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. 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.
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
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
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
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
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.
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.
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 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
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.
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
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.
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.
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 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 4˝ 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
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
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 five
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
Dutch nurse 'killed' war crimes judge
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 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.
"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
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
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
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 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
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
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.
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
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 startsÂ§?
At the first court hearing, Richard de Mulder
[colleague and collabororator 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
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
Posthumum 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.