Raj Persaud

Recently convicted of murdering seven babies and attempting to kill six others at the Countess of Chester Hospital between June 2015 and June 2016, neonatal nurse Lucy Letby has the grisly distinction of being the United Kingdom’s most prolific child serial killer. Over the course of Letby’s ten-month trial, believed to be the longest murder trial in UK history, prosecutors detailed how she had harmed the infants in her care by injecting air and insulin into their bloodstreams, infusing air into their abdomens, and dislodging their breathing tubes.

What would provoke a nurse, a caregiver by profession, to inflict such terrible suffering? Even after covering the trial and spending months in Letby’s presence, BBC journalist Judith Moritz struggled to understand her motivations. One text message hints at a possible god complex: “…sometimes I think, how do such sick babies get through & others just die so suddenly & unexpectedly?” Letby wrote. “Guess it’s how it’s meant to be.” But, in Moritz’s view, this does not provide a satisfying answer.

An examination of similar cases could offer insights into Letby’s psychological state. Serial-killer nurses, it turns out, are more common than many would like to believe. Consider Niels Högel, who admitted to killing 43 people while working as a nurse at two clinics in the northern German cities of Oldenburg and Delmenhorst between 2000 and 2005.

Högel, the most prolific serial killer in postwar Germany, embodies the gravity of the danger posed by a disturbed healthcare professional. Officials suspect that as many as 300 patients may have died by his hand.

As a psychologist explained during the trial, Högel did not seem to enjoy killing, nor did he do it for financial gain. Rather, Högel admitted to acting out of boredom, as well as a deep yearning to flaunt his superior resuscitation skills. After misusing medication to trigger cardiac arrest, reviving a patient was an act of personal aggrandisement, he was even nicknamed “Resuscitation Rambo” by admiring colleagues.

In his ruling, the judge cited a psychologist’s assessment that the former nurse was a narcissist who liked to portray himself as a hero. While Högel relished the excitement of resuscitation, and sometimes even succeeded in reviving patients, at least 87 died. Likewise, when Letby was on duty, infants in the Countess of Chester Hospital often inexplicably required emergency resuscitation.

Serial-killer nurses tend to use injectable medications like insulin, opioids and potassium chloride because they can be difficult to identify after death, as most healthcare professionals would know. Beverley Allitt, for example, killed at least two babies by administering large doses of insulin while working as a nurse at Grantham and Kesteven Hospital in Lincolnshire, England, between February and April 1991. She was ultimately convicted of murdering four infants in total, attempting to murder another three, and causing grievous bodily harm to six more.

One theory invoked in the Allitt case is that she suffered from Munchausen syndrome by proxy, a rare and controversial diagnosis in which a caregiver inflicts harm on a child to gain personal sympathy. It is similar to one of the possible motivations that the prosecution in the Letby case identified: the nurse was attacking babies to attract the attention of a doctor with whom it is alleged she had become infatuated.

Insulin injections were also Ontario nurse Elizabeth Wettlaufer’s weapon of choice. In September 2016, Wettlaufer admitted to killing eight long-term care residents and attempting to murder six others. Wettlaufer’s crimes were uncovered only because she spontaneously confessed while receiving drug-addiction treatment. She had never been under any suspicion, and it would have likely remained that way had she not implicated herself.

Wettlaufer may also have admitted the truth to a childhood friend, telling him: “A lot of what I’ve done has been triggered by my anger issues.” But how could killing people under your care become a means of acting out anger issues? Who hasn’t experienced homicidal urges against frustrating colleagues, or maybe undeserving patients blocking your precious beds, if you are a clinician struggling to run an under-resourced service?

The nature of their jobs put these health-care professionals in closer proximity to death than most ordinary people; regularly dealing with mortality could have warped their perspective. Or perhaps they were always drawn to the emotional intensity, and heightened bonding, produced in any team confronted with the ultimate crisis. In any event, because psychological screenings are secondary to technical skills when hiring in medical fields, and all these serial-killer nurses seemed to excel technically, dangerous pathology likely would not have been flagged when it’s often difficult to find the basically clinically competent.

None of the experts giving evidence during the Letby trial presented a coherent theory explaining her motivation; maybe even expert clinicians remain in denial about the demons in their midst. Although other “angels of death” can provide clues about what gives rise to such evil, the most worrying implication of the “god complex” explanation is that the next “angel” more likely will be found among the better, or even the best, nurses. And it will always be counterintuitive to search for a killer among the healers you most rely on in an emergency.

Raj Persaud is a psychiatrist and the author of The Mental Vaccine for COVID-19 (Amberley Publishing, 2021). Copyright: Project Syndicate, 2023. www.project-syndicate.org