Pennsylvania State Police

The Pennsylvania State Police investigated suspected patient killings connected to Charles Cullen’s nursing work in Pennsylvania, carrying concerns from an earlier digoxin death at Easton Hospital into the inquiry at Saint Luke’s Hospital. Its work joined staff observations, medical records, coroners’ findings, and a forensic review into a case that exposed both a disturbing pattern and the difficulty of proving individual responsibility from incomplete hospital evidence.

Role and investigative scope

The Pennsylvania State Police entered the account through two connected investigations. One concerned a patient who died at Easton Hospital after digoxin was found in the patient’s blood; the other grew from reports of unusual deaths at Saint Luke’s Hospital. The material describes state troopers working with local police, coroners, prosecutors, hospital staff, and an outside pathologist. It does not present the agency as acting alone: information moved between institutions, and the investigation’s progress depended on what each could identify, preserve, and share.

The agency’s reach extended beyond a single hospital or one kind of evidence. Troopers examined staff accounts and patient histories, while coroners assessed causes and manners of death and prosecutors considered whether the evidence could support charges. That division of work mattered. Suspicion could identify where to look, but medical and forensic findings had to establish what had happened to a patient, and investigative records had to connect that event to a person.

The Easton lead

Six years before detectives pursued the Somerset cases, digoxin had been found in the blood work of a patient who died after a suspected overdose at Easton Hospital. Charles Cullen had been working there at the time. An investigation followed a couple of years later, and the Pennsylvania State Police opened a file, but the inquiry was eventually abandoned; the agency had no further information on Cullen when Danny Baldwin called to check his name.

The old file transformed a name from background research into a potentially significant connection. Baldwin learned that the Easton death involved the same drug that had become important in the wider investigation. The resemblance was striking enough to sharpen the inquiry, but it did not by itself establish that Cullen had caused the Easton patient’s death. The earlier case had not produced a finding that could settle that question, and the passage of time had left the lead as an unresolved part of the record rather than a ready-made answer.

A second Easton-related investigation illustrates how employment records could frustrate that kind of retrospective work. Northampton County coroner Zachary Lysek investigated the death of Ottomar Schramm, interviewing dozens of people involved in Schramm’s care across the nursing home and hospital. A forensic pathologist found pneumonia to be the cause of death and digoxin overdose a contributing factor; the death was nevertheless classified as accidental. Lysek remained suspicious but lacked evidence to take the matter further.

Three years later, an unnamed source told Lysek that the nurse mentioned by witness Kristina Toth might have been Cullen. Lysek contacted the Pennsylvania State Police. When he also asked Easton Hospital about Cullen’s employment, an administrator found no record of a Charles Cullen working there. That answer was technically accurate: Cullen had worked at Easton through Health Med One, a personnel agency, rather than as a direct hospital employee. The false lead in the employment search revealed a practical weakness in reconstructing medical staffing: a list limited to direct employees could omit someone who had cared for a patient through an agency.

Saint Luke’s: a staff report becomes an investigation

The Saint Luke’s inquiry began with a nurse’s dissatisfaction with the hospital’s response. Pat Medellin had seen unusual deaths on her unit and had also seen Cullen removed after diverting dangerous medications. She believed he was responsible for the deaths and pressed the hospital to act. The administration told her Cullen had not harmed patients and closed its investigation.

On August 29, 2002, Medellin took her concerns to an acquaintance who worked for the Easton, Pennsylvania, Police Department. The information passed from that officer to a captain, then to a coroner and the Lehigh County District Attorney’s Office. Pennsylvania State Police troopers subsequently questioned Saint Luke’s staff. The sequence shows how the case moved beyond the hospital only after an employee carried the concern outside its internal process; it also explains why the agency’s inquiry depended on a report that the hospital had not accepted as grounds for further action.

The interviews supplied converging observations, not a single conclusive eyewitness account. Lynn Tester recalled patients who had been recovering dying suddenly after Cullen changed their IVs. Robin Saulsberry described seeing him leave a patient’s room shortly before the patient unexpectedly coded and died; she also recalled his intense attention to the electrocardiogram monitor. Saulsberry, who held a doctorate in chemistry, suspected that a patient had received Pronestyl, a drug Cullen had been found to have removed from the medication closet.

The reported pattern could be compared with Cullen’s working hours. Tester calculated that he had 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 Cullen worked on the cardiac care unit, followed by six months without a code after he left. Such comparisons made the staff’s suspicions more substantial and directed attention to timing, drug access, and patient outcomes. They did not, on their own, prove that Cullen caused any particular death.

Forensic review, limits, and later findings

Coroners Zachary Lysek and Scott Grim examined medical charts as the case developed. Lysek worried that Cullen might be responsible for many deaths, but recognized that speculation could not substitute for scientific evidence. The Lehigh County District Attorney’s Office retained forensic pathologist Isidore Mihalakis, who had also worked on the investigation into Helen Dean’s suspicious death at Warren Hospital. Mihalakis reviewed seventeen patient charts selected by Saint Luke’s over several months, but the paperwork yielded nothing prosecutable.

The later account identifies limitations in that review: Mihalakis was not given a written list of the diverted medications and apparently did not speak with nurses or review their statements about Cullen. He could not conclude from the charts that Cullen had harmed anyone. This did not erase the staff’s accounts; it meant that the forensic review, as conducted, could not convert their suspicions into a medical finding linking Cullen to a specific death. The gap between a pattern that looked alarming and evidence capable of establishing individual causation remained central to the investigation.

Saint Luke’s later conducted further inquiries after the district attorney referred the matter to law enforcement, including an outside physician’s review of patient charts. Those inquiries still did not lead the hospital to conclude that Cullen had harmed patients. Cullen ultimately confessed to killing, among others, five decedents at Saint Luke’s who were at issue in the cases described; seven patients in total have been specifically identified as killed by him there. The outcome makes the earlier interviews and medical records newly consequential, while preserving the distinction between what investigators could establish at each stage and what became known through Cullen’s later confession.

Significance

The Pennsylvania State Police investigation brought separate clues into contact: a past digoxin death, a nurse’s account of suspicious deaths, staff observations about IV changes and patient crashes, and a chart review that failed to confirm the suspicions. The inquiry’s path shows why recognition of a recurring pattern is not the same as proof of a particular homicide. It also shows how the completeness of an investigation can depend on mundane records—such as whether a hospital’s employment search includes agency nurses—and on whether forensic reviewers receive the medication evidence and firsthand staff accounts needed to interpret patient charts.