New Jersey is presented as an institutional landscape shaped by hospitals, investigators, and state law. The state’s significance in the account lies in the path from suspicious patient emergencies at Saint Barnabas Medical Center to the later investigation at Somerset Medical Center, and then to civil settlements and new reporting measures. Across that path, medical findings could expose a pattern of harm, but the evidence needed to establish responsibility—and the systems meant to act on it—did not always move at the same speed.

Hospitals and the first warning signs

At Saint Barnabas Medical Center, unexplained collapses began to look less like isolated medical crises. Fred Belf became violently ill after receiving heparin; when staff stopped the infusion, he improved, and his intravenous bag was sent for testing. The bag tested positive for insulin. Its exterior bore tiny needle marks, including several along its edges, a pattern that did not resemble the ordinary punctures made while connecting a bag to a patient’s line. The finding raised the possibility that intravenous bags had been deliberately tampered with in the hospital’s storage room.

The laboratory results widened the concern beyond the bags themselves. Patients who had seemed to become sudden, inexplicable diabetics had exceptionally high insulin levels, much of it foreign insulin that their bodies had not produced. Investigators first considered routine explanations, such as a misread prescription or a mislabeled vial. But the patient charts contained neither orders for insulin nor nursing notations that it had been administered. The absence of documentation left a troubling alternative: the drug may have been given without authorization, rather than as the result of an ordinary treatment error.

To see whether the incidents shared a human link, investigators compared patient emergencies with nursing schedules. Only three nurses had been working at every code they examined, and Charles Cullen drew particular attention. When questioned, he appeared markedly unconcerned; eventually, at a sit-down meeting, he refused to answer questions. The account thus places New Jersey’s first warning signs in a specific institutional setting: suspicious laboratory evidence, records that failed to explain it, and a staff investigation that narrowed attention to a nurse whose conduct did not settle the question.

Somerset and the limits of proof

The investigation later centered on Somerset Medical Center and the Somerset County Prosecutor’s Office. A toxicology report on Reverend Florian Gall found substantial digoxin in several tissues, while testing found none of roughly ninety-six other drugs examined. The report allowed investigators to classify the death as homicide and identify digoxin as the cause. It established that a murder had occurred, but it did not by itself establish who had administered the drug.

That distinction shaped the Somerset investigation. Pyxis records and Cerner printouts connected Cullen to access to medication and to activity across the ward, but the investigative team recognized that access was not proof of murder. Cullen could claim that medication orders were legitimate, and cancellations in the dispensing records could be characterized as mistakes. The electronic trail created a way to test suspicions; it could not alone resolve whether those suspicions were true. Investigators therefore sought evidence that would connect Cullen to a crime more directly, including a confession.

The case also crossed county and state lines. In a separate search, investigators and prosecutors searched Cullen’s house and car in Bethlehem, Pennsylvania, looking chiefly for controlled drugs that might have been stolen from a hospital. They found only ordinary medications, and analysis revealed nothing stronger than cold medicine. The fruitless search illustrates how the inquiry extended beyond New Jersey while remaining tied to its investigation: movement across jurisdictions expanded the search for evidence, but did not guarantee a result.

A warning that reached another hospital

The account shows concern about Cullen extending beyond the New Jersey institutions where the investigation had developed. After learning that he had taken a new nursing job at Montgomery Hospital, Tim Braun called the hospital’s vice president. He introduced himself as a Somerset County homicide sergeant and urged her to remove Cullen from that night’s schedule if she wanted to protect her patients. Braun did not disclose Cullen’s identity as a suspect or provide his background; he framed his warning narrowly, aware that making the call itself might create legal risk. The vice president promised to act immediately.

The episode gives New Jersey’s investigative role a reach beyond the state’s borders. Braun’s warning was a practical attempt to interrupt a possible opportunity for further harm, but it also exposed the limits imposed by what he believed he could safely say. The book presents the call not as a formal resolution of the case, but as an urgent intervention made while the investigation still lacked a straightforward public account of its suspicions.

Settlements and legislative response

After the criminal proceedings, families of victims or potential victims sued the hospitals where Cullen had worked. The suits against hospitals in New Jersey were settled out of court, and the files and settlement terms remained sealed. The account also notes that no hospital administrator faced criminal proceedings. The settlements therefore mark a civil aftermath without supplying a public record of the terms or a criminal finding against hospital leadership.

The New Jersey State Legislature responded with measures intended to strengthen reporting. The 2004 Patient Safety Act increased hospitals’ responsibility to report serious preventable adverse events to the New Jersey Department of Health and Senior Services. The following year, the Enhancement Act required hospitals to report certain limited information about healthcare professionals to the Division of Consumer Affairs, including the Board of Nursing, and to retain records of patient-care complaints and disciplinary actions for seven years.

The measures also carried a notable imbalance. Hospitals complying with the reporting provisions would not be liable for civil actions arising from their reports, but the account states that there was no penalty or civil liability for failing to comply. Thirty-five other states adopted the measures. New Jersey’s response thus appears both consequential and bounded: it formalized reporting duties and record retention, while leaving noncompliance without a stated penalty. In the book’s institutional portrait, the state is where clinical warning signs, law-enforcement demands, hospital interests, and legislative reform meet—and where improved rules do not erase the failures that made them necessary.