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Serial murder in the Netherlands: a look at motivation, behavior, and characteristics.

Something unusual was happening at a children's hospital in The Hague, Netherlands. The hospital administrator did not want to prejudge the situation, but another patient of Lucy's had died. Although her patients were extremely sick and sometimes terminally ill, the hospital staff did not expect them to die so suddenly. This, however, had happened more than once--actually, more than twice. Lucy's supervisor and several of her colleagues had alerted the administrator about the number of patients that had died immediately after she left their rooms. Therefore, the administrator decided to suspend Lucy, pending a review.


The review determined that within a 3-year period, eight of Lucy's patients had died while under her care. The hospital referred this information to The Hague Police Department on September 4, 2001. Investigators quickly discovered that Lucy had worked at another hospital where 19 elderly patients had died while under her care. Additionally, at least one patient had died at home after Lucy visited the person's residence. Indicted for the murder of 13 patients, Lucy was arrested on December 13, 2001.

The Netherlands Public Prosecution Service had only once before charged anyone with multiple counts of murder. Many members of The Hague District Attorney's Office, a component of the Prosecution Service, as well as the general public and the media simply could not understand how one person could be motivated to kill so many people. In fact, many believed that serial murder was an American problem; the Netherlands simply did not have serial killers.


The District Attorney's Office, in conjunction with The Hague Police Department, oversaw the investigation and prosecution of this case. In May 2002, the District Attorney's Office presented this case to the Behavioral Analysis Unit (BAU) at the National Center for the Analysis of Violent Crime (NCAVC), an entity within the FBI's Critical Incident Response Group (CIRG). Subsequently, BAU personnel conducted an on-site review of the case in the Netherlands, which led to a request for and the eventual expert testimony by a BAU member regarding the motivation, behavior, and psychological characteristics of serial murderers. (1) Although this case illustrates the relatively rare phenomenon of a female serial murderer, the traits and characteristics of female serial murderers are more similar than unique when compared with the broader population of male serial murderers.

Definition Difficulties

Like many other behavioral classifications that attempt to label complicated and complex sets of variables, efforts to standardize a definition of serial murder have failed to achieve a consensus. People often use serial murder, serial homicide, serial killing, multiple murder, mass murder, and sexual homicide interchangeably. The lack of a standard definition of serial murder, at times, may confuse those who investigate this sub-population of lethal criminals, and it also negatively impacts attempts by the courts, the criminal justice system, and the public to understand the problem. In general, previous efforts to define serial murder have included criteria relative to the number of victims, time elapsed between crimes, motivation, geographical mobility, and victim selection. The major shortcoming of any behavioral typology or classification is that reducing something complicated to a concise label does not necessarily adequately explain the phenomenon.


The FBI derived its current definition for serial killing from legislation that describes serial killing "as a series of three or more killings, having common characteristics such as to suggest the reasonable possibility that the crimes were committed by the same offender or offenders." (2) Stated in this manner primarily for jurisdictional/investigative reasons, the definition also includes the requirement that at least one of the killings occur within the United States. The criteria include three or more victims, common offense characteristics, and common offenders. The FBI uses the term killing vis-a-vis murder because the bulk of its efforts are investigative and occur prior to an offender's apprehension and adjudication.

The FBI's definition of serial killing makes no reference to underlying motivation, behavior, and psychological characteristics. The agency kept the definition intentionally broad to encompass the full array of serial killers.

Motivational Factors

The FBI's NCAVC has further classified homicides of all types and has addressed motivational factors. Historically, in criminology and behavioral science literature, motivation appeared as one of the earliest criteria used to classify homicides, with classification efforts focusing on the traditional motives of financial gain, revenge, elimination of an obstacle, jealousy, and sex. Much later, criminologists and other behavioral scientists recognized that serial murderers are motivated by a complex and complicated set of motives, often involving nontraditional ones. To describe a motivational model for a serial murderer as one-dimensional or in terms of only one motive would prove inaccurate. Rather, a serial murderer's motivations are multifaceted and most often reinforced by internal desires for gratification versus external rewards, such as profit or financial gain. This can be described further in terms of a dichotomy for violence based on the offender's desired outcome. This dichotomy involves the concept of instrumental violence versus affective violence. Instrumental violence occurs when the violence is a means to an end--an armed robber steals money from the cash register and kills the store employee to eliminate a potential witness. By contrast, affective violence is an end in itself, or, in other words, the death of the victim is itself the desired end. (3)

Serial murder also can be differentiated from other types of murder because it is more often predatory, premeditated, and deliberate. Serial murderers fantasize and plan the crime and pursue and ultimately kill their victims without the interpersonal conflict and emotional provocation common in other murderer-victim interactions and relationships.

The FBI continues to conduct interviews with serial murderers. In one study in the 1980s, the agency interviewed sexual murderers, the majority being serial murderers. The agency developed organized and disorganized typologies as a result of these interviews, primarily as a means to assess the level of an offender's criminal sophistication. (4) Generally, the organized offender commits well-planned and well-orchestrated offenses, whereas the disorganized offender commits more poorly planned and poorly executed offenses. For some time, criminal justice professionals have recognized these two rather broad categories of offenders who commit not only sexual murders but murders of all types.

The more organization demonstrated by an offender, the more likely the offender will be intelligent, socially competent, capable of skilled employment, evidence conscious, controlled, and able to avoid identification while accounting for a greater number of victims. Organized offenders also are more likely to select vulnerable victims to increase the probability of being successful and to avoid detection. They lack feelings of guilt or remorse and view their victims as mere objects that they can manipulate for their own perverse satisfaction and sense of power, control, mastery, and domination. Also, the murderers themselves reported that the excitement and stimulation that resulted from doing something forbidden, taboo, and illegal provided an additional motivational facet. According to some serial murderers, the more perverse or taboo the behavior, the more excitement and stimulation they experienced.

Organized serial murderers may kill in such great numbers due to fantasies that feed their predatory desires and lead them to compete with themselves in a perverted contest of "practice makes perfect." (5) In other words, they continue to kill, in part, due to a desire to improve upon their last murder. They also may compete with authority figures by continuing to operate undetected. They know something no one else knows, and the information is exclusive. A common belief is that information is power, and offenders can feel powerful because they know something authorities do not know. In addition, they understand their misbehavior, know the difference between right and wrong, and can choose when and where to act upon their urges.

Developmental Histories

Serial murderers, as well as other violent offenders, often have developmental histories that include childhood sexual or physical abuse; maternal or paternal deprivation, rejection, or abandonment; or exposure to violent role models in the home. However, many individuals have experienced childhood abuse, and the vast majority do not become criminals, much less serial murderers. Most abused children adjust and, as they mature, progress past their traumatic experiences. However, those individuals who become serial murderers do not adjust and put the trauma and its influence in the past. They ruminate about their mistreatment; dwell on their past experiences; and become frustrated, angry, and depressed.


They often express their chronic anger, which represents one of the internal motivational facets in the multifaceted motivational model, in their murders. A serial murderer once stated in a research interview that he was abused as a child and believed that he was mistreated all of his life. This made him angry, depressed, and miserable. He consciously decided to take revenge on society as a whole by committing his murders and making as many other people as he could just as depressed and miserable.

Depression and its collateral side effects are prominent in the histories of serial murderers. Behavioral scientists have recognized for some time that a fine line or close association may exist between murder and suicide. This association is illustrated, on the one hand, when depression is turned inward and manifests itself with symptoms of sadness, self-downing, apathy, hopelessness, helplessness, and ambivalence concerning living. Thoughts of self-harm and the act of suicide can result. Depression also can be turned outward and manifest itself with symptoms of irritability, hostility, and agitation. Thoughts of harming others and the risk of committing murder greatly increase as the result of these side effects of depression. In short, why would people who experience ambivalence concerning living or dying and have a state of mind that devalues life, including their own, place any value on someone else's life?

Serial murderers are mentally abnormal and exhibit the traits and characteristics of a variety of mental disorders without reaching the threshold of mental illness necessary for exculpability. At the core, evidence of severe personality disorder or paraphilia will exist and may include, but is not limited to, traits associated with antisocial personality disorder, psychopathy, sexual sadism, borderline personality disorder, and pedophilia. (6) The more organized serial murderers most often exhibit the traits and characteristics of the psychopath. Few, if any, organized serial murderers are psychotic at the time they commit their offenses.

Rare Phenomenon

Estimates of serial murder prevalence and the number of serial murderers are just that--estimates. No official statistics are maintained within the United States, and no known empirical data are available from international sources. What is known is that serial murder is a rare phenomenon and statistically, when compared with murders of all types, occurs infrequently. Like other types of murderers, serial murderers are predominantly male. Female serial murder, as a subset of serial murder, rarely occurs. When female serial murderers offend, they are more likely than their male counter-parts to kill victims in close proximity to themselves. In other words, their victims are more likely to be family members, paramours, those who were in their custodial care, and tenants. Female serial murderers also are more likely to poison their victims in a more impersonal, detached manner than males, who more often strangle, stab, or beat their victims. (7)


Another subset of serial murder include those committed by health-care workers in hospitals and nursing homes throughout the United States and other countries. A large number of health-care worker serial murderers are female due, in part, to the fact that female health-care workers outnumber male health-care workers by a wide margin. The differential of power between doctors and nurses also may play a role in a motivational model where a desire for recognition, attention, revenge, power, and control are contributing factors. The desire for excitement, stimulation, and attention from colleagues also have been reported as elements contributing to the murder of patients. (8) Additionally, some serial murderers in health-care facilities and elsewhere have reported that the act of murder relieved tension, stress, and frustration. (9)

Health-care worker serial murderers also are most often organized in their planning, victim selection, and efforts to avoid not only detection but also the suspicion of others. They are aware of risk factors that can increase the probability of being identified and apprehended. Vulnerable victims who are helpless and unable to resist, such as the seriously ill, elderly, or very young, are at greatest risk for victimization. Health-care worker serial murderers decrease risk to themselves by working independently and outside the observation of others. Working evening and night shifts when fewer workers are present frequently occurs in cases of health-care serial murder. (10)

Lucy's Legacy

Lucy kept a detailed diary of her troubled life. Though she did not specifically mention her victims, she wrote often of giving in to her "compulsion." In one instance, the date of these entries coincided with the death of one of her patients. Lucy recorded her struggles to understand her lack of feeling and compassion. She wrote of her "sociopathic" personality and her desire to understand this aspect of herself.

Lucy worked in critical care settings, and her patients were either elderly or children. In almost all of the cases, the victims were either comatose or had a diminished awareness of their surroundings. All were vulnerable and had impaired communicative abilities.

In the case of every victim, colleagues reported that Lucy developed a close rapport with either the patient or the patient's family. She seemed to spend an extraordinary amount of time with them. But, in every case, she had been seen alone with the victims shortly before their deaths or, at least, had made an observation in the medical record not witnessed by another health-care worker. In more than a few cases, Lucy reported a marked deterioration in a patient's status just before death. Strangely, a pattern developed where other nurses had made observations about patient progress that contradicted Lucy's. Also, the hospital accused Lucy of stealing drugs that, coincidently, happened to be the drugs her patients were taking. Autopsies revealed high levels of potassium in some patients. In others, missing morphine, attributed to Lucy, seemed to coincide with several victims' deaths. Though theft of drugs did not play a significant role in the evidentiary part of the verdict of the Court of Appeal, in the case of one victim, intoxication with the drug digoxine was established by expert witnesses beyond any doubt. The case of this little girl, and one other case in which intoxication with chloral hydrate was very likely, came to be important evidence for the court.

Though Lucy was indicted in the deaths of 13 patients and the attempted murder of 5 more, the investigation disclosed that 28 of her patients had died within a 4-year period, with 8 of those being children. Lucy was convicted on four counts of first-degree murder and three counts of attempted murder, as well as perjury, falsifying a high school diploma, and theft of several books from the prison library. Lucy received life imprisonment, the maximum sentence allowed in the Netherlands. (11)


Serial murderers receive attention in American movies and television programs that is disproportionate to their frequency when compared with murders of all types. Sadly, law enforcement professionals in this country also know, all too well, the tremendous suffering these crimes can cause in real life. Officials in the Netherlands, however, never had faced the devastating effects that a serial murderer can create until a children's hospital in The Hague reported an unusually large number of patients dying while under a certain nurse's care.

While this case illustrates that of a female serial murderer, it also provides a glimpse into the equally infrequent sphere of the health-care worker serial murderer. Investigating a case involving an offender whose occupation places a premium on saving lives presents a bitter irony even for the most experienced law enforcement professionals. But, examining the motivation, behavior, and characteristics of such individuals can help investigators and prosecutors not only bring the guilty individuals to justice but also cope with the trauma of such horrific acts.


(1) The authors based this article on a report written for the Public Prosecution Service, The Hague, Netherlands, in preparation for one of the authors' expert testimony at the subject's trial.

(2) Title 28, U.S. Code, Section 540B.

(3) A.H. Buss, The Psychology of Aggression (New York, NY: Wiley, 1961).

(4) R.K. Ressler, A.W. Burgess, and J.E. Douglas, Sexual Homicide: Patterns and Motives (New York, NY: Lexington Books, 1988).

(5) A.C. Brantley and F.M. Ochberg, "Lethal Predators and Future Dangerousness," FBI Law Enforcement Bulletin, April 2003, 16-21.

(6) Ibid.

(7) M.D. Kelleher and C.L. Kelleher, Murder Most Rare: The Female Serial Killer (New York, NY: Random House, 1998).

(8) C. Le Duff, "Prosecutors Say Ex-Doctor Killed Because It Thrilled Him," New York Times, September 6, 2000.

(9) C. Linedecker and W. Burt, Nurses Who Kill (New York, NY: Pinnacle Books, 1990).

(10) R.E Gaetjens, "A Review of Occupational, Behavioral, and Organizational Differences in Health-Care Worker Serial Homicide," (unpublished manuscript, December 20, 2000).

(11) The Dutch legal system allows appellate courts to essentially retry a case. Not only can a convicted party appeal a ruling but the government can appeal an acquittal. The convicted nurse appealed her conviction. On appeal, the defendant was convicted of seven counts of murder and four counts of attempted murder. Her life sentence was upheld.

COPYRIGHT 2005 Federal Bureau of Investigation
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Article Details
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Title Annotation:Health-care workers
Author:Kosky, Robert H., Jr.
Publication:The FBI Law Enforcement Bulletin
Geographic Code:4EUNE
Date:Jan 1, 2005
Previous Article:Gangs.
Next Article:The Bulletin notes.

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