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How did former nurse Charles Cullen get away with murdering dozens, and possibly hundreds, of patients during his 16-year career? The new Netflix documentary "" places the blame squarely on hospital administrators determined to put the interests of their institutions ahead of patient care.

The documentary, which is based on journalist Charles Graeber's book, , tells the story of how Cullen was able to move from hospital to hospital, even when he'd been suspected of causing patient harm. In some instances, he was fired, but was still given good references so he could get a job with a new employer.

Graeber said in the documentary that Cullen was "caught over and over and over again. ... Those who caught him or had a reason to suspect that something was wrong, passed him on with positive or neutral references, and he always found another job. That's the scandal."

The same may have happened at Somerset Medical Center in New Jersey, but officials at the New Jersey Poison Control Center who learned of four suspicious deaths at the hospital pushed its administrators to make a report, Steven Marcus, MD, director of the center at the time, told MedPage Today in a previous interview.

In the documentary, prosecutors said 3 months passed between the poison control center's warning and the hospital making a report to the Somerset County Prosecutor's office. The hospital made the report after conducting its own internal investigation, which detectives asked to review.

"I was expecting a binder," Detective Danny Baldwin said in the documentary. "But it was a document written by an attorney."

It did, however, mention the name of one nurse who'd been questioned -- Cullen. Detectives conducted a background check and found Cullen had two arrests in the 1980s, for drunk driving and for criminal trespass. When Baldwin and Detective Tim Braun called Pennsylvania State Police for more information about those arrests, they discovered a detective there had already been looking into Cullen after medications went missing from St. Luke's University Hospital in Bethlehem.

Missed Opportunities

The case had been brought to Pennsylvania detectives' attention by a St. Luke's critical care nurse, Pat Medellin, who was on duty when Cullen had been escorted out of the hospital and was asked to resign.

She thought back to a time when two patients who'd been very stable had coded within a week of each other. Medellin then looked at the records for 67 deaths, and calculated that Cullen shouldn't have been on duty for more than a quarter of them.

She found he was on shift during 40 of those deaths -- more than twice the number that would make sense, Medellin said in the documentary.

When she reported this to her manager, she said she was met with denial. So she made a report to Pennsylvania State Police, but the investigation was slow and ultimately closed without evidence of wrongdoing on Cullen's part.

Medellin alleged that St. Luke's was attempting to borrow money for the construction of a new site, and any tarnish on their record could have stopped the project from moving forward, so it was easier to let Cullen move on.

"They had a bond rating out for a whole new campus at the time," Graeber said in the documentary. "They just wanted him out of there as quietly as possible ... to minimize the danger of a lawsuit. They protected the institution at the cost of protecting the patients."

In another instance at St. Luke's Warren Hospital in New Jersey, a patient charged that a nurse injected his mother, Helen Dean, just before her death. An internal investigation turned up no evidence of wrongdoing, and once again Cullen was allowed to move on, according to the documentary.

Pyxis Reports and a Secret Weapon

Detectives Baldwin and Braun were concerned that their investigation could end up at a similar conclusion, with no evidence of harm. So Baldwin decided to focus on data from the hospital's Pyxis machines.

When hospital risk manager Mary Lund told Baldwin that the machines only stored data for 30 days, he suspected she was lying. A call to the manufacturer revealed there were no limits to data storage.

With those records in hand, prosecutors also made the hospital aware of a discrepancy on Cullen's employment application, which the hospital used as a basis to fire him.

While that took Cullen away from patients for a while, he continued to look for new jobs, so detectives knew they would need something stronger to keep him out of hospitals.

That's when they met critical care nurse Amy Loughren, who had been close with Cullen during their time at Somerset. While she initially defended her friend, her perspective changed when Baldwin showed her the Pyxis paperwork.

"It was so obvious that there was something sinister in that paperwork," Loughren said in the documentary. Cullen apparently would open the machine to take out potentially deadly medications, then cancel those transactions.

The revelation made Loughren think back to a code blue, where she discovered Cullen standing over the patient and pushing lidocaine. When the resident arrived at the code, he said the patient was allergic to lidocaine.

"I walked in on him murdering someone and I didn't see it," Loughren said.

At that moment she decided she would cooperate with law enforcement, and she ended up becoming their most valuable asset. For one, she printed out records from patient charts when no one was looking -- at great personal risk.

"I had a lot to lose, a career, a family," she said. "I had cardiomyopathy, I was worried about being disabled and not being able to have insurance."

The records helped, as did the family of a patient whose death at Somerset Medical Center was considered suspicious. The sister of Father Francis Gall allowed her brother's body to be exhumed to measure digoxin levels, which turned out to be excessively high.

Still, prosecutors had no confession, which would solidify their case. That's when Loughren agreed to meet Cullen while wearing a wire.

When Loughren told him that she knew he killed Father Gall, she said his whole demeanor changed. He replied that he wanted to go down fighting, and that was enough for detectives to arrest him.

He wouldn't confess to them, though, so once again, they relied on Loughren. They brought her in to the interview room, where she told Cullen that she had been implicated in the crimes. He would be the only one who could exonerate her.

She asked how he killed Father Gall, and he admitted to doing so with digoxin. The detectives took it from there, and on Sunday, Dec. 14, 2003, Cullen admitted to killing up to 40 people -- though experts suggest it was likely that he killed some 400 people.

Holding Hospitals Accountable

Without the criminal case, Cullen may have simply gotten a job at another hospital, where he could have kept on killing patients.

Bruce Ruck, PharmD, of the New Jersey Poison Control Center, described hospitals' motives in the documentary this way: "The hospital is afraid of being sued. Doctors won't bring their patients there, the community doesn't want to go there. The hospital loses money. The board starts firing people."

Marcus, the former poison control center director, had told MedPage Today that Somerset Medical Center was never held accountable for any of the deaths. The hospital was fined, he said, but that was a slap on the wrist.

New Jersey legislators did try to change the system by passing the "Cullen Law," which requires hospitals to report any impairment, incompetence, or professional misconduct by any healthcare provider that pertains to patient safety to the state licensing board. It also requires those reports to be disclosed to any potential future employers.

Still, while Cullen will spend the rest of his life in prison, Graeber noted that "those who were paid big bucks to be responsible have never been held responsible. They did a very good job at their job, which has more to do with the institution of private, for-profit healthcare. They didn't do good."

"They've been rewarded for their success in protecting the institution over the patients," he said.

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