Everywhere else in this archive, the body is the evidence. On a hospital ward it is the alibi.
That is the whole difficulty of this category. A patient who dies in a geriatric unit or an intensive care bed has done the expected thing, in a building designed for it, and the drugs used to kill them were in the room legitimately, on a trolley, signed out for someone. The nurses in this archive were not concealing deaths. They were producing deaths that required no concealment.
Elizabeth Wettlaufer gave overdoses of insulin to fourteen elderly residents across three Ontario care homes between 2007 and 2016. Eight died. Insulin overdose in an elderly nursing home resident produces a death that looks entirely ordinary, and the record is blunt about the consequence: no post-mortem was performed on any of them. Nine years, eight deaths, and not one examination.
Stephan Letter worked eighteen months on a ward at Sonthofen in Bavaria, during which there were more than eighty deaths on his shifts. He sedated patients and then injected a muscle relaxant, Lysthenon or Esmeron, which paralyses the respiratory system and is difficult to detect in blood afterwards. That is stated in this archive as the reason the deaths passed as natural for so long.
Waltraud Wagner devised something that needed no drug at all. She and three colleagues at the Lainz hospital in Vienna held a patient's nose and tongue and poured water into the mouth until the lungs filled, which in an elderly patient produces a death that looks entirely natural. The case named it the water treatment.
So the question in these cases is usually not how the killing was hidden. It is what was left afterwards to look at, and the answer to that decides the number the courts arrive at.
Letter's case sets it out most plainly. Prosecutors at Kempten exhumed more than forty patients. Another thirty-eight had already been cremated, and in those cases nothing could be recovered. Whatever the true total was, it was fixed at that point by what remained to be examined. He was convicted on twenty-eight counts against more than eighty deaths on his shifts.
Efren Saldivar, a respiratory therapist rather than a nurse, is the same arithmetic in the open. Twenty bodies were disinterred and six were found to contain Pavulon. He was convicted of six murders. His own estimates over the years have ranged from around fifty to more than two hundred, and the hospital's records for the period could not resolve it. Six is not a finding about how many people he killed. It is the number of bodies that still held the drug.
Niels Hogel required the exhumation of well over a hundred bodies from cemeteries in Germany, Poland and Turkey, and he has eighty-seven convictions. The commission that examined the case concluded that the real total is unknowable and probably exceeds three hundred, and it named the reason: a great many of the possible victims had been cremated.
With Genene Jones the material that went missing was paper. Infants on her shift at the Bexar County Medical Center in San Antonio suffered unexplained seizures and cardiac arrests and a number died, but those deaths were never charged at the time, because the hospital's records for the period had been destroyed under a document retention policy. She has two murder convictions against a suspected figure above sixty.
Charles Cullen put digoxin, insulin, epinephrine and other drugs into intravenous bags, sometimes into bags left in a supply room to be picked up at random, which meant he did not always know who would die. He has twenty-nine convictions, admitted about forty in interviews, and told investigators he had lost count and that it could be several hundred. A man who did not know who he had killed cannot supply a total, and neither could the wards he worked on.
A different failure runs alongside this one, and it has its own article: the employers who moved people on rather than report them. That is about what the institutions did with a suspicion. This is about what was left in the ground once they had.
Now the part that cuts the other way, because a category built on undetectable drugs will produce cases where the detection is the weak point.
Kristen Gilbert was convicted in 2001 of killing four patients at the Veterans Affairs Medical Center in Northampton, Massachusetts with injected epinephrine, a drug that is difficult to detect after death. The case was built on toxicology, exhumations and years of it. Then on January 5, 2001 the government conceded that the results purporting to establish high epinephrine levels in the victims were wrong, and withdrew its expert after he miscalculated. What convicted her was a pattern of deaths and two confessions reported by people close to her, not the science the case had been assembled around.
Robert Rubane Diaz is the inverse and the harder case. Post-mortem examination of patients who died on his wards in Riverside County in 1981 found high concentrations of lidocaine, and he was convicted of twelve murders and sentenced to death. Lidocaine concentrations measured after death are affected by post-mortem redistribution, in which the drug moves out of tissue into blood and produces readings far above what was present in life, and how large that effect is was not well understood in 1981. No court has accepted the objection and the conviction has never been quashed. It rests on a measurement whose reliability has been disputed by people qualified to dispute it, and a reader should know that.
So this is the one group in the archive where the physical evidence is both the only route to a count and, in at least two cases, the part that failed.
Which leaves the question of what actually stopped them. In one case it was the medical evidence: Diaz was arrested after post-mortem examination found the lidocaine. In the rest it was not.
Richard Angelo was injecting Pavulon and Anectine into patients at the Good Samaritan Hospital so that they would go into crisis while he was on duty and he could lead the resuscitation. He was caught on October 11, 1987 because a patient, Gerolamo Kucich, felt something going into his drip, pressed the call button, and told a nurse what he had seen. The nurse kept the urine sample. Wagner and her three colleagues were caught in 1989 when a doctor overheard them laughing about a patient's death in a tavern. Cullen was arrested after a colleague at Somerset Medical Center, Amy Loughren, agreed to work with detectives and recorded him. Letter was arrested for stealing medication, and the deaths on his shifts came into focus only during that investigation. Wettlaufer was never detected at all: the Gillese Inquiry found that the long-term care system had no mechanism that would have found her, and she was caught because she chose to say so.
A conscious patient, a joke overheard in a bar, a colleague wearing a wire, a theft charge, a confession nobody asked for. In a category where the method is designed to leave an ordinary-looking death, the thing that ended it came from outside the ward in almost every case, and by the time anyone went looking for the bodies, the number of them that could still answer had already been decided by a crematorium or a filing policy.