14 April 2010     Court of Arnhem
Acquittal in case Lucy de Berk


Lucia smiles

It's left hanging and it stinks……

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

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

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

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

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

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

# 10 ‘Murder’ cases

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it transpired that Lucia couldn't in any way be considered responsible, the suspicions towards those cases were also withdrawn.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

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

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

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

# Case 1.

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

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

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

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

# Case 2.

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

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

# Case 3.

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

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

# Case 4.

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

# Case 5.

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

# Case 6.

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

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

# Case 7.

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

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

# Case 8.

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

# Case 9.

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

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

# Case 10.

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

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

# The evidential construction

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

  • There is not one shred of hard evidence; Lucia was never caught doing anything suspicious, there are no suspicious materials.
  • That the Digoxin and Chloralhydrate story is simply untrue.
  • That the chain-evidence is pulled along by two defective locomotives.
  • The statistics were dealt with in a most peculiar manner.
  • There are contradictions and imperfections in the medical information and diagnostics.
  • There were many old wives tales.
  • The personality test indicates no relationship between Lucia's personality and the alleged crimes.
  • There was no motive for the alleged crimes.

# No hard evidence

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

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

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

# Remarkable application of statistics

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

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

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

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

# Contradictions and imperfections in the medical information and diagnostics

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

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

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

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

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

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

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

# Compulsion story

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

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

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

# Image forming

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

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

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

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

# No confession

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

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

# Emotions

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

# Collaborative medical story telling

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

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

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

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

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

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

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

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

A snowflake that became an avalanche … …

Metta de Noo-Derksen

27 October 2007