In November 2006 a court in Kempten, in southern Bavaria, convicted the nurse Stephan Letter of killing 28 patients at the hospital in Sonthofen, in the Allgäu region of the Bavarian Alps. He was 28. The court found him guilty of 12 counts of murder, 15 of manslaughter and one of killing on request, sentenced him to life in prison, and barred him from nursing for the rest of his life. The case was described at the time as the biggest series of killings in Germany since the Second World War.
The deaths took place from early 2003 until July 2004. Prosecutors said they began less than a month after Letter started work at the hospital. Most of the dead were elderly, and at first none of the deaths was treated as suspicious. What drew the police in was a report that drugs were missing.
Sonthofen lies southwest of Munich in the Bavarian Alps, near Kempten, where the case was tried. Prosecutors said the first suspicious death at its hospital came in February 2003, less than a month after Letter started work there. The Kempten court, as summarized in 2007 by the psychiatrist Karl H. Beine in the German medical journal Deutsches Ärzteblatt, found that the killings ran from January 2003 to July 2004.
His life before Sonthofen received little attention in the trial reports. AFP described him in court as baby-faced and bespectacled. At the verdict the presiding judge, Harry Rechner, said he was of above-average intelligence, with a measured IQ of 121, AFP reported.
His colleagues were heard at the trial. Beine, writing about the Kempten proceedings, noted that one colleague told the court that after a shared night shift Letter had come in and spoken about a patient who had died during the night in a crude, dismissive way. Beine cited that testimony as one of the irregularities that came to light only in court.
By the prosecution's count, 17 women and 12 men died. They ranged in age from 40 to 94, and most were over 75, the Associated Press reported when the trial opened. An AFP report on the verdict gave the eldest as 95 and said most of the patients were in their seventies. Among the dead were two gravely ill women, aged 40 and 47.
Not all of them were close to death. Wilhelm Seitz, a lawyer who represented the relatives of 11 of the dead as co-plaintiffs, said at the start of the trial that Letter had acted indiscriminately and without aim, that not all of the victims had been seriously ill, and that he had had no contact with some of them before. Relatives of some patients told reporters that their family members had been recovering and were looking forward to going home when they died unexpectedly, AFP reported.
The hospital's suspicion fell first on its drug supply, not on the deaths. In July 2004 police looked into reports that drugs were missing. Investigators found unsealed vials of medication in Letter's apartment, and they identified him as a suspect by comparing the times at which patients had died with his hours on duty, according to the Associated Press. He was arrested that month.
AFP reported that Letter confessed to killing patients after he was arrested for stealing medicine from the clinic. At his arrest he admitted some of the killings, saying that he had wanted to spare patients senseless suffering, and he said he could not remember the others.
Prosecutors said the patients died of lethal injections of a combination of medicines.
Once the link to his shifts was made, investigators went back through the deaths that had occurred while he worked at the hospital. They reviewed more than 80 deaths, exhumed more than 40 bodies and questioned more than 200 witnesses, the Associated Press reported in February 2006. AFP put the number of exhumations at 42 and said that in some cases they went ahead over fierce resistance from relatives.
The Kempten criminal police chief, Albert Mueller, called the case "the biggest series of killings in postwar Germany."
The case came to trial before the Bavarian state court in Kempten on charges covering 29 deaths: 16 counts of murder, 12 of manslaughter and one of killing on request, which the Associated Press described as mercy killing. Letter was also charged with two counts of attempted manslaughter. In one of those cases, prosecutors said, the patient recovered.
The trial opened in Kempten in early February 2006, when Letter was 27. He faced life imprisonment if convicted of the murder counts.
He told the court that he had killed patients but could not remember how many. He said again that his aim had been to spare them suffering. When the trial began he withdrew part of his confession, saying that investigators had tricked him, AFP reported. His lawyer, Juergen Fischer, argued that he had been driven by compassion for seriously ill patients.
The prosecution answered that the compassion claim did not fit many of the deaths. The prosecutor, Peter Koch, said that the explanation might hold for about half of the patients, but that Letter had killed many elderly people in cold blood, paying little attention to their medical histories. "He killed as though he was on an assembly line," Koch said, as AFP reported. Seitz, for the families, had made the same point at the start of the trial: some of the dead had not been seriously ill at all.
The trial lasted about nine months.
On November 20, 2006, the Kempten court convicted Letter of 12 counts of murder, 15 of manslaughter and one of killing on request, covering the deaths of 28 patients. He was sentenced to life in prison. The court ruled that his crimes were serious enough that he would not be eligible for release after 15 years, the point at which life prisoners in Germany are usually considered for parole. It also banned him for life from working as a nurse, according to Beine's account of the judgment.
Letter sat motionless as the sentence was read, AFP reported.
In giving the court's reasons, Judge Rechner described him as an active supporter of assisted suicide who seemed to want to end what he saw as senseless suffering. But the judge said the evidence showed that Letter had been "interested, at best, superficially in the state of health of the patients," the Associated Press reported. Rechner also spoke of the arrogance with which he had treated his victims, according to AFP.
The verdict covered 28 deaths, against the 29 named in the charges. How the remaining charge was resolved has not been reported.
Letter's lawyers said after the verdict that they would appeal, AFP reported. In August 2007, when Beine's study appeared in Deutsches Ärzteblatt, the judgment was not yet final because the appeal was still pending.
Beine, a psychiatrist at St. Marien-Hospital in Hamm, included the Sonthofen case as the eighth of the cases he reviewed in his 2007 article on series of killings in hospitals and care homes.
He found that most of the perpetrators he studied were nurses and that nearly all of them claimed to have acted out of compassion. Beine rejected that explanation. In his view, killing out of pity was incompatible with real compassion; the killers were more often unable to bear a patient's suffering and were relieving their own distress. He found that once a first killing had taken place, the readiness to kill again rose.
He also listed warning signs that, in the cases he studied, had been noticed too late or not acted on: medicines given without a prescription or without being recorded, unusually accurate predictions of when patients would die, nicknames such as "angel of death" among staff, and a brutal or cynical tone. He wrote that the perpetrators were often outsiders, and that colleagues showed what he called an active not-wanting-to-know. He criticized death certificates that were delayed, superficial or skipped, and supervisors who met early suspicions with weak inquiries, indifference or denial.
Beine warned against explaining such crimes too quickly as the product of an inhumane health system or callous superiors, an approach that in his view turned the perpetrator into a victim. He recommended closer monitoring of unexplained drug orders and use, stricter checks of death certificates, toxicological tests when suspicion arises, and a working climate in which staff could speak openly about strain and aggressive feelings.
Proven by the court's judgment of November 20, 2006: 12 murders, 15 manslaughters and one killing on request, covering 28 patients at the Sonthofen hospital between early 2003 and July 2004.
Charged but not part of the conviction as reported: the charges covered 29 deaths and two attempted killings. How the attempted manslaughter counts, and the remaining death named in the charges, were decided has not been reported.
Other deaths: investigators reviewed more than 80 deaths during his time at the hospital. That figure is the number of cases examined, not a count of killings; the court's findings covered 28 patients.
Details that vary between reports: when the killings began (February 2003, by the prosecution's account; January 2003, in Beine's summary of the court's findings); the age of the oldest patient (94 in Associated Press and China Daily reports; 95 in AFP's); and the number of exhumations (more than 40, Associated Press; 42, AFP). He was charged over 29 deaths and convicted over 28, and 12 of the convictions were for murder; describing him as convicted of 29 murders overstates the judgment.
Early 2003, less than a month before the first death counted by prosecutors: Letter begins work as a nurse at the hospital in Sonthofen, Bavaria.
January or February 2003: the first of the deaths later attributed to him by the court (January in Beine's summary of the judgment; February by the prosecution's account).
July 2004: police look into reports of drugs missing from the hospital; unsealed vials are found in his apartment, and he is arrested. He admits some killings.
2004 to 2006: investigators review more than 80 deaths, exhume more than 40 bodies and question more than 200 witnesses.
Early February 2006: his trial opens before the Kempten Regional Court on charges covering 29 deaths, plus two counts of attempted manslaughter. He withdraws part of his confession.
November 20, 2006: the court convicts him of 12 murders, 15 manslaughters and one killing on request, and sentences him to life with a ruling that bars release after 15 years, plus a lifetime ban from nursing. His lawyers say they will appeal.
August 2007: Deutsches Ärzteblatt reports that the judgment is not yet final because the appeal is pending.