This fall brings the release of two films on Netflix about Charles Cullen, the New Jersey nurse who admitted to murdering up to 40 patients but is suspected of having killed hundreds over his 16-year career.
One film, “The Good Nurse,” is a dramatized version of events starring Eddie Redmayne and Jessica Chastain, while the other is a documentary called “Capturing the Killer Nurse.” Both are largely based on Charles Graeber’s 2012 book with the same name as the Hollywood movie.
Medical toxicologist Steven Marcus, MD, was the director of New Jersey’s poison control center when his organization received two unusual calls about digoxin toxicity in two different patients at Somerset Medical Center within 2 weeks of each other in June 2003.
Marcus’ suspicions and persistence set the wheels in motion on the investigation that eventually resulted in Cullen’s arrest in December 2003.
Marcus, who hasn’t yet seen either film, spoke with MedPage Today about his role in the case and the flaws in a system that allowed Cullen to work for 16 years without any repercussions.
The conversation has been edited for clarity and brevity.
MedPage: When did you first suspect that someone at Somerset Medical Center was intentionally harming patients?
Marcus: I’m always a cynic and I’m always questioning things. The first call didn’t make sense. A woman was found to have digoxin in toxic levels and the only thing that they could blame it on was drinking this Korean tea. So that didn’t make sense, but it’s the kind of thing you put in the back of your mind.
Two weeks later, I overheard Bruce [Ruck, head pharmacist at the poison control center at the time] talking to somebody on the phone about it. I said I already spoke to them about unexplained digoxin toxicity. He said to them, ‘Have you already spoken to my director?’ As soon as they said “no,” the bells went off in my head.
When we asked about any other strange occurrences, they had these two cases with insulin overdoses.
This was either just wholesale bad medicine, or there was somebody attempting to kill people.
MedPage: What were your next steps? How did you try to sound the alarm?
Marcus: The first thing we did was say that we need to have a discussion with the [hospital’s] chief medical officer, risk management, the pharmacist, and the head of nursing to see if we can come up with a logical explanation.
We wanted to be sure that these four events were real and were documented. Then we would work together to try to come up with an approach to see if, in fact, there is somebody there that’s attempting to kill people — or is there a breakdown in their system someplace that allows for really severe medical errors to recur?
We did get into a telephone call, but there was a complete denial by the hospital. [They said] there was no way that this could be happening, and that there are obvious other reasons that it could occur. They were not willing to get involved, as far as we could tell, with any investigation.
MedPage: So what did you do next, given there was likely someone out there killing people?
Marcus: I had no clue who to call, so knowing that there was an outbreak in a hospital, I figured it has to be reported to the state.
Our grants were all administered through the Emergency Medical Services Branch of the Department of Health, so it made sense to call that group first. At the head of that group was the state epidemiologist.
After a second call with the hospital, I said it would work out a lot better if you call, rather than me. They said they absolutely won’t. I said I felt obligated. The chief medical officer said, “If you feel that way, go ahead.”
The epidemiologist … his comment was they were not going to study it epidemiologically but that it sounds severe enough that it probably ought to be investigated by the hospital licensing group, which was another part of the Department of Health.
So he gave me a name there, and I called them. I said, if you don’t find a logical explanation, you probably need to reach out to the Attorney General’s office and figure out where to go from there. And she assured me that would happen.
Then I became a little bit of a pest, reaching out there saying, “Where are we?”
That was in the second week of July 2003. It wasn’t until October that a call came in to the poison center from the Somerset County Prosecutor’s office, asking about digoxin. Bruce [Ruck] took the call and said, “Are you talking about the case at Somerset Medical Center?”
They asked what we knew and Bruce told them I had a thick binder of correspondence about it. They asked if we could talk.
I said, “Let’s get the attorneys to make sure that we dot every ‘i’ and cross every ‘t’ before we get ourselves too much further into this.” The [attorneys] said, “Of course, we will cooperate, but you need to get a subpoena.” We called them [the detectives] back and within a half an hour, they were at our doorstep with a subpoena.
MedPage: Had you been involved in a murder case before?
Marcus: No. I was aware of the outbreaks that had been reported previously. In 1982, the Tylenol case struck all of us in the business. Somebody put the cyanide into the capsules. I had a particular interest in [healthcare murders] before, but the Tylenol episode certainly crystallized my interest in the field.
MedPage: You met face-to-face with Cullen. What was that like?
Marcus: That was part of the plea bargain to take execution off the table. He would clear the minds of the people who thought their loved ones were killed by him. He would admit to the murders if he thought he had [committed them]. They asked me to sit with him and hash out which cases he was willing to admit to.
It was a bizarre experience. We met in a conference room in the Somerset County Courthouse. It was, I think, in February, so it was cold. And I don’t know whether the fact that I was freezing was because it was so cold or because it was just such an emotional experience.
We spent probably the better part of a day in that room discussing the cases. I would explain to him why there was evidence that he was probably involved. There were a couple that I couldn’t convince him that he was involved. And that was how the day was spent.
At the end I just sat there kind of wiped out. The detectives said, you know, doc, you look a little shocked. And I said, “Well, this was a strange experience.” They said to me, “You mean, you’ve never met a serial killer before?” I looked at them and said, “Have you?”
I tell people that, if you sat next to him on a bus or train, he would not have stuck out as someone unusual. There was nothing about his demeanor, nothing about his look, nothing that would have raised any suspicion.
MedPage: What do you think drove him?
Marcus: He was not an “angel of mercy,” that is for sure. These were not people who were in intense pain that were asking to be put out of their misery.
Some of the people were on the mend. One was leaving the hospital when he administered that digoxin to her and killed her. One was a 20-something kid. Some were directed at individual patients, but sometimes he would just go into the clean utility closet and grab an IV bag and put poison into it so that it would go to somebody random. I have no explanation as to why he committed such heinous crimes.
MedPage: Do you think that over his 16 years as a nurse, other colleagues had suspicions about him?
Marcus: There were attempts at other hospitals to report him. There was one place where the nurses went on record, saying he was not a good nurse and he was doing bad things. And the hospital just didn’t do anything.
Not only did they not do anything, but the next hospital came along asking them for a recommendation, and they didn’t tell the hospital “Don’t hire him.”
Part of the thought process is that the hospital could be sued if they gave a bad recommendation.
I mean, it is a business. Without bringing in revenue, the hospital can’t operate. So to some extent, you can understand that. The chief medical officer in Somerset, at one point said the reason they didn’t act faster is they didn’t want to have a total disturbance in the community, because everybody depended on the hospital.
MedPage: Was the hospital ever held accountable?
Marcus: There were no repercussions for Somerset. To my knowledge, they were fined for some minor problem as part of the licensing investigation. Something was found that would not have accounted for the overdoses. But it was a slap on the wrist.
MedPage: What changes are needed in the current system to prevent the next Charles Cullen?
Marcus: I don’t have the answer, but one thing needs to be education. People need to know that if they see something that doesn’t look right, they need to report it.
We have to educate people on who to report it to. And then you also have to educate the people that you are reporting to, on what to take seriously. Everybody has to be on the same page.
I think the COVID experience shows pretty well that we’re not very good at surveillance, and we’re not very good at doing public health. In my experience, it’s usually the compulsive, astute clinician who picks up, if not the first case, then other cases and makes some effort to intervene. That’s not a great way to run a system.
In our case, just think about the serendipity involved. Had we not had two calls — one from a nurse, one from a pharmacist — to the poison center within a couple of weeks; had I not been consulted on the first case; had I not walked by Bruce on the second case, Cullen might never have been stopped.
There are probably murderers out there killing people as we speak.