The Commonwealth of Pennsylvania is where an old, unresolved digoxin inquiry and a far larger investigation of deaths at Saint Luke’s Hospital converged on Charles Cullen. Its role in the book is less that of a surveyed landscape than of a layered investigative jurisdiction: hospital records, nurses’ observations, state-police files, forensic review, and civil litigation each reveal part of the case, but no single record initially supplies the whole explanation.

A prior warning at Easton Hospital

Six years before the Somerset County investigation reached this material, digoxin had been found in the blood work of a patient who died of a suspected overdose at Easton Hospital. Charles Cullen had been working there as a nurse at the time. A subsequent inquiry brought his file to the Pennsylvania State Police, but it was eventually abandoned, leaving investigators in the later case with a striking connection and little immediate resolution. The old file did not establish what Cullen had done; it established that a potentially relevant drug and a suspected overdose had already appeared in his employment history.

That connection surfaced when Danny Baldwin followed a handwritten note in Cullen’s record and called the Pennsylvania State Police. The trooper’s mention of digoxin was enough to change the apparent shape of the investigation: the same drug was associated with the Easton death and with the suspected poisoning of Reverend Florian Gall. The coincidence was compelling, but the investigators could not yet say whether it reflected a pattern or merely an unresolved lead. The old Pennsylvania inquiry therefore functioned both as a warning and as a limit: it pointed toward a connection without providing proof that could carry the new case.

The Saint Luke’s investigation

Danny Baldwin drove to a Pennsylvania State Police barracks and spent several hours being briefed by Corporal Gerald Walsh and Troopers Egan and Bruchak on the investigation of Cullen and incidents at Saint Luke’s Medical Center. The inquiry had begun after nurse Pat Medellin, troubled by unusual deaths and by Cullen’s removal from the hospital over medication diversion, pressed administrators to act. When she remained dissatisfied with their response, she took her suspicions to an acquaintance in the Easton police department. The concern moved through local law enforcement and the coroner to the Lehigh County District Attorney’s Office, prompting state troopers to interview hospital staff.

The nurses’ accounts described a recurring pattern around the night shift. Lynn Tester noticed patients who had seemed to be recovering dying suddenly after Cullen changed their intravenous lines. Robin Saulsberry recalled seeing him leave a patient’s room shortly before an unexpected code, and suspected the drug Pronestyl, which Cullen had been found dumping from the medication closet. Tester calculated that Cullen worked 26 percent of the hours but was present for 58 percent of the deaths. Another nurse recalled an average of twenty to twenty-two Code Blues a month while he worked in the unit, followed by six months without a code after he left. These observations made the cluster hard to dismiss, but they remained witness accounts and patterns to investigate, not, by themselves, proof of a particular administration or death.

The inquiry also exposed the difficulty of converting suspicion into a prosecutable case. A forensic pathologist, Dr. Isidore Mihalakis, reviewed seventeen patient charts selected by Saint Luke’s, but the paperwork yielded nothing prosecutable. Later documentation clarifies a significant limitation: he was not given a written list of the diverted drugs and apparently did not speak with the nurses whose suspicions had helped prompt the investigation. Without that context, his review could not establish that Cullen had harmed a patient. The absence of a conclusive finding in the charts was therefore not equivalent to a comprehensive resolution of the nurses’ concerns.

Records, employment, and the evidentiary gap

Saint Luke’s personnel record reduced Cullen’s departure to a resignation after reprimands and a medication issue; it did not name vecuronium or the other powerful drugs associated with the suspicions. The hospital’s inquiries likewise failed to reach a finding that he had harmed patients. In later accounts of the investigation, witnesses differed over what had been communicated and what investigators had understood. The record supports the existence of internal reviews and unresolved questions, not a simple claim that every hospital official possessed the same knowledge or reached the same conclusion.

The distinction mattered to Baldwin and Tim Braun. Drug-removal records and chart printouts could show that Cullen might have obtained drugs, but a possible route to a medication was not proof that he had used it to kill a named patient. Cancellations in the medication system could be presented as mistakes; chart activity could be read as suspicious without establishing criminal intent. Cullen had already left Saint Luke’s and moved on to Somerset Medical Center, narrowing the investigators’ prospect of catching him in the act. In this strand of the case, Pennsylvania supplied abundant leads, witnesses, and records, yet the central evidentiary step—from opportunity and pattern to proof of a specific killing—remained difficult.

Civil litigation and the later confirmation

The Pennsylvania investigation’s unresolved history resurfaced in lawsuits brought by five families of former patients against Saint Luke’s Hospital. The hospital argued that the claims were too old to proceed, but Lehigh County Judge Edward D. Reibman ruled that they remained relevant; Saint Luke’s ultimately settled with the families out of court. The settlement terms were sealed. Court materials described disagreements about what the hospital’s lawyers, managers, and nurses had known, including whether concern about diverted vecuronium had led to meaningful reviews of patient deaths. Those accounts preserve conflicting testimony rather than a single, uncontested institutional narrative.

The later confirmation came through Cullen’s confessions: he admitted killing, among others, the five deceased patients involved in those cases. Across the record, seven patients were specifically identified as having been killed by him at Saint Luke’s. That eventual disclosure sharply contrasts with the earlier inability of chart reviews and forensic examination to establish harm. It does not erase the evidentiary limits investigators faced at the time; instead, it shows how a case could contain repeated warnings and a substantial body of material while still lacking a prosecutable account of individual deaths.

Narrative significance

Pennsylvania connects an abandoned inquiry at Easton Hospital with the investigation, institutional reviews, and eventual legal aftermath surrounding Saint Luke’s Hospital. The sequence makes the difference between a warning sign and a provable crime concrete: a suspicious death, a drug in a blood sample, a nurse’s observation, a statistical imbalance, and a medication record each contribute information, but none automatically supplies the missing link between drug access and a specific patient’s death. The state’s investigative and legal institutions gradually assembled those fragments, while the hospital’s inconclusive reviews and the limits of retrospective chart analysis left consequential questions unresolved until Cullen confessed.