Every one of these cases has a point at which someone inside the institution noticed. A nurse kept a tally. A security chief said what he believed and could not prove it. A consultant pediatrician wrote a letter. Sometimes the person who noticed was ignored, sometimes overruled, sometimes managed out of the room. In the worst of the cases the person the employer chose to protect was the one under suspicion, and the employer protected him or her with a reference letter, a quiet resignation or a decision not to telephone the police. What follows is a record of who warned, who was told and what the employer did, and then of what courts, prosecutors and public inquiries concluded about those decisions. One case, from Ontario, runs the other way: there, the inquiry concluded, nobody inside the system saw enough to warn anybody.
Charles Cullen worked as a registered nurse for 16 years, in nine hospitals and a nursing home in New Jersey and Pennsylvania. Between 2004 and 2006 he pleaded guilty to murdering 29 patients and trying to murder six more. He told detectives the real number was 30 to 40, and investigators who worked the case believe it may be far higher. New Jersey courts imposed 11 consecutive life terms (Judge Paul W. Armstrong, March 2, 2006); in Pennsylvania he received life without parole for one Northampton County murder and six life sentences in Lehigh County (President Judge William Platt, March 10, 2006). The plea terms removed the death penalty in all seven counties. He was still serving life as of December 2025.
The case also exposed how he had been able to keep working. Several employers suspected him, fired him or let him resign, and none of their suspicions followed him to the next job. The first death in his pleas came on June 11, 1988, at Saint Barnabas Medical Center in Livingston, New Jersey: John W. Yengo Sr., 72, a municipal court judge. Cullen later admitted to killing other patients there. Salon dated his departure from Saint Barnabas to January 1992, during the hospital’s inquiry into contaminated intravenous bags. The hospital was looking into the problem, and Cullen left; there is no record that the next employer was told why.
Warren Hospital in Phillipsburg hired him next. CBS New York described that move as the start of the run of killings that lasted until 2003. A spokeswoman for Morristown Memorial Hospital, where he worked later, said in 2003 that he was fired in August 1997 for "poor performance," Salon reported. He was then out of work for six months and went to the emergency room at Warren seeking treatment for depression.
At St. Luke’s Hospital, the last Pennsylvania employer on his list, the exit was negotiated. Cullen told 60 Minutes in 2013 that St. Luke’s had offered him a neutral reference if he resigned, and that his license should have been taken away much earlier. He pleaded guilty to five murders at St. Luke’s.
What ended it was an employer acting on records. Somerset Medical Center in New Jersey fired him on October 31, 2003, and investigators from the Somerset County Prosecutor’s Office traced suspicious overdoses to him. Detectives asked Somerset for its drug-cabinet records and were told by the hospital that the data no longer existed; the manufacturer said it was stored indefinitely, and those records led to Cullen. He was arrested on December 12, 2003.
The aftermath was legal and financial. New Jersey enacted the Patient Safety Act on April 27, 2004, and the Health Care Professional Responsibility and Reporting Enhancement Act on May 3, 2005. Families sued: reports described a settlement of a lawsuit in February 2008, a jury award of $95 million in a related civil case in March 2010, and a jury ruling against St. Luke’s in related lawsuits in July 2014. A News 12 New Jersey report in December 2025 said a detective’s efforts to identify further victims had been shut down by superiors.
Niels Hogel worked as an intensive care nurse at two hospitals in Lower Saxony, in northwestern Germany, from 1999 to 2005. He killed patients and then joined the team that tried to bring them back. He wanted the praise that came with a successful resuscitation, the court in Oldenburg concluded. On June 6, 2019, the Landgericht Oldenburg convicted him of 85 murders and acquitted him of 15 further counts for lack of evidence; the judgment became final in September 2020. He was sentenced to life with a finding of particular gravity of guilt and a lifetime ban on working in nursing, elder care or rescue services. By an order of March 17, 2026, his minimum term was set at 28 years.
The case also put the hospitals on trial. Colleagues in Oldenburg had noticed, years before his arrest, that patients deteriorated and died far more often when he was on duty. In 2001 the unit kept a tally of the nurses on duty at resuscitations and deaths, a list later described in court. Hogel’s name had the most marks, 18, the taz reported in 2019. A handwritten note on the list said that endangering the department and the hospital was not acceptable, and that the suspicions were not enough to inform prosecutors. The list stayed inside the hospital. A later hospital manager had it from 2014 but did not hand it to investigators until 2016, according to the taz; the hospital said in June 2016 that it had given the list to investigators that April, and its management said it could not understand why staff at the time had judged the list too weak to bring in the authorities.
According to the prosecutors who later charged his superiors, the people responsible had recognized the danger he posed by the end of October 2001 at the latest. Several meetings discussed calling in law enforcement, the indictment said, but the decision was made not to inform the police. Prosecutors alleged that the superiors kept quiet out of concern for their own reputations and for the reputation of the unit and the hospital.
The hospital’s response was a transfer and then a farewell. Hogel was moved to the anesthesia department and drew attention there too. In 2002 the managing director and the director of nursing arranged for him to be released from work for three months on full pay, according to the 2019 indictment of his superiors. The prosecutor who later argued their case said the managing director had asked the works council to persuade him to resign, and that Hogel was given a choice between doing only patient transport and errands or leaving. He left with a good reference. The taz said he was "praised away." Prosecutors later called the reference false, because it concealed the danger he posed. With it, Hogel applied for a job at the hospital in nearby Delmenhorst and was hired.
At Delmenhorst the numbers climbed. Police death statistics showed that the unit’s mortality rate nearly doubled in 2003 and 2004. A police investigator testified in 2019 that when the figures were matched against duty rosters, Hogel had been on duty for about 75 percent of all deaths on the ward. Colleagues gave him a nickname that translates roughly as "resuscitation Rambo." A colleague at the Delmenhorst hospital caught him in June 2005; he was dismissed and arrested, and has been in custody continuously since May 2009.
The criminal justice system moved slowly too. In December 2006 the Landgericht Oldenburg convicted him of attempted manslaughter and dangerous bodily harm and sentenced him to five years; the Federal Court of Justice overturned that verdict. At a retrial in the summer of 2008 he received seven and a half years (AFP and Al Jazeera reported seven) and a lifetime professional ban. A police investigator testified in 2019 that he and a colleague had pressed for more investigation at the start, and that the whole case could have been dealt with in 2006 or 2007. The police received the hospital’s death figures only in 2006, because the hospital at first refused to name patients, citing data protection. The Oldenburg prosecutor’s office later apologized publicly for the delays. On February 26, 2015, the presiding judge, Sebastian Buhrmann, sentenced Hogel to life for two murders, two attempted murders and dangerous bodily harm at Delmenhorst, and apologized on behalf of the justice system for how slowly the case had moved. "That was not right," he said.
The superiors were tried. Seven former superiors were charged, and the trial opened in February 2022. In October 2022 the prosecution itself asked for acquittals, and the court acquitted all seven. The court’s finding, in short, was that although the superiors had suspicions and let him leave with a good reference, intent on their part could not be shown. In October 2018 Lower Saxony amended its hospital act, and dpa reported that ward pharmacists became compulsory in its hospitals from the start of 2022.
Genene Jones was a licensed vocational nurse in San Antonio, Texas, whose career in pediatric care ran from 1978 to 1982. In the pediatric intensive care unit at Bexar County Hospital, children on her 3 to 11 p.m. shift suffered so many sudden seizures, bleeding episodes and cardiac arrests that nurses called it the death shift. The hospital held several internal reviews, then replaced all of the unit’s licensed vocational nurses with registered nurses and let her go with a good recommendation. It did not call the police.
ProPublica, drawing on the later investigation, reported in 2017 that 42 children died in the unit between April 1981 and June 1982, that 34 of those deaths came on the 3 to 11 p.m. shift, and that Jones had cared for 20 of the children who died. A study by the federal Centers for Disease Control later concluded that a child in the unit was 25.5 times as likely to suffer a medical emergency, and 10.7 times as likely to die, while she was on duty. These are statistical associations. They do not show that any particular child was harmed by anyone.
Nurses began to talk. In October 1981 a registered nurse, Suzanna Maldonado, took her concerns to the head nurse, Pat Belko, who passed them to Robotham. Maldonado later testified that she kept a list of 42 infants who died on Jones’s shift between January 1981 and March 1982, and that Jones threatened her. After the unit was reorganized, Maldonado received anonymous notes reading "Your dead" and "Soon," Peter Elkind reported in Texas Monthly.
The hospital looked into the deaths several times without going to the authorities. An internal inquiry identified ten child deaths between May and December 1981 at which Jones had been present, Elkind wrote in 1983, and its report said the link could be coincidence but that wrongdoing could not be ruled out. On January 19, 1982, Dr. Robert Franks wrote to the dean of the medical school that a drug overdose had been documented in one child but nothing tied it to any employee. Two days later a chest surgeon, Kent Trinkle, threatened to move his young patients elsewhere. On January 25, 1982, a malpractice lawyer, Paul Green, advised the hospital that firing Jones or calling the district attorney without proof carried legal risk.
On February 15, 1982, an outside panel of six specialists led by Dr. Alan Conn, a veteran of intensive care in Toronto, began a review. Its report criticized how the unit was run and recommended that Robotham and Belko be moved from their posts. On March 2, 1982, the hospital administrator, Virginia Mousseau, announced that the unit would be staffed only by registered nurses. All seven licensed vocational nurses were replaced, and Jones resigned on March 17. Hospital officials suspected what one internal document called "purposeful nursing misadventure," ProPublica reported in 2017, but they feared lawsuits and bad publicity, and they gave her a letter of recommendation describing her as "loyal, dependable, and trustworthy." Vincent DiMaio, a former Bexar County medical examiner, said in a 2016 interview with Texas Public Radio that hospital staff saw the pattern and that the administration wanted to avoid bad publicity. "Unless they were awfully dumb, it was obvious what was going on," he said.
Dr. Kathleen Holland opened a pediatric practice in Kerrville on August 23, 1982, and hired Jones as her nurse. Holland had heard the rumors and had been warned, Elkind reported, but she said she trusted Jones. Over the next few weeks other children were rushed from Holland’s clinic to Sid Peterson Hospital in Kerrville after they stopped breathing or had seizures. Elkind counted seven patients and eight emergencies in 31 days. On September 17, 1982, 15-month-old Chelsea McClellan died; Jones was convicted of her murder in February 1984 and sentenced to 99 years. On September 22 a senior physician, Duan Packard, met the hospital administrator and other doctors to discuss the run of emergencies from the new clinic. That evening a surgeon, Joe Vinas, reported to an emergency meeting of the hospital’s executive committee that he had called a resident in San Antonio about the nurse. The resident’s reply, as Vinas reported it, was "You’ve got a baby killer on your hands."
In October 1984 Jones was convicted of injury to a child in the case of a four-week-old boy at the San Antonio hospital who survived, and received a concurrent 60 years. She was indicted again in 2017, as a 1977 Texas law was about to free her. In January 2020 she pleaded guilty to the 1981 murder of 11-month-old Joshua Sawyer, and Judge Frank J. Castro sentenced her to life. Four other charges were dismissed under the plea. She stands convicted of two murders and one count of injury to a child.
Michael Swango was a physician. In 2000 he pleaded guilty in federal court on Long Island to murdering three veterans at the Veterans Affairs Medical Center in Northport, New York, in 1993, and a month later he pleaded guilty in Columbus, Ohio, to the 1984 murder of Cynthia Ann McGee, a 19-year-old patient at Ohio State University Hospitals. Those four killings are the ones a court has recorded. He had already served prison time in Illinois: in 1985 he was convicted of six counts of aggravated battery for making ambulance co-workers ill, and he spent most of the years between his release in 1987 and his arrest in 1997 getting back into hospitals by hiding that conviction.
The warnings began at Ohio State. On February 7, 1984, a 69-year-old woman who had undergone back surgery hours earlier stopped breathing after Swango had been at her bedside. Three witnesses, a nursing student among them, saw or described what he did. Doctors revived her. Afterward she wrote notes asking who the blond doctor was. Physical evidence was never tested and was later thrown away because no investigator asked for it, The Lantern and The Blade reported.
Medical center officials met with two lawyers on February 8, The Blade reported, and the police were never called. The hospital put the inquiry in the hands of Dr. Joseph Goodman, a professor of neurosurgery. According to The Blade, he did not interview key nurses or residents, did not speak to the surviving patient’s roommate and did not examine the physical evidence, and no tests were carried out. He concluded the complaints were unfounded. Dr. Manuel Tzagournis, then the medical college dean, allowed Swango to return to work. A follow-up review by the medical director, Dr. Michael Whitcomb, consisted of three interviews and produced no notes. A 72-year-old leukemia patient died the day Swango was cleared, and two more patients died afterward, The Blade reported.
In late February the residency review committee voted not to keep him on after June, and he left the program on June 30, 1984. Three doctors nevertheless wrote letters supporting his application for a medical license, one rating him "good" and another "excellent"; the final letter described him as "exonerated" and wrongly said the February patient had died. He received his Ohio medical license in September 1984. Kirkus Reviews, summarizing James B. Stewart’s book Blind Eye, said administrators declined to discipline him because they "didn’t want to be sued by Swango."
Ohio State was not the last institution to hear. On October 26, 1984, Quincy, Illinois, police arrested him after six paramedics at the Adams County Ambulance Corps had fallen ill; the same day, Quincy investigators telephoned the Ohio State campus police, who told them they had never heard of him. United Press International reported his five-year sentence in August 1985. On June 27, 1997, he was arrested at O’Hare International Airport on a federal fraud warrant while on his way to a hospital job in Saudi Arabia. He pleaded guilty in March 1998 to a federal false-statement charge over his Stony Brook application. Federal prosecutors charged him with the three Northport murders in July 2000, days before he was due to leave prison on the fraud sentence. Judge Jacob Mishler imposed three consecutive life terms without parole on September 6, 2000, and Judge Lisa Sadler imposed life with parole eligibility after 20 years for the McGee murder on October 18, 2000.
Efren Saldivar pleaded guilty in a Los Angeles courtroom on March 12, 2002, to murdering six elderly patients and to trying to kill a seventh. The patients had been in Glendale Adventist Medical Center, in Glendale, California, in 1996 and 1997, when he was a respiratory care therapist there on the night shift. He was 32. On April 17, 2002, Judge Lance Ito sentenced him to six life terms plus 15 years to life for the attempted murder.
He joined the hospital in 1989 and worked the graveyard shift, when the hospital was quiet and he was largely unsupervised, according to a Crescenta Valley Weekly column. Many patients died during his shifts, the column said, but no alarm was raised because they were already close to death. Some co-workers began to talk. One respiratory therapist later told police that a colleague had said, more than a year before the investigation, that Saldivar had a "magic syringe." Staff joked that he had the "magic touch," and in the spring of 1997 a fellow therapist raised his suspicions with a supervisor, though there was no proof and the two men were known not to get along.
Some months before police became involved, the same therapist looked into Saldivar’s locker. He told police he saw several vials of medication there that did not belong. He had not reported it, he said, because he had been in the locker without permission while playing a prank. The Crescenta Valley Weekly column, written more than 20 years later, gives a fuller version: staff on the graveyard shift pried the locker open intending a prank, found syringes and vials he was not supposed to keep there, and kept quiet for fear of getting into trouble.
On March 3, 1998, Glendale police received an anonymous call saying that Saldivar had "helped a patient die fast." The column said the tip first reached the hospital, which called the police; hospital spokesman Mark Newmyer said the hospital had reported the matter at once. On March 11, 1998, Saldivar came to the police station and, in time, told detectives he had caused 40 to 50 deaths since 1989. The confession was all the police had. He was held for 48 hours and released for lack of evidence. The state Respiratory Care Board suspended his license on March 27, 1998, the hospital said it had fired him, and it placed its whole respiratory care staff, about 40 people, on paid leave. Within weeks he retracted his account, telling ABC’s 20/20 he had invented it because he was depressed and suicidal. By January 2001 his license had been revoked, according to Lawrence Livermore National Laboratory. He was charged that month, and in 2002 pleaded guilty.
In March 1983 a jury in Trondheim convicted Arnfinn Nesset, the former manager of a nursing and old people’s home in Orkdal, of murdering 22 of its elderly residents and of trying to kill another. It acquitted him of two further murder counts. He was 46, a trained nurse with a quiet manner. United Press International called it Scandinavia’s biggest peacetime mass murder case. He was sentenced to 21 years in prison, the maximum then allowed, and 10 years of preventive detention. He was moved to supervised release in 1993 and freed in 2004.
The warnings in Orkdal were whispers. In 1977 Nesset obtained a drug for the home that, Adresseavisen wrote in 2002, had no place in a nursing home. The same year, staff began to talk among themselves about a run of sudden and unexpected deaths and whether their manager might be behind them. The paper said there were few clear signs, and that the suspicion hung over the home for about three more years. Staff saw him carrying a laboratory basket in and out of patients' rooms. No one in authority looked into the rumors.
In late fall 1980 it emerged that Nesset had altered a pharmacy prescription and ordered the drug in large quantities several times. When he was confronted, he said it was meant for putting down a dog, an explanation the paper said was hard to believe. The county physician and the police were told. UPI credited a local journalist with finding that large quantities had been sent to the home. Nesset was arrested in January 1981. He confessed during almost 1,000 hours of questioning, and the number of killings he admitted varies by report, at 27, 30 or 31. Shortly before the trial he withdrew every confession. In 2024, at 87, he asked for the case to be examined again. He died in a nursing home in December 2025, aged 89. The staff who whispered worked for the man they suspected, and he was the person any complaint would have had to reach.
Kristen Gilbert was a registered nurse at the Veterans Affairs Medical Center in the Leeds section of Northampton, Massachusetts, from March 1989 to February 1996. In March 2001 a federal jury in Springfield convicted her of murdering four veterans who were patients on her ward and of trying to kill two others. The jury did not impose a death sentence, and she was sentenced to life without parole.
By late 1995, nurses on Ward C were asking why so many patients were dying and why Gilbert was so often nearby, and they began watching her quietly. Three of them reported the pattern in February 1996, the Associated Press said, along with missing doses of a stock medication. The Associated Press’s 1998 figure was 85 missing doses. The hospital did not call the police. Gilbert was arrested on October 8, 1996, on a federal charge of telephoning a bomb threat to the hospital on September 26, 1996, and sentenced to 15 months in prison. The charges for the patient deaths followed in November 1998, while she was serving that sentence.
Lucy Letby was a neonatal nurse at the Countess of Chester Hospital in the northwest of England. In August 2023 a jury at Manchester Crown Court convicted her of murdering seven babies and attempting to murder six others in the hospital’s neonatal unit between June 2015 and June 2016. A second jury convicted her in July 2024 of the attempted murder of another baby girl. She was sentenced to whole life orders, 15 in all, which mean she will never be released. She has always denied harming any baby. The Court of Appeal refused her permission to appeal in May 2024 and again in October 2024. A group of doctors and scientists working with her legal team has disputed the medical evidence, and the Criminal Cases Review Commission confirmed in February 2026 that a review of her convictions is under way. The convictions stand.
Consultant pediatricians on the unit had come to see a pattern in the deaths and collapses and had identified Letby as the common factor. She was removed from clinical duties in 2016; LBC reported that she was then given clerical work, which she did until 2018.
The Thirlwall Inquiry, led by Lady Justice Thirlwall, published its report on September 15, 2026, under the headline finding of a "profound failure of management, governance and safeguarding." It concluded that senior nurses "never accepted" that the consultants' concerns were, or might be, justified. The consultants who had raised concerns were themselves investigated during a grievance that Letby brought, and three of them were told to apologize to her. Plans were drawn up to return her to the neonatal unit and later abandoned. The hospital’s leadership commissioned a series of reviews, including one by the Royal College of Paediatrics and Child Health, which did not address whether babies were being deliberately harmed; the college accepted at the inquiry that its review could not answer the doctors' concerns and should never have been undertaken. The inquiry did not reexamine the convictions.
CBS News, with the Associated Press, reported that the police investigation opened in May 2017, about a year after she left the ward. The parents, the inquiry found, learned only in 2018 that a nurse’s actions might have caused the collapses and deaths. Before the police were called, an inquest into Child A’s death was held in October 2016. It returned a narrative conclusion that the cause could not be determined. The Press Association has reported that the consultants' concerns about Letby, which had by then led to her removal from clinical duties, were not mentioned at that inquest.
Letby was arrested on July 3, 2018, and charged in November 2020. The Nursing and Midwifery Council struck her off the register on December 12, 2023. In January 2026 the Crown Prosecution Service decided not to charge her over further babies at the Countess of Chester and at Liverpool Women’s Hospital; that decision was upheld on review in August 2026.
Elizabeth Wettlaufer was a registered nurse in Ontario from 1995 to 2016. Between 2007 and 2016 she deliberately harmed fourteen people in her care, most of them elderly residents of long-term care homes in Woodstock, London and Paris. Eight of them died. On June 1, 2017, she pleaded guilty in Woodstock to eight counts of first-degree murder, four counts of attempted murder and two counts of aggravated assault, and on June 26 she was sentenced to life in prison with no chance of parole for twenty-five years.
In this case the question is not who ignored a warning. None of the deaths had been treated as suspicious. Families, co-workers, managers, provincial inspectors, coroners and the nurses' regulator all missed what she was doing, according to the public inquiry that followed. The offenses came to light only because, in September 2016, she checked herself into the Centre for Addiction and Mental Health in Toronto and told her psychiatrist what she had done. The sentencing judge, the police and the prosecutors all said she would never have been caught otherwise, and the inquiry’s commissioner reached the same conclusion.
The employment record is where the system could have caught her, and where it did not. Her first nursing job was at Geraldton District Hospital in northern Ontario, where she worked from June to October 1995. In September 1995 she collapsed at work after taking a controlled drug from the hospital’s supply, an episode a Canadian Press report on the later inquiry described as an apparent suicide attempt. The hospital fired her and, as the law required, reported her to the College of Nurses of Ontario. The College put conditions on her license and monitored her; at the 2017 disciplinary hearing its lawyer said it had concluded at the time that she had not tried to harm patients. The inquiry report says the conditions were lifted in May 1998. In June 2007 she was hired at Caressant Care in Woodstock. Her only reference came from her support work job, and the home’s director of nursing told the inquiry in 2018 that she had not known about the Geraldton episode.
Caressant Care disciplined her several times for poor performance. In August 2012, according to documents before the inquiry, administrators raised concerns about patient safety and warned that they would ask the College to review her fitness to practice if she did not improve. She told her employers she was caring for her father and that a change in her medication had left her not feeling like herself. In March 2014 the home ended her employment after a series of medication errors. Documents filed at the inquiry showed that the home gave her a reference letter and a settlement of $2,000, and the director of nursing told the inquiry that, knowing what she knew later, she would never have given the reference.
The home filed a termination report with the College, dated April 17, 2014, summarizing her performance problems and medication errors. The College decided that no investigation was needed and placed no restrictions on her license. It took no step beyond what the inquiry called "banking with notice": the report was kept on file in case further concerns arose. The inquiry concluded that this decision showed the College had no serious concerns about the care she gave. Recommendations 40 to 49 of the inquiry’s report were later directed at the College. The commissioner, Eileen Gillese, released the report on July 31, 2019. Reporting on it said systemic failures in long-term care allowed the crimes.
The employers in these cases did not, for the most part, miss the signs. They saw a tally, a list, a pattern on a ward, a letter from a consultant, a run of emergencies from a new clinic. What they did with what they saw followed a recognizable order: an internal inquiry, then a transfer or a resignation, then a reference, and only rarely a call to the police. In San Antonio the hospital took legal advice that firing a nurse without proof carried risk. In Oldenburg the managers decided against telling the police, prosecutors alleged, to protect reputations. In Chester the people who raised the alarm were told to apologize. In Pennsylvania a hospital offered a neutral reference to a nurse it suspected, by his own account. In Ontario nobody saw enough to warn at all, and the inquiry did not blame any single employer for that. The courts then divided on what to do about it: in Texas and New Jersey, civil juries and settlements; in Germany, a trial of superiors that ended in acquittals; in England, an inquiry report. None of those outcomes undid the choice made at the time, which each time was the same one: to treat a warning as a problem for the institution.
• 1977: staff at the Orkdal nursing home begin to talk about unexpected deaths (Nesset).
• January 1981: Arnfinn Nesset arrested.
• October 1981: nurse Suzanna Maldonado reports concerns about Genene Jones’s shifts.
• March 2, 1982: the San Antonio hospital announces its pediatric unit will be staffed only by registered nurses; Jones resigns March 17 with a letter of recommendation.
• September 17, 1982: Chelsea McClellan dies in Kerrville.
• March 1983: Nesset convicted.
• February 1984: Ohio State’s internal inquiry clears Michael Swango; he leaves the program June 30, 1984.
• October 26, 1984: Swango arrested in Quincy, Illinois.
• June 11, 1988: first death in Charles Cullen’s pleas.
• January 1992: Cullen leaves Saint Barnabas after the hospital’s inquiry into contaminated intravenous bags.
• 1995: Wettlaufer’s first hospital fires her and reports her to the nursing regulator.
• February 1996: three nurses report the pattern on Ward C (Kristen Gilbert); October 8, 1996, Gilbert arrested on a bomb threat charge.
• March 3 to 27, 1998: Efren Saldivar’s tip, confession, release and license suspension.
• March 14, 2001: Gilbert convicted.
• October 2001: by this date, prosecutors later said, superiors at the Oldenburg hospital had recognized the danger posed by Niels Hogel.
• March 12, 2002: Saldivar pleads guilty.
• 2002: Hogel released from work on full pay and leaves with a good reference.
• 2002: Cullen resigns from St. Luke’s, having been offered a neutral reference, he later said.
• October 31 and December 12, 2003: Cullen fired by Somerset Medical Center and arrested.
• June 2005: Hogel caught at Delmenhorst.
• 2007 to 2016: the offenses to which Wettlaufer later pleads guilty; April 17, 2014, Caressant Care files a termination report with the regulator.
• 2016: consultants' concerns lead to Lucy Letby’s removal from clinical duties at the Countess of Chester Hospital.
• September 2016: Wettlaufer tells her psychiatrist what she had done.
• May 2017: police investigation of Letby opens.
• June 1, 2017: Wettlaufer pleads guilty.
• July 3, 2018: Letby arrested.
• June 6, 2019: Hogel convicted of 85 murders.
• July 31, 2019: Ontario inquiry report released.
• January 16, 2020: Jones pleads guilty to the murder of Joshua Sawyer.
• October 2022: the seven superiors of Hogel are acquitted.
• August 2023: Letby convicted and sentenced.
• March 2026: Hogel’s minimum term set at 28 years.
• September 15, 2026: Thirlwall Inquiry reports.