Saint Luke’s Hospital’s handling of concerns about Cullen diverting medication

Saint Luke’s Hospital’s handling of concerns about Cullen diverting medication became a study in the distance between detecting a drug-control problem and confronting the possibility that patients had been harmed. After unauthorized vecuronium bromide was found and a nurse raised a specific clinical concern, the hospital’s investigation repeatedly failed to identify suspicious deaths. Its responses included closing the inquiry, dismissing further warnings, ordering additional chart reviews, and referring Cullen to the state nursing board. Later, Charles Cullen confessed to killing five patients involved in the civil cases; seven patients have been specifically identified as killed by him at Saint Luke’s.

The inquiry and its limits

The hospital’s internal investigation began against a background of diverted vecuronium and questions about whether the drug had been administered to patients. Attorney Paul Laughlin recalled proposing that patient charts be reviewed to determine whether the diverted medication had been improperly given and caused harm. But the record does not establish clearly what Laughlin learned during his investigation or what conclusions he reached. His account was that no particularized suspicion of Cullen harming patients had been brought to his attention; interview notes and later testimony, however, left room for a different inference.

The uncertainty was not simply whether medication had gone missing. The inquiry had to establish whether it had reached patients and whether any resulting harm could be linked to Cullen. Those are distinct questions, and the later civil record exposed how differently participants understood what the investigation had established. The evidence presented in the suits did not yield one uncontested account of what Laughlin knew, or when he knew it.

Medellin’s warning and the closure

Nurse Patricia Medellin said she met with Laughlin on the night he confronted Cullen and that he had asked her to call if she had further thoughts. After learning that opened vecuronium containers had been found in receptacles and hearing other nurses’ concerns that patients might have been harmed, she telephoned Laughlin on or about June 7, 2002. She described a possible clinical pattern: unauthorized vecuronium could slow patients’ heart rates, followed by codes when their hearts stopped. She also told him that no patients in the CCU at the time should have been receiving the drug.

According to Medellin’s deposition, Laughlin told her the investigation was closed and that he was confident Cullen was not harming patients. She challenged that confidence by pointing to work she understood had not been done: comparing the drugs delivered by the pharmacy with those actually used on patients, and comparing the numbers of patient codes on day and night shifts when Cullen was working. She testified that Laughlin nevertheless said he was certain Cullen was not hurting anyone and that the investigation was not open for further review. The episode turns on a sharp contrast: Medellin offered a mechanism by which the diverted drug might have harmed patients, while the hospital attorney’s reported response treated the inquiry as settled.

Warnings within the hospital

Medellin also testified that she took her concerns to her supervisors. Thelma Moyer, the clinical coordinator, and Ellen Amedeo, the CCU nurse manager, allegedly dismissed them and told her the investigation was closed. Afterward, Medellin compared the list of patients who had died in the CCU with Cullen’s shifts and concluded that a disproportionate number had died while he was on duty. She did not present her list to the supervisors: she feared repercussions, particularly after what she described as their lack of receptivity and almost angry responses to her earlier concerns.

That sequence matters because the staff member who made the comparison did not regard the pattern as proof, but saw it as information worth pursuing. Her fear of consequences helped keep that information from becoming part of the hospital’s review. The account therefore describes more than a disagreement over medical interpretation: it shows how the response to an internal warning could inhibit a nurse from bringing forward additional analysis.

Further reviews and an unresolved conclusion

After returning from leave in July 2002, Saint Luke’s general counsel Seymour Traub directed Laughlin to prepare a report and ordered further chart reviews. Risk Manager Rader and Nursing Supervisor Koller were assigned to examine charts for patients who had died over the weekend when the diverted medications were found. Koller testified that she had never performed a similar review and did not know its purpose when asked to examine the charts. Rader, for her part, testified that Laughlin said he could find no evidence of foul play. Rader and Koller identified neither suspicious vecuronium administration nor suspicious deaths, and the additional review did not uncover Cullen’s involvement in patient deaths. The hospital’s chief executive officer then referred him to the Pennsylvania State Nursing Board for follow-up as it saw fit.

After the district attorney notified the hospital that the matter had been referred to law enforcement, Saint Luke’s undertook further investigations, including a patient-chart review by an outside physician. That review also failed to lead the hospital to conclude that Cullen had harmed patients. The later confession changes the meaning of these negative findings without erasing what they were: the reviews did not identify the killings at the time, while Cullen ultimately confessed to killing, among others, the five decedents at issue in the civil cases. Seven Saint Luke’s patients have been specifically identified as his victims.

Civil litigation and the record left behind

Five families of former patients brought civil suits against Saint Luke’s. The hospital argued that the cases were too old to proceed under the two-year statute of limitations; Lehigh County Judge Edward D. Reibman ruled that the claims remained relevant. The hospital ultimately settled with the families out of court, and the specific settlement terms are sealed. Court records nonetheless preserved testimony about what staff and counsel had been told, what reviews were undertaken, and how the hospital described its conclusions.

The record does not support collapsing every uncertainty into a single claim that each reviewer knew Cullen was killing patients. It does document repeated opportunities for concerns to be tested against clinical patterns and medication use, alongside reported assurances that the investigation was closed or that no evidence of foul play existed. The eventual confessions stand in stark contrast to the hospital’s inability to identify patient harm through its own inquiries, making the handling of the warnings—and the limits of the reviews—central to the episode’s significance.