A Regulatory Response to Healthcare Serial Killing

      Healthcare serial killing is difficult to detect, which makes protecting patients from this insidious harm challenging. In 2016, Elizabeth Wettlaufer confessed to murdering eight long-term care residents, attempting to murder four others, and assaulting two more while working as a registered nurse in Ontario, Canada (
      • R v. Wettlaufer
      OSCJ Court file 05/17 (Agreed statement of facts on guilty plea). Exhibit 1 at Long-term care homes inquiry.
      ). These events prompted the College of Nurses of Ontario (CNO), along with partners in the system, to question what can be learned from this tragedy so that the suffering of families and victims was not in vain. Can serial killers be detected and prevented? Where there are potential threats to patient safety, regulators must take action to reduce risk and prevent harm. Determined to learn from the horrendous crimes and contribute to the learning of others, CNO began with an extensive literature review related to healthcare serial killers. From the literature review, this article describes common factors associated with healthcare serial killers, their victims, their crimes, and possible detection. Several recommendations based on the literature are proposed.


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        • 25-year-old man blameworthy of killing
        Legal monitor worldwide.
        2018, March 24
        • Belgian ‘deacon of death’ jailed for 27 years
        Agence France Presse - English.
        2018, February 1
        • Dahm L.L.
        Regulation of nurses: Should the NPDB be expanded?.
        Michigan State University Journal of Medicine and Law. 2007; 11: 33-69
        • Dean M.M.
        Verdict: Gosnell guilty of murdering 3 babies.
        in: The Philadelphia Daily News. 2013, May 14
        • Dubinski K.
        Nursing home didn’t follow reporting rules, Wettlaufer inquiry hears.
        in: CBC News. 2018, June 11 (Retrieved from)
        • Dubinski K.
        Wettlaufer’s ‘Grim Reaper’ behaviour prompted co-worker to check death records.
        in: CBC News. 2018, June 25 (Retrieved from)
        • Dye J.
        Megan Haines jailed for 27 years for murdering patients at nursing home.
        in: The Sydney Morning Herald. 2016, December 16
        • Eddy M.
        German nurse is thought to have killed at least 86.
        in: New York Times. 2017, August 28 (Retrieved from)
        • Esmail A.
        Physician as serial killer—The Shipman case.
        New England Journal of Medicine. 2005; 352: 1843-1844
      1. Federal Bureau of Investigation. (n.d.) Serial murder: Multidisciplinary perspectives for investigators. Retrieved from

        • Field J.
        • Pearson A.
        Caring to death: The murder of patients by nurses.
        International Journal of Nursing Practice. 2010; 16: 301-309
        • Finnish nurse gets life for murdering five patients
        The Telegraph.
        (Retrieved from)
        • Flin R.
        • Bromiley M.
        • Buckle P.
        • Reid J.
        Changing behaviour with a human factors approach.
        BMJ. 2013; 346: f1416
        • Forrest A.R.W.
        Nurses who systematically harm their patients.
        Medical Law International. 1995; 1: 411-421
        • Forsyth C.J.
        Posing: The sociological routine of a serial killer.
        American Journal of Criminal Justice. 2015; 40: 861-875
        • German midwife jailed for giving patients blood thinner
        The Canadian Press.
        (Retrieved from)
        Date: 2016, October 28
        • Grierson J.
        Stepping Hill nurse Victorino Chua jailed for life.
        in: The Guardian. 2015, May 19 (Retrieved from)
        • Guthrie B.
        • Love T.
        • Kaye R.
        • MacLeod M.
        • Chalmers J.
        Routine mortality monitoring for detecting mass murder in UK general practice: Test of effectiveness using modelling.
        British Journal of General Practice. 2008; 58: 311-317
        • Hoerr K.
        Nursing home worker found guilty of murdering two residents.
        in: Australia Broadcasting Corporation News. 2016, September 29 (Retrieved from)
        • The Joint Commission
        Developing a reporting culture: Learning from close calls and hazardous conditions.
        Sentinel Event Alert. 2018, December 10; 60 (Retrieved from)
      2. Killer nurse jailed for life: Judge brands Victorino Chua ‘indescribably wicked’ as he sentences him to a minimum of 35 years for murdering and poisoning patients.
        in: Daily Mail Online. 2015, May 19
        • Kizer K.W.
        • Yorker B.C.
        Health care serial murder: A patient safety orphan.
        The Joint Commission Journal on Quality and Patient Safety. 2010; 36: 186-191
        • Klinkhammer G.
        Patient killing: How a carer became a killer.
        Deutsches Ärzteblatt. 2015; 112 (Retrieved from): A1774-A1775
        • Knoll J.
        Serial murder: A forensic psychiatric perspective.
        Psychiatric Times. 2006; 23 (Retrieved from): 64-68
        • Long-Term Care Homes Public Inquiry
        Overview report: The College of Nurses of Ontario.
        (Retrieved from)
        • Long-Term Care Homes Public Inquiry
        The public inquiry into the safety and security of residents in the long-term care homes system.
        (Retrieved from)
        • Lubaszka C.K.
        • Shon P.C.
        Reconceptualizing the notion of victim selection, risk, and offender behavior in healthcare serial murders.
        Journal of Criminal Psychology. 2013; 3: 65-78
        • Lubaszka C.K.
        • Shon P.C.
        • Hinch R.
        Healthcare serial killers as confidence men.
        Journal of Investigative Psychology and Offender Profiling. 2014; 11: 1-28
        • Lucy D.
        • Aitken C.
        A review of the role of roster data and evidence of attendance in cases of suspected excess deaths in a medical context.
        Law, Probability and Risk. 2002; 1: 141-160
        • Macrae C.
        Early warnings, weak signals and learning from healthcare disasters.
        BMJ Quality & Safety. 2014; 23: 440-445
        • Marks K.
        Nurse Roger Dean pleads guilty to Sydney nursing home deaths.
        in: The Independent. 2013, May 27
        • McQuigge M.
        Victims’ families, survivor speak at Wettlaufer inquiry.
        in: The Globe and Mail. 2018 (Retrieved from)
        • Patel M.
        Serial killer: Elderly victims of serial killers.
        International Journal of Criminology & Sociological Theory. 2015; 8: 1-11
        • Pérez-Peña R.
        • Kocieniewski D.
        • George J.
        Death on the night shift: 16 years, dozens of bodies; through gaps in system, nurse left trail of grief.
        The New York Times. 2004; (Retrieved from)
        • Professional Standards Authority
        The role of risk in regulatory policy: A review of the literature.
        (Retrieved from)
        • Professional Standards Authority
        Right-touch regulation revised.
        (Retrieved from)
        • R v. Wettlaufer
        OSCJ Court file 05/17 (Agreed statement of facts on guilty plea). Exhibit 1 at Long-term care homes inquiry.
        (Retrieved from)
        • Ramsland K.M.
        Inside the minds of healthcare serial killers: Why they kill.
        Praeger Publishers, Westport, CT2007
        • Ramsland K.
        • DeVito D.
        Nurses who kill.
        in: Iyer P.W. Nursing Malpractice. 3rd. Lawyers and Judges Press, Tucson, AZ2007: 909-923
        • Reid S.
        Compulsive criminal homicide: A new nosology for serial murder.
        Aggression and Violent Behavior. 2017; 34: 290-301
        • Rogojan P.
        Deviant workplace behavior in organizations: Antecedents, influences, and remedies.
        (Diploma Thesis). Retrieved from
        • Rourke S.
        • Ward T.
        Healthcare serial killers: Patterns and policies.
        in: Medscape. 2017 (Retrieved from)
      3. Serial killer nursing aide sentenced to life behind bars: Angelo Stazzi killed five elderly patients with insulin.
        in: ANSA. 2014, March 31 (Retrieved from)
        • The Secretary of State for Health by Command of Her Majesty
        Trust, Assurance and Safety – The Regulation of Health Professionals in the 21st Century.
        (Retrieved from)
        • Starr L.
        What can we learn from Quakers Hill?.
        Australian Nursing & Midwifery Journal. 2015; 22: 37
        • Tsang C.
        Patient safety in English general practice: the role of routinely collected data in detecting adverse events.
        (PhD Thesis). Retrieved from
        • Velliquette B.
        Nurse pleads guilty to involuntary manslaughter.
        in: Herald-Sun (Durham, North Carolina). 2012, June 5
        • White J.H.
        • Lester D.
        • Gentile M.
        • Rosenbleeth J.
        The utilization of forensic science and criminal profiling for capturing serial killers.
        Forensic Science International. 2011; 209: 160-165
        • Williams R.S.
        Report of the grand jury in re county investigating grand jury XXIII.
        (Retrieved from)
        • Woods D.
        US doctor may have killed 60.
        BMJ. 2000; 321 (Retrieved from): 657
        • Worker at nursing home arrested for throwing old man from veranda
        Japan Economic Newswire.
        2016, February 16
        • Yardley E.
        • Wilson D.
        In Search of the ‘Angels of Death’: Conceptualising the Contemporary Nurse Healthcare Serial Killer.
        Journal of Investigative Psychology and Offender Profiling. 2016; 13: 39-55
        • Yorker B.C.
        Hospital Epidemics of Factitious Disorder by Proxy.
        in: Feldman Marc D. Eisendrath S.J. The Spectrum of Factitious Disorders. American Psychiatric Press, Washington, DC1996: 157-174
        • Yorker B.C.
        Expert report of Professor Beatrice Crofts Yorker.
        (Exhibit 163 at Long-term care homes inquiry. Retrieved from)
        • Yorker B.
        • Kizer K.W.
        • Lampe P.
        • Forrest A.R.W.
        • Lannan J.M.
        • Russell D.A.
        Serial Murder by Healthcare Professionals.
        Journal of Forensic Sciences. 2006; 51: 1362-1371


      Erin Tilley, BHSc, BScN, MN, RN, PMP, FRE, is a Strategy Consultant, College of Nurses of Ontario (CNO), Toronto.


      Catherine Devion, BA, MLS, is a Librarian, CNO.


      Anne L. Coghlan, BScN, MScN, RN, is Executive Director and CEO, CNO.


      Kevin McCarthy, BScN, MPPAL, RN, is Director, Strategy, CNO.

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