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.
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.
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
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
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 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.
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).
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
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
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
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
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
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
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.
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
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
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
Whether scientific knowledge now threw a different light on the
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
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
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.
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.
4 September 2001
8.00 hrs Nurse approaches superior – she is concerned about
frequency of resuscitations during Lucia's shifts. It just cannot
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
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 –
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
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
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
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
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 Lucia de Berk not guilty of murdering
April 14, 2010
Nurse Lucia de Berk has been formally found not
guilty of murdering seven patients and attempting to murder three
more, ending one of the biggest miscarriages of justice in Dutch legal
De Berk, who always maintained her innocence, was
jailed for life in 2004.
The case against her was largely based on
statistical evidence and claims that a baby had been poisoned.
That supposed murder, later disputed by
toxicologists, led prosecutors to state that other patients had also
been killed by her.
Following campaigns by doctors and statisticians,
De Berk was released from jail in 2008 pending a review of the case
and eventual retrial. In March, the public prosecution department
urged judges to find her not guilty.
The way is now clear for De Berk, once described as
the Netherlands' most notorious serial killer, to make a substantial
claim for damages.
Justice minister Ernst Hirsch Ballin told reporters
he has sent De Berk a letter apologising for her incarceration. 'What
has been done to her is dreadful,' he said.
The former nurse is entitled to 'generous'
financial compensation, he said. De Berk spent over six years in jail.
Public prosecution department chief Harm Brouwer
has already apologised to De Berk in a private meeting last week, Nos
The public prosecution department has also
apologised to families of the people deemed to be De Berk's victims.
The alleged murders and attempted murders took
place at three hospitals between 1997 and 2001. They came to light
after police began investigating the death of a baby girl named Amber.
De Berk's eventual conviction was based on two
deaths, including that of baby Amber, which toxicology reports said
could have been caused by digoxin poisoning.
All the other patients were either very old or very
sick and died as a result of 'medically unexplained' causes. In these
cases, De Berk was on duty 'noticeably often' when someone died, the
prosecution department had claimed.
The statistical probability of her being present at
so many deaths was central to the prosecution's case. None of the
alleged victims underwent post mortem examinations.
Dutch nurse gets life for murdering four
By Andrew Osborn - Guardian.co.uk
March 25, 2003
A Dutch nurse thought to be one of the most
prolific serial killers in the Netherlands was yesterday jailed for
life after a court found her guilty of the murder of four of her
patients and the attempted murder of three others.
Lucy Isabella Quirina de Berk, 41, has repeatedly
protested her innocence but a court in the Hague yesterday concluded
that she had killed three babies and one elderly woman by lethal
It also found her guilty of trying to murder two
other babies and another pensioner.
The case has captured the public imagination
because of the large number of people who died under suspicious
circumstances in De Berk's care - she was initially accused of killing
13 and of attempting to murder five others.
It has also raised fears that the Netherlands'
ground-breaking decision to legalise euthanasia may allow doctors and
nurses to get away with murder.
The presiding judge, Jeanne Kalk, said: "[De Berk]
went about her work in a refined and calculating way when the chance
of discovery was small. Apparently she believed she was qualified to
hold the power of life and death over these people."
The murders happened between 1997 and 2001 at three
hospitals in the Hague. In each case the patient died of an overdose
of either potassium or morphine and De Berk was the last person to be
at the bedside.
During her trial statisticians testified that the
chances of her being present coincidentally at each death were one in
A verdict had been expected last October, but De
Berk was ordered to undergo psychiatric tests.
Her conviction was secured with the aid of
apparently damning entries in her personal diary.
"I gave in to my compulsions ... I don't even know
why I am doing it ... I will take this secret with me to the grave ...
still I hope I am helping people by this," read one such entry.
De Berk's lawyer said yesterday he would appeal
against the ruling, which he alleged was based solely on
Nurse accused of killing 13 patients insists
she's innocent as trial ends
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
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
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
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
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
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
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
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
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
"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
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
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
June 19, 2002
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.
killings are alleged to have taken place between February 1997 and
Ms De Berk, 40, has been in
custody for six months and is due to go on trial in The Hague in
"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.
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
May 8, 2002
nurse has been accused of murdering 14 people, according to public
Her victims are said to include
babies, young children and elderly patients at four hospitals in
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.
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
"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
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
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
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
* 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.
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
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
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
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".
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
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.
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.
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
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.
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
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.
Metta de Noo-Derksen
27 October 2007
It's left hanging and it stinks…
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
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
I've also learned about the case. As a
staggering succession of false conclusions.
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.
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.
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"
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.
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
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…
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
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
# 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.
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
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
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
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
# No hard evidence
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
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,
# Remarkable application of
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
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.
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…
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
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
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
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.
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.
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” …
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
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…
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
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
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
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…
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
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