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Lucia de Berk, often called Lucia de B. or Lucy de B (born September 22, 1961 in The Hague, Netherlands) is a Dutch licenced paediatric nurse, who was subject to a miscarriage of justice.

She was sentenced to life imprisonment in 2003 for four murders and three attempted murders of patients in her care. After an appeal, she was convicted in 2004 of seven murders and three attempts. Her conviction was controversial in the media and amongst scientists, and was questioned by investigative reporter Peter R. de Vries.

In October 2008, the case was reopened by the Dutch supreme court, as new facts had been uncovered that undermined the previous verdicts. De Berk was freed, and her case was re-tried; she was exonerated in April 2010.

Charges

As a result of an unexpected death of a baby (Amber) in the Juliana Kinderziekenhuis (English: Juliana Children's Hospital, JKZ) in The Hague on 4 September 2001, earlier deaths and cardiopulmonary resuscitations were scrutinised.

Between September 2000 and September 2001 there appeared to have been nine incidents, which earlier had all been thought unremarkable but now were considered medically suspicious. Lucia de Berk had been on duty at the time of those incidents, responsible for patient care and delivery of medication. The hospital decided to press charges against her.

Life sentence

On 24 March 2003, De Berk was sentenced by the court in The Hague to life imprisonment for the murder of four patients and the attempted murder of three others. The verdict depended in part on a statistical calculation, according to which the probability was allegedly only 1 in 342 million that a nurse's shifts would coincide with so many of the deaths and resuscitations purely by chance. De Berk was however only sentenced in cases where, according to a medical expert, other evidence was present or in which, again according to a medical expert, no natural causes could explain the incident.

In the appeal on 18 June 2004, De Berk's conviction for the seven murders and three attempted murders was upheld. The crimes were supposed to have taken place in three hospitals in The Hague: the Juliana Child Hospital (JKZ), the Red Cross Hospital (RKZ) and the Leyenburg Hospital, where De Berk had worked earlier.

In two cases the court concluded that there was proof that De Berk had poisoned the patients. Concerning the other cases the judges considered that they could not be explained medically, and that they must have been caused by De Berk, who was present on all those occasions.

The idea that only weaker evidence is needed for the subsequent murders after two have been proven beyond reasonable doubt has been dubbed chain-link proof by the prosecution and adopted by the court. At the 2004 trial, besides a life sentence, De Berk also received detention with coerced psychiatric treatment, though the state criminal psychological observation unit did not find any evidence of mental illness.

Important evidence at the appeal was to be the statement of a detainee in the Pieter Baan Center, a criminal psychological observation unit, at the same time as Lucia de Berk, that she had said during outdoor exercise: "I released these 13 people from their suffering". However, during the appeal, the man withdrew his statement, saying that he had made it up.

The news service of the Dutch Broadcasting Foundation (NOS) and other media that followed the process considered the withdrawal of this evidence to be a huge setback for Public Prosecution Service (OM). A series of articles appeared over the following years in several newspapers, including Vrij Nederland and the Volkskrant, raising doubts about the conviction.

The case was next brought to the Netherlands Supreme Court, which ruled on 14 March 2006 that it was incorrect to combine life imprisonment with subsequent psychiatric detention. Other complaints were not taken into consideration, and the evidence from a re-analysis by a Strasbourg laboratory was not considered relevant. The Supreme Court gave the matter back to the Court in Amsterdam to pass judgement again, on the basis of the same factual conclusions as had been made before. Some days after the ruling of the Supreme Court, De Berk suffered a stroke and was admitted to the hospital of Scheveningen prison.

On July 13, 2006, De Berk was sentenced by the Court of Appeal in Amsterdam to life imprisonment, with no subsequent detention in psychiatric care.

Doubts

A committee of support for Lucia de Berk was formed that continued to express doubts about her conviction. Philosopher of science Ton Derksen, aided by his sister, geriatrician Metta de Noo-Derksen, wrote the Dutch language book Lucia de B: Reconstruction of a Miscarriage of Justice. They doubted the reasoning used by the court and the medical and statistical evidence that was presented. See also the English-language article Derksen and Meijsing (2009).

Chain-link proof

Of the seven murders and three attempted murders finally attributed to De Berk by the court, the court considered two proven by medical evidence. According to the court, De Berk had poisoned these two patients. The court then applied a so-called chaining-evidence argument. This means that if the several attempted or actual murders have already been established beyond reasonable doubt, then much weaker evidence than normal is sufficient to establish that a subsequent eight “suspicious incidents” are murders or attempted murders carried out by the same defendant.

For the two murders found proven by the court in The Hague, many experts do not exclude a natural cause of death. In the case where digoxin poisoning was alleged, and supposedly detected by independent measurements in two Dutch laboratories, the method used in those laboratories did not exclude that the substance found was actually a related substance naturally produced in the human body. The Strasbourg laboratory used a new method, a test of high specificity and sensitivity, and did not support the digoxin overdose hypothesis.

In the second case, the intoxication could have been an overdose caused by a faulty prescription. For both children, it was not clear how and when De Berk was able to administer the poison. Regarding the digoxin case, the prosecution gave a detailed reconstruction of the timing. However, other parts of the evidence discarded by the prosecution showed by the time-stamp on a certain monitor that at the alleged moment of poisoning De Berk was not with the patient at all, and that the specialist and his assistant were with the patient at that time.

The prosecution initially charged De Berk of causing thirteen deaths or medical emergencies. In court, the defence was able to show definitively that De Berk could not have been involved at all in several of these cases. For instance, she had been away for several days; the idea that she was there was due to administrative errors.

Furthermore, all deaths had been registered as natural, with the exception of the last event. Even that last event was initially thought to be a death by natural causes by the doctors responsible for the child, but within a day, on being connected by other hospital authorities with De Berk and her repeated presence at recent incidents, it became classified as an unnatural death.

Statistical arguments

The court made heavy use of statistical calculations to achieve its conviction. In a 2003 TV special of NOVA, Dutch professor of Criminal Law Theo de Roos stated: "In the Lucia de B. case statistical evidence has been of enormous importance. I do not see how one could have come to a conviction without it". The law psychologist Henk Elffers, who was used by the courts as expert witness on statistics both in the original case and on appeal, was also interviewed on the programme and stated that the chance of a nurse working at the three hospitals being present at the scene of so many unexplained deaths and resuscitations is one in 342 million.

This value was wrongly calculated. If one wishes to combine p-values (right tail probabilities) of the statistical tests based on data from three separate wards, one must introduce a correction according to the number of tests, as a result of which the chance becomes one in a million.

Biased reporting meant that this lower figure was invalid. Events were attributed to De Berk once suspicions began to fall on her, which could not have had anything to do with her in reality. The statisticians Richard D. Gill and Piet Groeneboom calculated a chance of one in twenty-five that a nurse could experience a sequence of events of the same type as Lucia de Berk.

Philip Dawid, Professor of Statistics at the University of Cambridge (UK), stated that Elffers “made very big mistakes. He was not sufficiently professional to ask where the data came from and how accurate the data were. Even granted the data were accurate, he did some statistical calculations of a very simplistic nature, based on very simple and unrealistic assumptions. Even granted these assumptions, he had no idea how to interpret the numbers he got”. Professor DasGupta, a toxicologist from the University of Houston, (Texas, US) commented on the complete lack of toxicological evidence with regard to the claimed digoxin intoxication.

The use of probability arguments in the De Berk case was discussed in a 2007 Nature article by Mark Buchanan. He wrote:

The court needs to weigh up two different explanations: murder or coincidence. The argument that the deaths were unlikely to have occurred by chance (whether 1 in 48 or 1 in 342 million) is not that meaningful on its own - for instance, the probability that ten murders would occur in the same hospital might be even more unlikely. What matters is the relative likelihood of the two explanations. However, the court was given an estimate for only the first scenario.

At the initiative of Richard D. Gill, a petition for a reopening of the Lucia de Berk case was started. On 2 November 2007 the signatures were presented to the Minister of Justice, Ernst Hirsch Ballin, and the State Secretary of Justice, Nebahat Albayrak. Over 1300 people signed the petition.

Diary

Lucia de Berk's diary also played a role in her conviction. On the day of death of one of her patients (an elderly lady in a terminal stage of cancer) she wrote that she had 'given in to her compulsion'. She wrote on other occasions that she had a 'very great secret' and that she was concerned about 'her tendency to give in to her compulsion'. De Berk has stated that these were references to her passion for reading tarot cards, which she explains she did secretly because she did not believe it appropriate to the clinical setting of a hospital. However, the court decided they were evidence that she had euthanised the patients.

According to the court, the reading of cards does not accord with a 'compulsion' nor with 'perhaps an expression of fatigue', as she described it at the time. De Berk's daughter Fabiënne stated in an interview on the television program Pauw & Witteman that some of her mother's notes in the diaries are 'pure fiction' which she intended to use in writing a thriller.

Dutch Forensic Institute Report

After the appeal proceedings were closed, but before the judges delivered their verdict, the Public Prosecution Service received, via the Netherlands Forensic Institute (NFI), a report from a forensic laboratory in Strasbourg on the evidence for digoxin poisoning. The report subsequently lay in a drawer of the NFI for two years, but it did turn up in time for the final evaluation of the case before the Supreme Court.

According to the Public Prosecution, the report contained no new facts, but according to De Berk's defence the report proved that there was not a lethal concentration of digoxin in the first case. The Supreme Court accepts the facts reported by the judges at the appeal court, and is concerned only with jurisprudence and correctness of the sentence, given those facts. The report therefore was not admitted into the final considerations of the sentence given to De Berk.

Posthumus II Commission

In general, in the Dutch legal system, cases are not re-opened unless a new fact, called a novum, is found. New interpretations by experts of old facts and data are generally not considered a novum.

In spite of this, Ton Derksen submitted his and Metta de Noo's research on the case to the Posthumus II Commission. This ad hoc, non-permanent commission examines selected closed cases and looks for evidence of errors in the police investigation indicating "tunnel vision" and misunderstanding of scientific evidence.

Derksen pointed out that the medical experts who had ruled out the possibility of death by natural causes had not been given all relevant information, that the hypothesis of digoxin poisoning was disproven, in particular by the Strasbourg analysis, and that the statistical data were biased and the analysis incorrect, and the conclusions drawn from it invalid.

The commission announced on 19 October 2006 that this was one of the few cases it would consider in detail. Three men, recruited by the Public Prosecution service from the full Posthumus II committee, considered the following matters, having been instructed to focus on possible blemishes in the criminal investigation:

Whether there were also unexplained deaths when Lucia de Berk was not present, unknown to the public prosecutor.

Whether the expert witnesses were given all relevant available information.

Whether scientific knowledge now threw a different light on the digoxin question.

In October 2007, the commission released its report and recommended that the case be re-opened. They concluded that the case had been seriously marred from the start by tunnel vision. In particular, the same persons, chosen from close circles of the hospital authorities rather than on the basis of recognised relevant expertise, had first helped the hospital in its internal investigations, then had advised the police, and finally had appeared before the courts as independent scientific experts. They noted that there was strong disagreement concerning whether or not baby Amber had died of digoxin poisoning.

On 2 April 2008, De Berk was released for three months because after re-examination of the death of the last "victim", a natural death could no longer be ruled out.

Case reopened

On 17 June 2008, the Advocate-General of the Supreme Court, G. Knigge, made a request for the Supreme Court to reopen the case. On 7 October 2008 the court acceded to his request, acknowledging that new facts uncovered by Knigge substantially undermined earlier evidence.

In particular, an independent team of medical researchers with access to all available medical information had reported to Advocate-General Knigge that the death which sparked the case appears to have been a natural death. The key toxicologist of the earlier trials had agreed with the new medical findings, pointing out that at the time of the trial, the court had only given him partial information about the medical state of the child. De Berk's statements about her doings on the night of that child's death had also been shown to be correct; indeed, during the period in which the courts had earlier concluded that she must have administered poison, the baby was actually being treated by a medical specialist and his assistant.

De Berk was allowed to remain free while awaiting a retrial at the Court of Arnhem, which first adjourned while further investigations were made. The public prosecution had asked for extensive new forensic investigations, but this request was turned down by the court. Instead it commissioned further independent medical investigations into the cases of two more of the children, again allowing a multidisciplinary medical team access to all possible medical data concerning the children.

At a session on 9 December 2009, the court stated that new integral medical investigations of the last nine months had confirmed that the cases of Amber, Achmed and Achraf were all natural deaths/incidents. These were the only cases where there was previously claimed proof of De Berk's culpability.

The appeal hearing ended on 17 March 2010. Witnesses heard on the final day stated that the deaths at the Juliana Children's hospital were natural, sometimes caused by wrong treatment or bad hospital management, and sometimes unexpected because of faulty medical diagnosis. The behaviour of the nurses, including De Berk, during a couple of medical crises turned out to have been swift and effective, saving lives on several occasions. The Public Prosecution capitulated, formally requesting the court to deliver a not guilty verdict. On 14 April 2010, the court delivered the not guilty verdict.

It was the new finding of allegedly very high digoxin levels in autopsy blood in a child who was under the care of Lucia de Berk that resulted in her second conviction and life sentence for murder, i.e., at the 2004 appeal hearings. Moreover, this was despite it already being known at that time that digoxin levels on autopsy blood should be expected to be far higher than blood digoxin in a living patient. Living heart cells extract digoxin from the blood, concentrating it at levels up to 1,000 times the therapeutic digoxin levels in the circulating blood. Heart cells die within minutes after death, allowing this digoxin to diffuse into the blood in the heart and in the surrounding large blood vessels – the sites from which blood is extracted by pathologists for blood chemistry analysis. Moreover, the autopsy blood did not originate from a proper blood sample but was squeezed out of a piece of gauze left inside the body after two autopsies had disturbed all the organs.

Without the misinterpretation of the autopsy blood digoxin levels, there would not have been any consideration of digoxin poisoning – and no criminal investigation would have occurred. Furthermore, a chemical used in pharmaceutical natural rubber (in syringes, ampoule seals and I.V. apparatus) manufacture, MBT (mercapto-benzothiazole), leaches into injections (Ref. 1)(Ref. 1: J.H. Meek and B.R. Pettit, Avoidable accumulation of potentially toxic levels of bezothiazoldes in babies receiving intravenous therapy;Lancet, 1985, Vol. 2, pp 1090–1092). It can cause death as a cumulative toxin (Ref. 1), or from anaphylaxis. MBT is measured as digoxin (Ref. 2:J.J.Reepmeyer, Y. H. Jule, "Contamination of Injectable solutions with 2-mercaptobenzothiazole from rubber closures", The Journal of Pharmaceutical Sciences , Vol. 72, 1983, pp 1302–1305), using the test methods applied in the criminal investigations of Lucia de Berk and of a Canadian nurse, Susan Nelles.

Susan Nelles, was similarly charged with murder of children by digoxin poisoning at the Toronto Hospital for Sick Children in 1981. She was not convicted because, as in the de Berk case, all the evidence was circumstantial. It was not until 1993, that the causes for high digoxin on autopsy blood were explained in the Canadian Nurse Journal. The causes of high autopsy blood digoxin are discussed thoroughly in a 2011 book, “The Nurses are Innocent – The Digoxin Poisoning Fallacy” (Dundurn Press, Toronto). This book presents facts in defense of Susan Nelles which apply similarly to the false charge of digoxin poisoning directed against Lucia de Berk.

Compensation

On 12 November 2010, it was revealed that De Berk had received an undisclosed amount of compensation from the Ministry of Justice. The news was first broadcast by a local TV station in the West of the Netherlands. It was later confirmed by the ministry to the Dutch news agency ANP.

Timeline

4 September 2001

8.00 hrs Nurse approaches superior – she is concerned about frequency of resuscitations during Lucia's shifts. It just cannot be coincidence…

16.00 hrs Contact with the police.

5 September 2001

Police begin interviewing nursing staff and doctors.

17 September 2001

Director Smits of Juliana Children's Hospital and Red Cross Hospital files official complaint with the police – 5 murders and 5 attempted murders.

13 December 2001

Lucia is arrested and remanded in custody.

24 March 2003

Court in the Hague sentences Lucia to life imprisonment for 5 murders and 2 attempted murders.

18 June 2004

High Court of the Hague sentences Lucia to life on 7 counts of murder and 3 of attempted murder. Lucia also gets TBS (is made a ward of court with mandatory psychotherapy) – an instrument aimed at rehabilitation.

14 March 2006

Court of Appeal refers case back to the Court of Amsterdam – judgement is upheld but point in law must be clarified – is TBS compatible with a life sentence?

13 June 2006

Court of Amsterdam rules TBS is incompatible with life imprisonment. Amends sentence to just life.

27 July 2006

Case is submitted to the Buruma Committee (assesses merit of referring case to Committee Evaluation Closed Criminal Cases – CEAS).

18 October 2006

Board of Procurators General accepts Buruma Committee recommendation of further investigation in the case of Lucia de B. The Grimbergen triumvirate is set up to carry out the brief. It consists of M.S. Groenhuijsen (Professor of Criminal Law at Tilburg University), P. Vogelzang LL.M (former head of the Utrecht District police and other offices), J.W.M. Grimbergen LL.M (Assistant Procurator General with the Arnhem Office of the Public Prosecutor, Chairman).

29 October 2007

Grimbergen Report recommends that Public Prosecutors initiate a request for judicial review and requests further investigation.

29 October 2007

Public Prosecutor forwards request the same day to the Supreme Court Procurator General, who promises a response in two to three weeks.

2 November 2007

Petition to reopen Lucia's case handed to the Dutch Minister of Justice and his Undersecretary.

13 December 2007

Undersecretary Albayrak denies request temporarily to suspend Lucia's detention (on grounds of health).

14 December 2007

Petition appears as advertisement in the NRC newspaper.

5 January 2008

Light for Lucia torch procession at Nieuwersluis prison.

14 January 2008

Undersecretary of Justice informs Parliament of her refusal temporarily to suspend Lucia's detention.

15 January 2008

Lucia and her lawyer Ton Visser appeal the Undersecretary of Justice's decision.

7 February 2008

Theatre play "Lucy, a monster trial" premieres in Amsterdam.

2 April 2008

Attorney General of the Supreme Court, G. Knigge LL.M presents the Board of Procurators General his enquiry, which draws the conclusion that the argumentation to prove digoxin poisoning is untenable.

The Minister of Justice grants Lucia temporary suspension of her sentence for three months. In the morning Lucia leaves Nieuwersluis prison – after more than six years of detention.

17 June 2008

Attorney General Knigge presents his official demand for revision to the Supreme Court.

7 October 2008

The Supreme Court decides to reopen Lucia's case and refers it to the Court in Arnhem.

26 January 2009

Police searches the house of a niece of Lucia on an anonymous tip for diary fragments that were never missing. Nothing found.

5 February 2009

At the Court in Arnhem the Public Prosecutor requests a full investigation. Lucia's lawyer Franken doubts the purpose of this.

19 February 2009

Court in Arnhem orders a limited investigation.

9 December 2009

The new rapports confirm that digoxine poisoning is highly unlikely. The Public Prosecutor rests its case.

17 March 2010

The Court in Arnhem hears the case. Lucia expected to be present. Dutch national television covers the trial.

14 April 2010

Final verdict in the case of Lucia de Berk: Acquitted

Nurse accused of killing 13 patients insists she's innocent as trial ends

Canadian Press

Tuesday, September 24, 2002

THE HAGUE (AP) - A Dutch nurse accused of murdering 13 patients with drug overdoses insisted she is innocent Tuesday, saying her love for life is so vast she could never kill another person.

Lucy Quirina de Berk's comments brought to a close the five-day trial and judges went into deliberations. They will issue their verdict Oct. 8 and sentence de Berk if she is found guilty. In a final appeal to the court, de Berk, who spent her teenage years in Canada, said prosecutors had unfairly portrayed her as a calculating killer and that she isn't the evil person they made her out to be. "It is true that I often questioned my own life," de Berk told the panel of three judges. "But I never questioned that of another."

"My mother always said I was a difficult and she was right, but to say I killed people just isn't true."

De Berk, who has a history of depression and worked as a prostitute in Vancouver and the Netherlands, has been described by prosecutors as a sociopath who skilfully killed her patients with lethal overdoses of medication for 4½ years.

"We cannot predict what the court will rule," said prosecution spokeswoman Astrid Rijsdorp. "But we are coinvinced she took their lives," she said.

De Berk has admitted lying under oath about her credentials and stealing copies of patient records. Her lawyer Ton Visser argued Tuesday that those offences can't be accepted by the court as proof of an intent to kill.

Visser called for the dismissal of charges, arguing that the prosecution's case was sloppy and inconclusive.

The 41-year-old suspect has been charged with 18 counts of murder and attempted murder at four hospitals in the Hague area. She is a suspect in several other cases, but prosecutors said they didn't have enough evidence to prove her involvement.

De Berk's alleged victims, ranging from infant children to a 91-year-old Chinese judge at the United Nations war crimes tribunal, died between 1997 and 2001 in varying circumstances that puzzled medical experts who testified in her trial.

The defendant's brother, who gave a statement to investigators, called his sister a good liar and said he believed she was capable of killing. Several colleagues were quoted as saying de Berk had an unhealthy attachment to terminally ill patients.

Prosecutors called an FBI expert on serial killers to sketch a profile of the "typical" culprit in multiple murder cases and a toxicologist to explain how her alleged victims had died.

In nearly all cases, chronically ill patients turned blue and died suddenly and unexpectedly while de Berk was on duty. A number of them, including a six-month-old girl successfully operated for heart trouble, had been expected to return home soon.

But the fact that people died while in de Berk's care isn't enough to implicate her in murder, Visser argued. "Coincidence exists," he said.

"If people are ill and are deprived of oxygen they discolour, that doesn't have to mean it was Lucy's fault," he said.

None of the witnesses directly linked de Berk to the deaths or said they were sure she had committed the crimes in her indictment.

Further countering prosecution allegations, Visser cited witness statements describing de Berk as a caring, competent and involved member of her hospital team. Her performance, he said, had not been doubted until prosecutors opened a criminal investigation in Sept. 2001.

De Berk described her difficult youth with alcoholic parents who she said were unable to give her attention. After dropping out of high school and breaking from her family, she was tricked into prostitution and later robbed and beaten by customers.

On Monday, prosecutors requested that she be sentenced to life imprisonment, saying she is a danger to society.

"They have portrayed me as a bad person and I'm just not like that," de Berk told the court in her final plea.

"I love life and would never take that away from anyone," she said.

Dutch nurse 'killed 13 by lethal injection'

Hague court hears woman deny hospital murders

By Andrew Osborn - Guardian.co.uk

September 18, 2002

A Dutch nurse accused of carrying out a killing spree on patients in her care went on trial yesterday for the murder of 13 people, including four babies.

Lucy Isabella Quirina de Berk, 40, allegedly administered lethal injections of morphine or some other drug to at least 13 patients. She is charged with the attempted murder of five others.

The deaths occurred between 1997 and 2001 at three different hospitals in the Hague.

The victims were aged between two months and 91 years and prosecutors claim that Ms De Berk deliberately preyed on the very young and the very old so as not to arouse suspicion. She was, they say, "obsessed with death" and a psychopath.

One of the victims was a 91-year-old Chinese judge at the Yugoslav war crimes tribunal.

Rene Elkerbout, a spokesman for the Hague district court, where the case is being heard, says it is the most serious murder trial the city has ever seen: "Thirteen victims is a record for us. We've never had anything like this before."

Ms De Berk denies the charges and yesterday, on the opening day of her trial, she tried to pin the blame on negligent doctors whom she claimed had failed to realise how seriously ill the patients in her care were.

One of the 13 people who died under her supervision was a physically and mentally handicapped six-year-old Afghan boy, Ahmad Noory, who died as a result of a lethal overdose of sleeping medication. Yesterday Ms De Berk denied she had killed the boy.

"I have a clear conscience. I didn't do a thing," she told the presiding judge, Jeanne Kalk. "Of course it [his death] is strange but I don't know how it happened.

"I warned the doctor that the child was very ill and nothing was done. Nobody did anything when I told them Ahmad had stopped responding and couldn't be woken up."

It was the first time that Ms De Berk had broken her silence on the case since her arrest last December.

Her lawyers say there is little real evidence against her and not a single witness: much of the prosecution case is based on the premise that she appeared to be the only person present when the patients died.

The fact that many of those who died were children born with physical abnormalities or elderly people suffering from terminal illnesses also complicates the prosecution's task.

However, in March investigators exhumed the bodies of three children initially believed to have died of terminal illnesses and discovered traces of toxins in their blood.

Ms De Berk is also accused of forging her professional qualifications and prosecutors claim that her reading matter indicates she has an unhealthy interest in murder. Searches of her home unearthed books such as Inside the Home of a Serial Killer.

In a country where euthanasia has just become legal - though it has been informally tolerated for decades - the case has touched a raw nerve.

The new law lays out strict criteria for mercy killing but the De Berk case has revived fears that medical staff could get away with murder more easily.

The indictment against Ms De Berk shows she had a troubled childhood. Her alcoholic parents moved to Canada when she was a teenager and she worked as a prostitute in Vancouver.

The trial, which is expected to last until Monday, will hear from a toxicologist and an FBI expert on serial killers. A verdict is not expected for a fortnight. Ms De Berk could face life imprisonment.

Dutch nurse 'killed' war crimes judge

BBC News

June 19, 2002

A judge with the war crimes tribunal for the former Yugoslavia has been identified by Dutch prosecutors as one of the alleged victims of a nurse charged with murdering 13 people over a four-year period.

Chinese judge Haopei Li died in November 1997 at the age of 91. No details on the cause of his death were released at the time.

The nurse, Lucy Isabella Quirina de Berk, is accused of killing both children and elderly people in her care by giving them a lethal dose of morphine and potassium.

The killings are alleged to have taken place between February 1997 and September 2001.

Ms De Berk, 40, has been in custody for six months and is due to go on trial in The Hague in September.

Obsession

"The judge was one of her victims," Evert Boerstra, spokesman for the Hague prosecutors office told BBC News Online.

Mr Boerstra said was no indication that Li's position at the UN court had anything to do with his alleged murder.

A founding member of the 11-member war crimes tribunal in The Hague, the judge was due to retire the same month as his death.

Ms De Berk got into medical training using a fake high school diploma, her indictment says.

Prosecutors described her as a classic psychopath "obsessed with death".

Ms De Berk spent her teenage years in Canada after moving to Winnipeg from the Netherlands with her alcoholic parents, and later worked as a prostitute in Vancouver, prosecutors say.

Dutch nurse accused of 14 murders

BBC News

May 8, 2002

A Dutch nurse has been accused of murdering 14 people, according to public prosecutors.

Her victims are said to include babies, young children and elderly patients at four hospitals in The Hague.

Prosecutors have described the woman as a "classic psychopath".

The killings are alleged to have taken place over a four-year period between February 1997 and September 2001.

The nurse, who has also been charged with four attempted murders, is due to go on trial in The Hague in June.

Lethal overdose

The woman, aged 40, is accused of killing five babies and children and nine elderly people in her care, by giving them a lethal dose of drugs.

"The nurse is suspected of killing the victims by giving them substances such as potassium... and morphine," Hague prosecutors said in a statement.

"In certain cases, the nature of the deadly substance could not be determined."

Some of the deaths were said to have occurred in a children's ward and a prison infirmary, but the prosecutors' statement gave no indication of the illnesses suffered by the victims.

Babies less than a year old and patients as old as 91 were among the victims, prosecutors said.

The nurse, whose name has not been released, is also charged with four attempted murders and forging school certificates to enable her to qualify for medical training.

She was suspended from her last job at a hospital in The Hague in 2001 following the death of a baby. She has since been sacked.

According to the Associated Press news agency, the woman is a former resident of Winnipeg, Canada, who is obsessed with death and has attempted suicide seven times in the past decade.

The bodies of three children she allegedly killed were disinterred for examination in March, according to the news agency.

Synopsis/reconstruction of the Lucia de Berk case

Math.leidenuniv.nl

* Supervisors at the hospital are suspicious because of a small cluster of deaths and the repeated presence of a particular and striking nurse in the shifts when the deaths occur; there has been some gossip among some colleague nurses, too, concerning her past.

Actually, an intensive care ward has just been closed for economization reasons and the cluster is probably due to a change in case-mix on the ward in question. There is also nervousness among the staff because of reorganization, merger, possible job losses.

* After a lull, a new event (Achraf) raises suspicion again to high levels. Gossip increases.

* Lucia is deliberately given heavy night shifts while Amber's situation is rapidly deteriorating though the responsible specialist is not aware of this and has told the parents that she can go home [to die?] soon.

* Amber dies on Lucia's shift, the hospital goes into Red Alert. Press release, newspaper items, letters written to parents of dead children. "Sorry, it seems we may have a serial killer here, but don't get angry, we are in full control of the situation". Some days later the police are also involved. 9-11.

The police come to law-psychologist and ex-statistician Henk Elffers with the story, thinking that it is probably much ado about nothing. He convinces them that it is NOT chance, something really is going on! It is indeed not chance as he understood it, his formulation of "chance" is the wrong one. His analysis is inappropriate. Moreover the data he was given were biased, and moreover, (adding insult to injury) he blundered in his calculations. He ALSO resolved all possible data-analysis choices available to him, in the way most damning to Lucia, whether by luck or bad judgement, we shall never know. Though repeatedly hearing the extensive scientific arguments against his methodology he never retracted them.

In the meantime the hospital authorities have come up with lots more deaths and incidents at other hospitals. We had a serial killer, now we also have the people she killed. It just remains to get the proof. How did she do it and why?

After a year, someone comes up with the digoxin theory and a (provably wrong) reconstruction is given of how Lucia poisoned Amber with digoxin. The situation right now is that there is good reason to believe she did not die of this at all [Dasgupta - top world authority on digoxin poisoning].

Uges: "the mystery is not what Amber died of, but how come she was still alive". The available material was of "such bad quality that the actual cause of death is idle speculation".

De Wolff, alone, does still support the digoxin theory as cause of death, but he rules out that it was administered by Lucia. There are still the mysteries of where did the piece of gauze come from, which was found at the second autopsy, but so far not claimed by anyone, and from which a sample of bloody fluid was squeezed out. And why was the last real blood sample taken of Amber, taken while she was still alive, get thrown away the week _after_ a murder investigation starts?

At the first court hearing, Richard de Mulder [colleague and collaborator of Elffers, a lawyer with an MBA and a computer hobby] supports Elffers' analysis and conclusion, and convinces the court that "the coincidence needs explanation".

They understand this as follows: "Lucia needs to explain the coincidence". She is unable. Five possibilities offered her by Elffers "by way of example" do not give her any help. The fact that Lucia denies killing, and cannot explain her presence, shows she is a liar and a killer, and the fact that no evidence can be found of how she killed anyone else, shows how refined a killer she is. The fact that the times of death were unpredicted and that no common cause could be found provides a link between them (!). The diary provides a motive - a compulsion - because of a coincidence between a diary entry and a death of a terminally ill aged cancer patient on her ward. The non-coincidences are not reported. Lucia is convicted of only 4 of the murders and 2 of the attempted murders, with which she was originally charged. She is given a life sentence.

Both Lucia and the prosecution appeal. The prosecution wants more murders pinned on Lucia. This requires even stronger reliance on the statistics since other key parts of the evidence have significantly weakened in the meantime. However moral probabilist Meester and computer scientist and logician van Lambalgen insist that there is not a single well defined probability in such a case. The judges obligingly remove reference to any particular probability and any particular calculation-method from their summing up. The fundamentally wrong argument of Elffers and de Mulder, based moreover on wrong data, remains in its entirety, but in verbal form and carefully avoiding use of the words "probability" or "statistics". The first page of the summing-up reports that indeed, no statistical probability calculation is used in the conviction. Exeunt statisticians. Lucia is convicted for 7 murders and 3 attempts (still less than she was charged with). The court increases the sentence to life, followed by detention in psychiatric care.

The evidence from Strasburg, further destroying the digoxin argument, arrives too late for the trial. It is lost in a drawer at the Netherlands Forensic Institute for two years. The Supreme Court removes detention in psychiatric ward after the life sentence, since Lucia has not pleaded that she was mentally disturbed when doing the crimes. (She still declares her innocence).

Committee Posthumus II ("Evaluation of closed cases") does take Lucia's case into consideration and passes the dossier to a committe of Three Wise Men, recruited from the larger committee. The "three wise men" are to report to the Public Prosecution Service and they have a Public Prosecutor as chairman, a professor of criminal law and part-time judge, and a retired policeman from the board of Rotterdam's Feyenoord football team, as advisory members. They are instructed by the "entrance committee" - i.e., by themselves - to see if errors have been made in the police investigation. They are not instructed to look at errors made by the prosecution. There can be no errors made by the judges, since the case has now been to the ultimate authority, the Supreme Court. They can in principle make a recommendation that the case be reopened. This advice would then be considered by the Supreme Court. The Supreme Court has the power to send the case to be reopened by a normal appeal court.

The Supreme Court will only request reopening of the case if "new evidence" is available, of such import, that had it been available to the judge during the trial, it would likely have impacted the judge's conclusion, or if new evidence shows that key evidence gathered by the police was not actually legal. The Three Wise Men have not instructed themselves to see if there is new evidence. Nor can they conclude that the wrong conclusions were drawn from existing evidence (this is legally speaking impossible, since the case is legally closed).

They are only to see if police procedures were imperfect. They might conclude that there were failings in police procedure but they could easily imagine that this did not impact the verdict significantly, if they are not to evaluate the judge's argument anyway.

As said, the three wise men will report to the Chief of the Public Prosecution Service, not to the Supreme Court.

The Chief Public Prosecutor will consult with the Minister of Justice before acting in this situation. Both he and the Minister of Justice believe that the system in the Netherlands works perfectly. Moreover they believe that public faith in the system was already too badly shaken by the events which led to the installation of committee Posthumus II. That committee is part of an operation to restore public faith in our system, which is not subject to any of the faults which have beset the systems of other countries in recent years. They will be highly reluctant to allow public faith to be shaken by the reopening of yet another case.

Posthumus II only received requests to consider 25 cases, and only took up 3 of them. These small numbers are said to confirm that the system is indeed working very well, as was expected; the public's worries were unfounded and public faith in the system can be restored. (In the UK, the CCRC receives about 2000 cases per year, admitting about 25; almost all of these 25 finally lead to overturned convictions). The criteria for consideration by Posthumus II are however extremely stringent. It is only admitted that police investigators could err, by misinterpreting scientific evidence, thereby inadvertently leading public prosecutors astray. The only members of the "public" who were allowed to submit a case are established scientists who have done significant new research on it.

A recent survey shows that the Dutch public is actually highly satisfied by the justice system in the country (fourth European place). The scandals which led to installation of the Posthumus II committee have had no impact on this at all. I hope that the chief public prosecutor and the minister of justice will take this to mean that no harm whatsoever need be done to public faith in the system by reopening this case too.

The ‘murders’

Metta de Noo-Derksen

27 October 2007

It's left hanging and it stinks…

I've been playing with the idea of putting together a little brochure containing the major points of the last three years. On December 13th 2001 Lucia was imprisoned. In June of 2004 I began to worry… What a time…

The brochure didn't come to anything (yet), but perhaps it is good to put down here some things that are of importance. As a short summary of those last bizarre years.

Over the last few years I've come to know Lucia as a strong woman, who is trying, for her daughter and for her partner, to survive this nightmare in which she finds herself.

I've also learned about the case. As a staggering succession of false conclusions.

Two years ago I was in the Jewish Museum in Berlin. They have a tree there where visitors can hang cards containing wishes. For peace, against racial hatred, against senseless violence. I hung a card in that tree with the wish “Light for Lucia”. We had just entered into the fray with Lucia's case. And in the terrifying dungeon within that museum I felt the same emotions as I had during my very first visit to Nieuwersluis, the prison in which Lucia is incarcerated. My daughter felt that my card and the associations in this museum were inappropriate. Actually, I thought so too. “But” I said, attempting to justify my perhaps rather impulsive act, “Isn't at the core of Lucia's case the fact that feelings of fear within a group can be transformed into an insane speculation against that other one”.

Since May 2004 I began, due to my medical knowledge and from the bizarre stories emanating from the direct area of the hospital, to have increasing doubts about the judicial process surrounding Lucia. Much was negotiable within the medical diagnostics and the applied logic. Moreover I saw simply that communication between the Public Prosecutor and the experts lacked the appropriate objectivity and distance.

# 10 ‘Murder’ cases

On the 18th of June 2004 Lucia was convicted in the Court of Justice in the Hague of 7 murders and 3 attempted murders. She received a sentence of life imprisonment with TBS (enforced psychiatric treatment), a very unusual and extreme level of punishment. Initially almost thirty cases were considered suspect. When in most of these cases it transpired that Lucia couldn't in any way be considered responsible, the suspicions towards those cases were also withdrawn. A case being considered suspect was dependent therefore on Lucia's presence at the scene and appeared not to be based on any unequivocal diagnosis. The physician was the one to judge whether a death was murder or natural causes. Much wisdom was attributed to him in this process, though it is well known that physicians are not always (cannot always be) equally consistent and objective in their judgement.

Peculiar also is a story that circulated that the Rode Kruis Hospital, a sister hospital to the Julliana Kinder Hospital, had all the suspect cases sat in a drawer, ready for if they were asked if there were any deaths at the hospital during the period that Lucia worked there, in which she might be involved. Remarkable drawer they have there in that hospital.

But anyway, there's still enough – let's say everything – worth negotiating with those 7 murders and 3 incidents, of which only two were – marginally – declared proven and the others had to be pulled along by the so called chain evidence.

Let us look at these children and elderly people were not permitted to just have died, sometimes even years after their deaths.

# Case 1.

The most important point of contention concerns a small baby that is supposed to have died of an injection of Digoxin, administered by Lucia. The doctors said that she was recovering well after a very complex heart operation. And that she would be able to go home shortly. The parents were, of course, also hopeful that this would be the case.

But the child wasn't at all as well as was reported. It was evident that there were multiple issues, Microcephalie, Pulmonary Hypertension, Decompensatio, Atelectasen and Necrotic Ileus. This meant that the child was increasingly short of breath, drank with difficulty, was vomiting, had a painful and swollen tummy and very smelly diarrhoea. The oxygen levels had to be raised and "Plastabletten" were increased.

How relevant is the whole Digoxin investigation if you consider that the child had been becoming more and more sick for days, more and more short of breath. Naturally as doctor in attendance you'll feel powerless and uncomfortable if you've just said “it's not that bad” and the child dies almost as soon as you leave the room.

But that happens to every doctor once in a while. C'est la vie – Le mort – and not the Digoxin.

# Case 2.

This little boy was given Chloralhydrate because he was very restless, a notoriously risky sedative, which he was receiving in high doses and where necessary an extra dose was administered. One day he is drowsy and is shown to have a high concentration of Chloralhydrate in his blood. He also has pneumonia and is dehydrated. After being connected to a drip he improves fairly quickly. This incident wasn't even noticed by the head of department, there was also no report made of it. At the time it was assumed that there had been an interaction with other medications – Benzodiazepines and Kalcid.

Lucia noticed that the child's condition had deteriorated and she reported this fact. That was just about the only proof the court needed that Lucia had tried to kill the child with Chloralhydrate. This construction of evidence was to be the second Locomotive for the chain evidence. Apparently the judge had no knowledge of the risks of Chloralhydrate, interactions with other medicines, dehydration and of the "Pharmagenetics" and the many mistakes concerning the administering of medications, whereby the medication concerned has a notorious reputation.

# Case 3.

A little boy is admitted to the JK hospital because his mother is anxious. The doctor indicates clearly to her and to the nursing staff that it is purely a "social symptom". The next day the child suffers an apnoea. Everyone is shocked… this was unexpected. According to the doctor in attendance also inexplicable (which was also the view of all the experts).

It would certainly have been explicable had the doctor known and reported the fact that this child suffered from an illness (Freeman Sheldon) whereby these types of apnoea attacks sometimes occur, especially if there is an infection of the airways. There were other children in the boy's family who had been seriously ill, some had even died. His mother wasn't without reason more worried than the doctors.

# Case 4.

A boy with Haemophilia has fallen over and receives extra medication from the paediatrician to stop the bleeding. Two weeks later he is admitted in a comatose condition to the hospital. The bleeding in his head has, in the mean time, become "thickened". Following a brain operation his condition remains critical. One day his breathing becomes laborious. The doctor's assistant prescribes Ventolin (a medicine to help stop restriction of the airways). And while Lucia administers the Ventolin (via nose drops) with the child on her lap and at the same time – through her caring – takes the child's blood pressure, the child's breathing becomes more difficult and he passes away. “Now” the court says “Lucia gave the child the wrong treatment, measuring blood pressure and administering Ventolin at the same time isn't permitted”. And, during the court case, there is much squabbling about this method of treatment of hers. The cause of the shortness of breath is hardly discussed. Perhaps it was smothering. No one talks about a re-introduction, with a rapid accumulation, of the muscle relaxant; Baclofen which – especially with a heavily disabled child – could cause breathing depression. Ventolin is, in a situation such as this, a peculiar medicine to have been used.

# Case 5.

This boy also had a complex clinical picture. He has serious oesophageal bleeding for which blood transfusions are necessary. With great difficulty in the evening they carried out an exploratory operation. The child dies in the night. The doctors in attendance signed a death certificate. According to the doctors there were multiple likely causes for this seriously sick child's death. A year later this death suddenly starts to be considered suspicious. There is no proof, but that doesn't matter now that there is chain evidence. It must have happened the way case#1 and case#2 did; because Lucia was present…

# Case 6.

This involves the same boy as in case#2. A couple of weeks after the Chloralhydrate raising incident he dies on the day of a surgical procedure. He's been under narcosis, receives Chloralhydrate again, that actually should have been stopped. They forgot. He received his other sedatives on top of the Dipiperon drops which were supposed to have replaced the Chloralhydrate. In the evening, after Lucia has left for home, he dies.

The experts say that all that medicine – plus the Chloralhydrate which wasn't stopped – would have been too much, especially once the Dipiperon started. After the death the doctors apparently thought this too because they signed for death by natural causes. It is really quite brazen, in such a situation, to suddenly accuse the nurse of murder, simply because she happened to look in on the child before she left for home.

# Case 7.

This little baby had been in Intensive-care due to a sepsis (blood poisoning). There she had been given a too high concentration of luminal in the blood (prescribed) to counter the convulsions. But that wasn't the problem, that can happen. According to the JK hospital a year later it was deemed suspicious that after the child had been transferred a short hesitation in her breathing occurred. Wasn't the transfer just a little too early? The judge however decided that Lucia had committed attempted murder. (and that, just a few days before she was to qualify as paediatric nurse!!).

Should we, in future, consider all dysmature babies that need a restart-smack (to stimulate the breathing) as candidates for a murder investigation?

# Case 8.

This terminally ill patient suffering from cancer with secondary tumours all over is discussed in depth in the compulsion story – see elsewhere for more on this site. It was necessary to have her death considered as a murder in order to round off the compulsion story. The word compulsion was written in Lucia's diary on the day that this seriously ill woman died. If this woman had been murdered then the word compulsion must relate to an inner urge to murder and not the laying of Tarot cards. The experts saw no reason to note an unnatural death. The judge did.

# Case 9.

This elderly lady with various illnesses has an Ileus (bowel closure). She is admitted from her care home, they apparently don't trust her situation there. The hospital's policy is to wait. One day she has strong stomach pains, she becomes anxious and restless. Lucia stays by her side and calls for the assisting doctor. The doctor administers Buscopan. In the morning this lady dies.

The court decides that there certainly can't be a bowel closure. After all, the court said, the day before the death this patient actually had “2x a little watery def (faeces)” and therefore there must be a passage through the bowel. Every second-year medical student would raise an eyebrow reading this. The thin def, mr.judge, was the overspill diarrhoea and actually a sign that the bowel is well and truly blocked and the faeces is making one last attempt to find a way out. Why did no doctor ever explain this to the judge and also not tell them that Buscopan was absolutely not appropriate in this situation.

# Case 10.

I don't want to say much about this elderly gentleman here. He had a liver abscess that presented a varying picture. He died after a reasonably good day, but there were also bad days before that as is often the case with abscesses.

It is worth noting that a medical expert stated in his evidence that each death separately would be judged as being of natural causes, but that when all the cases were grouped together there must be talk of unnatural deaths…

# The evidential construction

As stated earlier the decree was, to legal insiders, already suspect due to its laborious construction and the argumentation. The use of language is pompous and many side avenues are gone down in order to present and emphasize, as well as they could, a negative image of this criminal. When the court's evidence is held up to the light of day we notice that:

• There is not one shred of hard evidence; Lucia was never caught doing anything suspicious, there are no suspicious materials.

• That the Digoxin and Chloralhydrate story is simply untrue.

• That the chain-evidence is pulled along by two defective locomotives.

• The statistics were dealt with in a most peculiar manner.

• There are contradictions and imperfections in the medical information and diagnostics.

• There were many old wives tales.

• The personality test indicates no relationship between Lucia's personality and the alleged crimes.

• There was no motive for the alleged crimes.

# No hard evidence

The court shows in only one (of the 7) case of murder and in just one of the attempted murders how Lucia was supposed to have carried out these murders or attempts at murder. In the murder of child A Lucia is supposed to have given the child an injection of Digoxin approximately one and a half hours before the death. The presentation of evidence of this Digoxin poisoning is, despite the very carefully scripted reconstruction, not at all convincing and has, in the meantime, been found to be unacceptable by internationally renowned Digoxin experts such as Dasgupta and Koren.

What's more, it is quite remarkable that an important test result from a lab in Strasbourg remained in a drawer at the NFI (National Forensic Institute) for 2 years. Why, is a mystery. The NFI had actually just asked the lab in Strasbourg for a “miracle” because they couldn't, until shortly before the verdict, show any proof of a Digoxin poisoning.

In the remaining 6 proved cases of murder and the 2 attempted murders the court didn't even take the trouble to explain how Lucia could have committed her ‘crimes’, without leaving any signs. The concept of chain evidence replaced this; the first two, so-called, proofs of murder or attempted murder were to be the Locomotives; the wagons behind, with the other cases, were to be viewed in the same light. Put, therefore, enough unproven cases behind an apparently proven case and it appears, from the outside, convincing.

# Remarkable application of statistics

The only fact that made Lucia a suspect was her presence at ‘so many’ incidents of death. An initial statistical calculation was made by doctors in the JK hospital in the Hague about the chances of a nurse being present at ‘so many’ instances of death. Later the legal psychologist dr.Elffers made further calculations and came to the conclusion that “it couldn't have been a coincidence”. The chance that Lucia would be present at all the stated cases was, according to him, one in 342 million.

Moreover the data supplied by the hospital, was incomplete. In a reappraisal Ton Derksen arrives at a figure of one in 48 and professors of statistics Gill and Groeneveld one in nine.

The ‘huge number’ 1 in 342 million, made, in 2001, all the cases where Lucia had been present suspicious.

It is significant that a medical expert states in his evidence that each death when examined individually may be considered a death by natural causes, but when all the cases are viewed collectively there must be a case for unnatural deaths.

# Contradictions and imperfections in the medical information and diagnostics

How can the police and jurists pass judgement on medical matters? They are, in fact, completely dependant on the advice and methods of medical practitioners.

In the case of Lucia de B the medical information was presented by the JK hospital in summarized form and was used in the investigation in that form. This information was moreover not always complete and had, as has been stated, it's blind spots. Above all, a doctor in the JK hospital played a coordinating roll in the judicial investigation. However objective the practitioner wishes to present himself it appears to me to be very undesirable that a member of the prosecuting party decides which investigation is carried out, which experts should be involved, etc…

In Lucia's case the medical statements play a very important roll. As soon as a doctor states that an unnatural death is in fact a death by natural causes the whole process is stopped.

Judges expect to hear clear statements from medical experts. They have to do this on the basis of interpreting telegram-like notes. The doctor in attendance who wrote these notes perhaps had other ideas in his head than those of the doctor interpreting it years later.

The court set up dubious criteria for defining the notion of ‘unnatural death’. According to this court there is talk of an unnatural death if that death is inexplicable and occurred while Lucia was present. Translated to our daily lives, you really should watch out if your neighbour has a heart attack shortly after you have visited him. Nevertheless a doctor or nurse can just wait until it's his or her own turn to be convicted.

Where the practitioner would prefer to place some small nuances or uncertainties around a question of life or death a jurist wants an absolute yes or no answer. Hesitancy on the practitioner's part is in danger of being interpreted as a “no” in a court room when asked “are you sure that the patient didn't die an unnatural death…?”

In not one of the deaths in the Lucia case did the doctors in attendance or the experts show a unified opinion. Sometimes it's easy for information to be interpreted – within certain margins – in differing ways. Things in medicine just aren't that clear cut. It is however astonishing, to say the least, that the court chose time and time again for the most damning testimonies, even if these were consistently in the minority. With this the court assumed a particularly superior level of expertise for itself.

# Compulsion story

Lucia was, according to the court, under a compulsion to kill. The word compulsion was used by Lucia seven times – as a fancy word – in her diary writings. One of these times was on a day that a patient died during her shift at the hospital. This elderly patient was terminally ill, had secondary tumours all over her body, up to and including her pericardium. The doctors in attendance and expert witnesses certainly did not view her death as an unexpected occurrence. A surgeon wrote, however, a few days after the court case, a very resolute letter to the court. He thought he knew for certain that her death at that moment had been unexpected. The court accepted his opinion. Was this because it was only with this patient that the word compulsion could be linked to a suspicious death?

The word compulsion meant, for Lucia, a strong urge, not being able to resist laying down Tarot cards for patients. She had been seriously involved in the Tarot for a long time. She felt that this form of ‘alternative medicine’ was very improper for a nurse to be involved with and something that she should resist doing and keep secret.

According to the Pieter Baan Centre (PBC) Lucia does not suffer from a mental disorder that could bring her to commit murder. The experts at the PBC found, in contrast to the court, that “that carry-on with the Tarot cards” actually fitted in with Lucia's personality.

# Image forming

According to the court Lucia was deceitful and cunning. Forensic psychologist Ligthart, who had never even met Lucia personally, let alone examined her, talked at an early stage of the police investigation of a ‘classic psychopath’. His opinion was adopted by the Public Prosecutor and later also by the court, whilst the opinion of the PBC as well as that of the witness-expert professor Jan Derksen who was called in at a later stage, was pushed to one side.

An FBI agent was flown in to tell the Dutch jurists all about serial killers. Other ‘self-appointed experts’ also explained in great detail why Lucia fully satisfied the criteria of a serial killer. The stories about Lucia which were brought into free circulation by the police and the Public Prosecutor's Office, were used as an illustration of this but never actually verified.

The Canadian police report, in which it is said that there is no evidence at all for arson or any violent behaviour, remains undiscussed. Only the suggestion that a serial killer also enjoys starting fires remains hanging in the air. The tales too of Lucia supposedly having poisons in her home, that she was a member of a group of witches, that she had a cross branded onto her chest, that she placed her own obituary in the newspapers, that she'd burned her diaries, all remain circulating, unchallenged.

In this way the image is more and more frequently reinforced of a horribly hysterical character. The stories are proven to be false but still, even now, people say “the evidence isn't correct but that person is still no good” …

# No confession

Lucia has never admitted to anything, despite exhausting and humiliating interrogation. If she had confessed and – as her lawyers suggested – had given as her motive that she wanted to release seriously sick children and elderly patients from their suffering – like Martha U. – she could have expected a considerable reduction in sentence. Lucia categorically refused to gain a reduction of sentence in this manner. That would mean her lying… and she couldn't and wouldn't do that.

It is painful to have to read in the judgement how Lucia is criticised for not confessing and therefore not helping to solve the case…

# Emotions

Whoever takes the trouble to read the judgement of the court of justice of the Hague, is hit by the tone of blind hatred towards Lucia and the distain for her lawyers. This is literally to be seen and heard on TV and radio broadcasts “It is the accused who smothered this life in the bud…, it is the accused who has damaged confidence in Dutch hospitals”. The judges were so emotional that they sentenced Lucia to life imprisonment plus, on top of that, TBS (enforced psychiatric treatment). The heaviest punishment ever given, since the death penalty disappeared from Dutch law in 1870. The court of appeal too couldn't understand how a punishment that was meant to remove someone permanently from society (lifelong imprisonment) could be combined with a measure designed to reintegrate a person back into that society.

# Collaborative medical story telling

You may ask yourself how it is possible in a civilised society for a person to be sentenced to the highest possible punishment while there is not one piece of concrete evidence that points to her guilt?

Professor Wagenaar introduced the term collaborative story telling in alleged sexual cases, whereby tunnel vision existed due to transferring and exaggerating feelings of angst. This mechanism of paranoid induction appears at first glance to be unlikely in an affair of this magnitude. Actually it could be conceivable, when one considers that the people involved in this process trusted each other, when they were confronted with the fearful suspicions; they were colleagues or acquaintances. On the other side, a certain dependency existed in some relationships and often they were simply not able to evaluate the allegations.

Lucia worked as a nurse in a hospital in which the vicissitudes and uncertainties of an amalgamation existed at that time. A doctor spoke of “too many children dying”. Something that has never shown up in the mortality figures! On the contrary, in the period when Lucia worked there the mortality rate was actually lower (six) than in the preceding and intervening years (seven).

Lucia was, coincidentally, ‘often’ in the area when there was a resuscitation going on. That was considered suspicious. Moreover ‘they’ could tell you a thing or two about her. Situations where death had occurred where she was involved gained a certain colouration. Police and the justice system allowed themselves to be taken in by this hospital gossip. People often knew each other and trusted each other all too easily…

Lucia's complete past was delved into and made public, and indeed, she came from a different background than most of her colleagues. Even before a court was involved, the media were portraying her as the Angel of Death.

Shamelessly blackening her character, portraying her as some kind of witch, often with gross untruths, that was a whole lot easier than proving she'd ever committed any murders. Using Lucia's duty roster a list was made up of 30 ‘suspicious’ deaths in the four hospitals in which Lucia had worked. This list had to be drastically cut down. Usually because Lucia could in no way be connected. Those rejected cases were never investigated further. Apparently, all of a sudden, there was nothing noteworthy about them anymore. But when Lucia was around, then the cause of death was very quickly seen as being suspicious.

The insinuations and whipped-up fears in the JK hospital are central to the Lucia case. The hospital played moreover an important role from the start of the investigation and brought their conclusions outside very quickly “it cannot be a coincidence”. Medical experts, who were initially asked for their advice in an amicable manner, were later used as judicial expert witnesses. The information concerning case histories wasn't gathered by an independent medical-jurist team, but rather by the complainant hospital concerned. Some relevant data remained completely without scrutiny during the court case. And something that shouldn't be viewed in bad faith, but certainly was a subjective factor during the investigation is the collegiality within the medical and jurist professions.

The experts were initially often not in agreement, but this didn't mean that a protest was issued against the point of view. The jurists were given incomplete information that had to be converted into legal language.

A snowflake that became an avalanche …