’ cardiothoracic surgery in 1982 prompted the hospital administrator to set up an external investigation. This committee concluded that a variety of factors such as staff shortages, poor communication between staff and the variability of the junior medical staff were responsible for the spate of unexplained deaths. In addition, it recognized that Jones was possibly implicated. As a result of this inquiry, the hospital moved to replace all LVNs with registered nurses, thereby making Jones redundant in March 1982. The letter of reference given to her had no reservations about her abilities or her suitability as a paediatric intensive care nurse. By August 1982, Jones was employed as a practice nurse in a rural community in Texas. A 14-month-old female was admitted to hospital suffering from unexplained seizures. Two months later this child died. Five other children had suffered seizures in unusual circumstances. Again, suspicions were aroused, but it was only after the discovery of a ‘missing’ vial of succinylcholine with puncture marks in the rubber cap that a criminal investigation was begun. This culminated in the conviction and sentencing of Jones to 60 years’ imprisonment; more than 3 years after concerns had first been raised. This case is unusual in that a conviction was obtained. Table 1 shows that this has not been the outcome of the majority of criminal prosecutions. Most cases of carers who kill patients in an ICU involve nurses. Court action against doctors has centred on negligence and euthanasia issues with a few exceptions such as the Manchester, UK, general practitioner P. Harold Shipman [2]. The ICU also features heavily – with some writers calling a murder allegation an occupational hazard of nursing the critically ill.