Forensic Nursing Applications: Preventing Crime in Hospitals Southern California Association of Heal

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Forensic Nursing ApplicationsPreventing Crime
in HospitalsSouthern California Association of
Healthcare Risk ManagersFebruary 19, 2008

• Beatrice Crofts Yorker, RN, JD, MS, FAAN
• Dean, College of Health and Human Services
• California State University, Los Angeles

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What Is Forensic Nursing?

• Forensic means having to do with the law
• Forensic Nursing is the application of nursing
  science to
• public or legal proceedings
• the application of the forensic aspects of health
  care
• the bio-psycho-social education of the registered
  nurse in the scientific investigation and
  treatment of trauma and/or death of victims and
  perpetrators of abuse, violence, criminal
  activity and traumatic accidents.

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Background on Crime in Hospitals

• Munchausen Cases
• Publish or Perish
• Nurse charged with murder
• Sexual Assault in hospitals

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MSBP

• Munchausen Syndrome Making oneself ill for the
  purpose of getting medical attention
• Not Malingering
• Not Hypochondriac
• Case study
• By Proxy simply means instead of making your SELF
  sick, you make a dependent in your care sick.

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Roy Meadows Seminal Article

• 4 year old female with recurrent urinary tract
  infections
• 14 month old child with sodium poisoning
• Nurses, laboratory technicians, doctors, and
  social workers as detectives

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Obtaining Evidence

• Indirect
• Upon separation from the caretaker the childs
  condition improves/the child thrives
• Medical chart review shows multiple system
  involvement, failure to appropriately follow
  medical advice, etc.

• Direct
• Toxicology screens
• Eye witness account, charting of observation of
  caretaker behavior
• Covert Video Surveillance

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British Experience

• Southalls study
• Backlash
• Problem Research
• No informed consent

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Scottish Rite Hospital

• 
  
• Hall et al. study published in Pediatrics
• Retrospective chart review, no IRB consent issues
• Important that MSBP was ruled out

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Covert Video Surveillance

• Fourth Amendment
• Title III
• Court Decisions to date No specific ruling,
  however similar cases
• Drug possession, arms, ATM
• No reasonable expectation of privacy in a
  pediatric hospital room
• Obtain consent in admission form
• Exception to consent for photography in cases of
  child abuse

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• 1. Hospital has capability
• Recommended for all large tertiary pediatric
  hospitals
• (Standard of Care according to Hall)
• Costly
• Requires security personnel 24/7
• Can burn out nursing staff
• 2. Outsource to private surveillance company
• Good for small community hospitals with less
  pediatric volume

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Protocol

• Probable cause or suspicion of abuse, can get a
  warrant, or at very least, call interdisciplinary
  meeting
• Decide who will be the primary nurse
• Work with security dept. and rotate staff every 3
  hours
• The more personnel are prepared regarding what to
  expect the better, however always be prepared for
  the unexpected.

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Protocol

• NEVER have un-supervised video surveillance
• Constant security monitoring
• Immediate contact capability with nursing staff
• Keep notes by security
• Establish guidelines for time elapsing, e.g.
  smothering, injection, medicines, fabricating,
  other abuse

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• Exaggerate The perpetrator deliberately
  embellishes a genuine problem.
• Fabricate The perpetrator deliberately makes up
  a problem story - OR makes it look as if a
  problem exists.
• Induce The perpetrator deliberately causes a
  problem to exist. 
• Exaggeration/fabrication cases should be
  considered as potentially lethal as cases in
  which inducing is suspected or confirmed. A
  caretaker may perpetrate MBP maltreatment through
  one or a combination of exaggeration,
  fabrication, or inducing. The perpetrator may
  change methods throughout the life of the case.

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Case studies

• Video clips
• Active Inducer
• Fabricator
• Sadistic Child Abuse
• Neglect

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PCF

• It is much smarter to use suspected Pediatric
  Condition Falsification than MSBP
• This allows you to video tape in cases in which a
  variety of possible motives underlie the
  alteration/fabrication of the childs condition.
• Use medical fraud as additional grounds for
  prosecution

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Serial Murder in Hospitals

• First article Nurses Accused of Murder American
  Journal of Nursing, 1988
• Second article Murder Charges against Nurses,
  Journal of Nursing Law, 1994
• Third article Serial Murder by Healthcare
  Professionals, Journal of Forensic Science, 2006
  (International team of co-authors)

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Prevalence

• 90 prosecutions of healthcare professionals for
  serial murder of patients in their care since
  1970
• 1970s 10
• 1980s 21
• 1990s 23
• 2000s 40 and counting (30 not in US)

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Legal Outcomes

• 53 have been convicted
• 4 for attempted murder
• 5 pled guilty to lesser charges
• 44 of these for serial murder
• 25 have been indicted and are either awaiting
  trial or the outcome has not been published
• 8 were acquitted of murder charges
• 3 of these were liable for civil damages ranging
  from 450,000 to 27 million.
• 4 successfully appealed their convictions

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Geographic locations

• Country Incidents
• Country Cases
• Austria 4
• Belgium 3
• Brazil 1
• Canada 1
• England/Wales 12
• Egypt 1
• France 1
• Germany 14
• Holland 3
• Hungary 1
• Ireland 1
• Italy 1
• Japan 1
• Norway 1
• Poland 4
• Russia 4

• State Incidents
• US State _ Cases
• Alabama 2
• California 3
• Florida 3
• Georgia 1
• Illinois 1
• Indiana 3
• Maryland 2
• Massachusetts 1
• Michigan 4
• Missouri 1
• New Hampshire 1
• New Jersey 1
• New York 2
• Oklahoma 1
• Ohio 1
• Oregon 2

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Gender
21
High tech environments
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Profession Types
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Injection

• Potassium Chloride
• Digoxin
• Respiratory paralyzing agents
• Epinephrine
• Insulin
• Lidocaine
• Morphine (more prevalent in UK Europe)

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Other methods
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Other Methods

• Injection 51
• Unknown 25
• Suffocation 11
• Water in lungs 4
• Air embolus 3
• Oral med's 3
• Equipment tampering 1
• Poisoning 1
• TOTAL 99 (some used more than 1 method)

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Victims

• Victim characteristics Persons who were
  critically ill or very old, infants and seriously
  ill children were most likely to be victims of
  serial murder. Some killers were associated with
  a specific type of patient (e.g., elderly
  victims) or with a specific diagnosis.

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Victim numbers

• There were a total of 307 patient deaths that
  resulted in convictions for murder. In most of
  the incidents the caregiver was suspected of
  being linked to many more deaths than for what
  were actually prosecuted.
• The total number of suspicious deaths associated
  with the 53 convicted healthcare providers was
  2,081. This may be a significant undercount.
• In addition, there were 130 patients who survived
  an injection and the healthcare provider was
  convicted for attempted murder or assault.

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Video Segments

• Serial Murder Video Segment 1
• Serial Murder Video Segment 2

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Case studies

• Georgia
• Florida
• New York
• England
• Indiana
• England
• Europe

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Psychodynamics

• Factitious Disorder/Munchausen Syndrome by Proxy
• Attention
• Euthanasia Rationalization by some killers. Not
  authentic euthanasia with full informed consent.
• Sociopathy Power and control
• Hero syndrome
• Disdain
• Mother Teresa Syndrome fine line between
  aggression and need to be needed, improve self
  esteem (P. Lampe)
• Move patients out, overwork (B. Salisbury)
• Profit kickbacks from a funeral parlor, payment
  from organ transplant industry (Poland, Russia)

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Prevention

• Employment practices
• Risk Management
• Medication control
• Routine data review
• Encourage reporting
• Night and evening shift supervision

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Early detection

• Routine toxicology screens post arrest
• Save equipment, vials, tubing, syringes
• Review death, arrest stats monthly by unit, by
  shift, by total hospital and compare to each
  other and to selvesmonitor trends
• Strict pharmacy accounting for each dose of
  medication

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Surveillance (implement at any significant
trend)

• Covert video surveillance
• Overt video surveillance
• Chart review
• Personnel tracking
• Background checks ??
• Behavior documentation
• Increase data collection in identified unit

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Surveillance(if trend reverses)

• Track identified personnel
• Shift from overt to covert surveillance
• Evaluate data for evidence of criminal activity
• Once probable cause of a crime exists notify
  law enforcement
• If necessary notify licensing board

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Staff member resigns

• Provide information to future references
• Notify adult protective services??
• Consider national licensing board data sets

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Non-surveillance detection

• Nursing staff report suspicions
• Patient or patients family report getting a drug
  that made them feel sick/stop breathing/die
• Autopsy results
• Caregiver with Munchausen syndrome

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Working with Law Enforcement

• REASONS WHY DONT
• Negative publicity
• Fear of Civil Suits by patients for negligence
• Fear of Civil Suits by nurses for libel/slander
• Fear investigation will reveal poor record
  keeping

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Working with Law Enforcement

• REASONS WHY SHOULD
• Keep confidentiality
• Support staff
• Better outcomes
• Patient safety
• Prosecution
• Public Relations

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Burden of Proof

• Criminal case Beyond a reasonable doubt
• Civil case A preponderance of the evidence

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InterventionRisks if fire Risks
if not

• A law suit for wrongful discharge, slander,
  libel, etc.
• 50,000

• Wrongful death(s)
• 500,000 to 8,000,000 (or until maxed out)

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Sensitivity in investigation

• Gender and race issues
• Media coverage
• Entrapment

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Prosecution

• Good smoking gun evidence
• Documentation
• Toxicology results
• Eye-witness testimony
• Epidemiology questionable
• Profile evidence not recommended

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Planning Arrest

• Obtaining a confession
• Searching the home
• Health record search
• Keeping other staff calm
• Media control

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Civil suits

• Jane Bolding-8 million
• Joseph Akin-Class Action against 21 hospitals
• Michael Beckelic-27 million
• Richard Williams-450,000
• Charles Cullen-see news article
• Vickie Dawn Jackson-pending

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Sexual Assault of Patients

• Risk of some patients assaulting other patients
• Cases in which staff sexually molest patients in
  their care
• Psychiatrist
• Dentist
• Anesthesiologist
• Nursing staff

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Child Pornography Sexual Abuse

• A 54-year-old respiratory therapist has been
  arrested on 40 counts of possession, manufacture
  and distribution of child pornography and two
  counts of lewd and lascivious acts on two
  children under 14. In all, the charges involve
  nine children.
• San Diego Police Chief William Lansdowne (left)
  and Children's Hospital CEO Blair Sadler appeared
  at a news conference yesterday announcing the
  arrest of a hospital employee. A cell phone
  allegedly was used to take photographs of
  bedridden children at the 59-bed convalescent
  center, which is part of the Children's Hospital
  complex in Kearny Mesa. Some of those images were
  distributed on the Internet.

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2nd worker in 6 weeks accused of molestation
April 16, 2006 For the second time in less
than six weeks, an employee at Children's
Hospital stands accused of molesting a patient
and amassing a cache of child pornography on his
home computer. Incredulous hospital staffers
and police announced yesterday that registered
nurse Christopher Alan Irvin, 32, was taken into
custody Friday afternoon. I couldn't believe
it. I just couldn't believe it, said Blair
Sadler, president and CEO of Children's Hospital
and Health Center. To have this event occur in
March and this (latest) event to occur in April
is just shocking. . . . But more importantly,
we're mad as hell. San Diego Assistant Police
Chief Cheryl Meyers said there doesn't appear to
be a connection between Irvin and a hospital
worker arrested March 8.
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Questions from the Audience

• ?????????????
• byorker_at_calstatela.edu
• Thank you SCAHRM!