Image courtesy of David Kwiatoski's Facebook profile
The Associated Press reported the guilty plea of David Kwiatkowski who worked at 4 hospitals in Michigan, including the University of Michigan Medical Center[1].
“Hospital technician David Kwiatkowski pleads guilty to stealing drugs, infecting patients with hepatitis C
Kwiatkowski, 34, said he was 'guilty' of 'killing a lot of people' by stealing painkiller syringes and replacing them with saline-filled syringes tainted with his blood.
A traveling hospital technician accused of causing a multistate outbreak of hepatitis C last year pleaded guilty Wednesday to federal drug charges in New Hampshire under an agreement that calls for him to serve 30 to 40 years in prison.
According to the plea agreement filed Monday, Kwiatkowski told investigators he had been stealing drugs since 2002 — the year before he finished his medical training — and that his actions were "killing a lot of people." His lawyers have declined numerous interview requests.
Forty-six people in four states in hospitals where Kwiatkowski worked have been diagnosed with the same strain of hepatitis C he carries: 32 patients in New Hampshire, seven in Maryland, six in Kansas, and one in Pennsylvania. One of the Kansas patients died, and authorities say hepatitis C, which can cause liver disease and chronic health problems, played a contributing role.”[2]
Mr. Kwiatkowski worked in the interventional radiology facility at UMMC from August 21, 2006 until December 8, 2006 when he resigned while under suspension for suspicion of stealing narcotics from the hospital[3]. There were three investigations of the theft of narcotics during Mr. Kwiatkowski’s employment and he was a suspect in each case. The hospital did not report the thefts to UM police until after the third incident.
The first investigation was conducted by Hospital Security Officer, Jacob Mouro with regard to the theft of 1 vial of Versed and 1 vial of Fentanyl from a procedure room in the interventional radiology facility on Sept 21, 2006[4]. A nurse, Linda Campbell, had set up two sets of medications for the procedure and left the room for a few minutes. When she returned one of the sets was missing. Hospital Security Officer, L. Smith, interviewed all of the employees in the area during the time that the nurse was out of the room, including David Kwiatkowski, but no one took responsibility. There was no drug testing and the theft was not reported to the police.
The second investigation was conducted by Hospital Security Officer, Thomas Schottin, with regard to the theft of two vials of Versed and two vials of Fentanyl from a procedure room in the interventional radiology facility on October 10, 2006[5]. A nurse, Sophia Jan, had prepared the vials for a procedure and left them on the counter with a post-it note on them and in a Kleenex box. The procedure was cancelled and the vials were left unattended and went missing between 1:15 PM and 1:35 PM. David Kwiatkowski was again one of the employees working in the area. There was no drug testing and the theft was not reported to police. Hospital Security Officer, L. Smith interviewed Kwiatkowski and tried to contact the human resources departments at each of the hospitals he had previously worked at. The hospitals said that they could not release any information about his employment or resignation.
The third investigation was conducted by Hospital Security Officer, Ryan Walter, with regard to the theft of 1 vial of Fentanyl from the control room of the interventional radiology facility on December 7, 2006[6]. A nurse, Staci Royer, had left a vial of Fentanyl on the counter in the control room and left to get a glass of water. Further interviews were conducted by Hospital Security Officer, Laura Dodd. Another employee, Laura Bushy, had seen Mr. Kwiatkowski in the control room during the short time that Staci Royer was absent. He claimed to be looking for a Band-Aid. A search eventually found the vial of Fentanyl in another procedure room. This time Mr. Kwiatkowski was suspended and Hospital Security called campus police, who examined the vial for fingerprints. None were found. Mr. Kwiatkowski agreed to resign and the police investigation was closed.
Between 2007 and 2011, Mr. Kwiatkowski moved around the country working at many different hospitals, all presumably unaware of his history. According to his plea agreement, Mr. Kwiatkowski admits the following[7];
“The defendant worked at multiple health care facilities in Michigan between 2003 and 2007. The defendant was terminated from a position with St. Joseph Mercy Health System in 2004 after testing positive for controlled substances. The defendant was terminated by William Beaumont Hospital in 2004 for "gross misconduct." The defendant resigned from a position at the University of Michigan Hospital in 2006 while an investigation related to missing controlled substances (including fentanyl) was under way. The defendant resigned from a position at Oakwood Annapolis Hospital after he was suspended pending an investigation of his potential controlled substance use.
Beginning in November of 2007, the defendant began working as a "traveler." Working through various placement agencies, the defendant would take short-term positions at different medical facilities. Between 2007 and 2011, the defendant worked in New York, Pennsylvania, Maryland, Arizona, Kansas, Georgia, and New Hampshire.
In May of 2008, the defendant was terminated from a placement at the University of Pittsburgh Medical Center. On or about May 7, 2008, an employee witnessed the defendant remove a syringe of fentanyl from an operating room. Subsequent testing showed that the defendant had replaced that syringe with another syringe that did not contain fentanyl. A search of the defendant's person revealed three empty syringes bearing "fentanyl" labels. While a basic drug screen of the defendant did not reveal any controlled substances, a more sophisticated analysis later detected the presence of fentanyl in the defendant's system.
Less than two weeks later, the defendant began a placement at the VA Medical Center in Baltimore, Maryland. The defendant worked there between May and November of 2008. While the defendant was working at the facility, a patient received fentanyl during a procedure on or about May 27, 2008. The patient had no known risk factors for Hepatitis C. The patient subsequently has been found to have a strain of Hepatitis C that has been genetically linked to the strain of Hepatitis C with which the defendant is infected.
Between July of 2009, and January of 2010, the defendant worked at Johns Hopkins University Hospital in Baltimore, Maryland. At least six patients who were treated at Johns Hopkins during the time frame that the defendant worked at the hospital have been found to have a strain of Hepatitis C that has been genetically linked to the strain with which the defendant is infected.
Between March of 2010, and April of 2010, the defendant worked at the Arizona Heart Hospital in Phoenix, Arizona. According to witnesses and records from Arizona, on or about April 1, 2012, the defendant was found unresponsive in a restroom. A needle and syringe labeled "fentanyl" were observed by witnesses to be floating in the toilet. After regaining consciousness, the defendant flushed the toilet and expressed concerns about going to jail. He later admitted to injecting himself with fentanyl, but denied a history of drug use. Subsequent drug testing showed that the defendant had marijuana and cocaine in his system. Although no opiates were detected in the defendant's system, the drug screen did not specifically test for fentanyl.
In May of 2010, the defendant worked at Hays Medical Center in Hays, Kansas. While the defendant was working in Kansas, he was told by a physician that he had Hepatitis C. At least six patients who were treated at Hays during the time that the defendant worked there have been found to be infected with a strain of Hepatitis C that has been genetically linked to the strain with which the defendant is infected.
One of these individuals, KS Patient #1, underwent cardiac catheterization procedures on or about June 7, 2010, and July 12, 2010. Records show that the defendant participated in both procedures. KS Patient #1 has died and a coroner has concluded that Hepatitis C played a contributing role in the patient's death.
In April of 2011, the defendant took a temporary position at Exeter Hospital in Exeter, New Hampshire. He subsequently was hired as a full-time employee in the fall of 2011. The defendant's coworkers noticed that the defendant sometimes exhibited unusual behavior, including sweating, having bloodshot eyes, leaving procedures before they were completed, and telling false stories…
In May of 2012, representatives of Exeter Hospital identified several unexplained cases of Hepatitis C involving individuals who had been treated at the CCL. The defendant also was diagnosed with Hepatitis C and falsely advised caregivers and others that he was unaware that he had this disease when he in fact had been aware of this diagnosis since 2010. A public health investigation was initiated that later determined that the source of the outbreak of Hepatitis C was drug diversion by the defendant. The medical literature contains several examples of situations where health care workers transmitted Hepatitis C by stealing fentanyl, injecting the drug into their body, refilling the syringe with saline, and then allowing the contents of the saline-filled syringe (which was tainted with the Hepatitis C virus) to be injected into the patient…
He also admitted that while working at Exeter Hospital, he would "swap out" fentanyl by taking a syringe of fentanyl and replacing it with a syringe of saline. He would use the fentanyl by injecting it into his arm. Afterward, he would refill the used syringe with saline and then perform another swap…
The defendant admitted that he had been diverting controlled substances, including fentanyl, since approximately 2002…
As a result of the defendant's actions, public health departments and the Centers for Disease Control and Prevention ("CDC") conducted a massive public health investigation. Public health authorities recommended that over 11,000 people get tested for possible Hepatitis C infection as a result of the defendant's conduct.
The CDC has conducted genetic testing known as quasispecies analysis that can determine the genetic relatedness between different samples of the Hepatitis C virus. That testing has determined that at least 32 patients who were treated at Exeter Hospital, six patients from Johns Hopkins, one patient from the VA Medical Center in Baltimore, and six patients from Hays Medical Center all share the same strain of Hepatitis C as the defendant. Based upon the defendant's admissions and the scientific and epidemiological evidence, the defendant's drug diversion conduct resulted in each of these infections. Several of the victims who were infected with Hepatitis C have experienced very serious health complications.”
The U.S. Attorney who is prosecuting this case in New Hampshire had the following to say about the lack of reporting by his previous employers;
"I can tell you that based on information we've derived so far, his conduct should have been reported to law enforcement authorities — conduct in diverting drugs and acquiring controlled substances," Kacavas said Tuesday. "I think that had he been stopped from diverting drugs some years ago, maybe this would not have happened."[8]
His remorse is limited. He had the following to say;
“You know, I’m more concerned about myself, my own well-being,” he told investigators. “That’s all I’m really concerned about and I’ve learned here to just worry about myself and that’s all I really care about now.”[9]
Many hospitals had the opportunity to stop Mr. Kwiatkowski before he infected all of these people, including the University of Michigan Medical Center. There seems to be an oft repeated pattern of employers who do not want to risk a lawsuit from an employee, who were perfectly willing to allow that employee to resign without any warning to future employers about the circumstances of their firing.
Mr. Kwiatkowski was accredited by the American Registry of Radiologic Technician until his accreditation was revoked after his arrest in September 2012[10]. One of the ethical requirements of accreditation is that any technologist who is accredited by ARRT must report any violations of ethical standards by another accredited technologist to the ARRT. Apparently, no one reported Mr. Kwiatkowski to ARRT.
The Centers for Disease Control in Atlanta has investigated 6 outbreaks of Hepatitis C that were the result of hospital workers diverting drugs from patients[11]. All but one of those cases involved multiple infected patients. The long delays in reporting and the difficulty of linking the cases to an individual make it all the more important that hospitals aggressively investigate and report cases of drug diversion by employees.
This case also illustrates the problems that have been evident between the Hospital Security Department and the Campus Police. Hospital security took responsibility to investigate what was a crime, the theft of narcotics. They did not report any of the incidents to the campus police until the third theft. Other employers performed drug testing on Mr. Kwiatkowski after suspecting him of diverting narcotics. Why didn’t the University of Michigan? When he was finally caught by New Hampshire police, they conducted a search and found multiple syringes marked “fentanyl”. Why didn’t the campus police ask for a search warrant? Once he resigned from UM, the campus police closed the case, with no regard for the risk that he posed to future patients. Diane Brown, spokesperson for the UM Dept. of Public Safety said last year in an article in AA.com as follows;
Kwiatkowski, formerly of Canton, was interviewed by U-M’s Department of Public Safety as a part of the investigation Dec. 15, 2006, but was never considered an official suspect because there wasn’t enough information to turn the case over to the prosecutor’s office, Brown said.
It even appears that he learned at UM that taking the vials would alert others to the missing drugs, which lead him to refine his method to replacing the syringes with ones containing saline tainted with his own blood.
This case should provide an object lesson and should be taught in every hospital management program and to every campus police department in the nation.
[1] 01 Kwiatkowski resume
[2] http://www.nydailynews.com/life-style/health/hospital-tech-pleads-guilty-infecting-patients-hepatitis-article-1.1426542
[3] 02 Kwiatkowski department personnel file
[4] 03 Investigation report of the first incident
[5] 04 Investigation report of the second incident
[6] 05 Investigation report of the third incident
[7] 06 Plea Agreement
[8] http://www.fosters.com/apps/pbcs.dll/article?AID=/20120725/GJNEWS_01/707259933
[9] http://theblondepharmacist.com/2012/07/28/who-is-david-matthew-kwiatkowski/
[10] 07 ARRT Certification
[11] http://www.concordmonitor.com/news/4220717-95/story.html
“Hospital technician David Kwiatkowski pleads guilty to stealing drugs, infecting patients with hepatitis C
Kwiatkowski, 34, said he was 'guilty' of 'killing a lot of people' by stealing painkiller syringes and replacing them with saline-filled syringes tainted with his blood.
A traveling hospital technician accused of causing a multistate outbreak of hepatitis C last year pleaded guilty Wednesday to federal drug charges in New Hampshire under an agreement that calls for him to serve 30 to 40 years in prison.
According to the plea agreement filed Monday, Kwiatkowski told investigators he had been stealing drugs since 2002 — the year before he finished his medical training — and that his actions were "killing a lot of people." His lawyers have declined numerous interview requests.
Forty-six people in four states in hospitals where Kwiatkowski worked have been diagnosed with the same strain of hepatitis C he carries: 32 patients in New Hampshire, seven in Maryland, six in Kansas, and one in Pennsylvania. One of the Kansas patients died, and authorities say hepatitis C, which can cause liver disease and chronic health problems, played a contributing role.”[2]
Mr. Kwiatkowski worked in the interventional radiology facility at UMMC from August 21, 2006 until December 8, 2006 when he resigned while under suspension for suspicion of stealing narcotics from the hospital[3]. There were three investigations of the theft of narcotics during Mr. Kwiatkowski’s employment and he was a suspect in each case. The hospital did not report the thefts to UM police until after the third incident.
The first investigation was conducted by Hospital Security Officer, Jacob Mouro with regard to the theft of 1 vial of Versed and 1 vial of Fentanyl from a procedure room in the interventional radiology facility on Sept 21, 2006[4]. A nurse, Linda Campbell, had set up two sets of medications for the procedure and left the room for a few minutes. When she returned one of the sets was missing. Hospital Security Officer, L. Smith, interviewed all of the employees in the area during the time that the nurse was out of the room, including David Kwiatkowski, but no one took responsibility. There was no drug testing and the theft was not reported to the police.
The second investigation was conducted by Hospital Security Officer, Thomas Schottin, with regard to the theft of two vials of Versed and two vials of Fentanyl from a procedure room in the interventional radiology facility on October 10, 2006[5]. A nurse, Sophia Jan, had prepared the vials for a procedure and left them on the counter with a post-it note on them and in a Kleenex box. The procedure was cancelled and the vials were left unattended and went missing between 1:15 PM and 1:35 PM. David Kwiatkowski was again one of the employees working in the area. There was no drug testing and the theft was not reported to police. Hospital Security Officer, L. Smith interviewed Kwiatkowski and tried to contact the human resources departments at each of the hospitals he had previously worked at. The hospitals said that they could not release any information about his employment or resignation.
The third investigation was conducted by Hospital Security Officer, Ryan Walter, with regard to the theft of 1 vial of Fentanyl from the control room of the interventional radiology facility on December 7, 2006[6]. A nurse, Staci Royer, had left a vial of Fentanyl on the counter in the control room and left to get a glass of water. Further interviews were conducted by Hospital Security Officer, Laura Dodd. Another employee, Laura Bushy, had seen Mr. Kwiatkowski in the control room during the short time that Staci Royer was absent. He claimed to be looking for a Band-Aid. A search eventually found the vial of Fentanyl in another procedure room. This time Mr. Kwiatkowski was suspended and Hospital Security called campus police, who examined the vial for fingerprints. None were found. Mr. Kwiatkowski agreed to resign and the police investigation was closed.
Between 2007 and 2011, Mr. Kwiatkowski moved around the country working at many different hospitals, all presumably unaware of his history. According to his plea agreement, Mr. Kwiatkowski admits the following[7];
“The defendant worked at multiple health care facilities in Michigan between 2003 and 2007. The defendant was terminated from a position with St. Joseph Mercy Health System in 2004 after testing positive for controlled substances. The defendant was terminated by William Beaumont Hospital in 2004 for "gross misconduct." The defendant resigned from a position at the University of Michigan Hospital in 2006 while an investigation related to missing controlled substances (including fentanyl) was under way. The defendant resigned from a position at Oakwood Annapolis Hospital after he was suspended pending an investigation of his potential controlled substance use.
Beginning in November of 2007, the defendant began working as a "traveler." Working through various placement agencies, the defendant would take short-term positions at different medical facilities. Between 2007 and 2011, the defendant worked in New York, Pennsylvania, Maryland, Arizona, Kansas, Georgia, and New Hampshire.
In May of 2008, the defendant was terminated from a placement at the University of Pittsburgh Medical Center. On or about May 7, 2008, an employee witnessed the defendant remove a syringe of fentanyl from an operating room. Subsequent testing showed that the defendant had replaced that syringe with another syringe that did not contain fentanyl. A search of the defendant's person revealed three empty syringes bearing "fentanyl" labels. While a basic drug screen of the defendant did not reveal any controlled substances, a more sophisticated analysis later detected the presence of fentanyl in the defendant's system.
Less than two weeks later, the defendant began a placement at the VA Medical Center in Baltimore, Maryland. The defendant worked there between May and November of 2008. While the defendant was working at the facility, a patient received fentanyl during a procedure on or about May 27, 2008. The patient had no known risk factors for Hepatitis C. The patient subsequently has been found to have a strain of Hepatitis C that has been genetically linked to the strain of Hepatitis C with which the defendant is infected.
Between July of 2009, and January of 2010, the defendant worked at Johns Hopkins University Hospital in Baltimore, Maryland. At least six patients who were treated at Johns Hopkins during the time frame that the defendant worked at the hospital have been found to have a strain of Hepatitis C that has been genetically linked to the strain with which the defendant is infected.
Between March of 2010, and April of 2010, the defendant worked at the Arizona Heart Hospital in Phoenix, Arizona. According to witnesses and records from Arizona, on or about April 1, 2012, the defendant was found unresponsive in a restroom. A needle and syringe labeled "fentanyl" were observed by witnesses to be floating in the toilet. After regaining consciousness, the defendant flushed the toilet and expressed concerns about going to jail. He later admitted to injecting himself with fentanyl, but denied a history of drug use. Subsequent drug testing showed that the defendant had marijuana and cocaine in his system. Although no opiates were detected in the defendant's system, the drug screen did not specifically test for fentanyl.
In May of 2010, the defendant worked at Hays Medical Center in Hays, Kansas. While the defendant was working in Kansas, he was told by a physician that he had Hepatitis C. At least six patients who were treated at Hays during the time that the defendant worked there have been found to be infected with a strain of Hepatitis C that has been genetically linked to the strain with which the defendant is infected.
One of these individuals, KS Patient #1, underwent cardiac catheterization procedures on or about June 7, 2010, and July 12, 2010. Records show that the defendant participated in both procedures. KS Patient #1 has died and a coroner has concluded that Hepatitis C played a contributing role in the patient's death.
In April of 2011, the defendant took a temporary position at Exeter Hospital in Exeter, New Hampshire. He subsequently was hired as a full-time employee in the fall of 2011. The defendant's coworkers noticed that the defendant sometimes exhibited unusual behavior, including sweating, having bloodshot eyes, leaving procedures before they were completed, and telling false stories…
In May of 2012, representatives of Exeter Hospital identified several unexplained cases of Hepatitis C involving individuals who had been treated at the CCL. The defendant also was diagnosed with Hepatitis C and falsely advised caregivers and others that he was unaware that he had this disease when he in fact had been aware of this diagnosis since 2010. A public health investigation was initiated that later determined that the source of the outbreak of Hepatitis C was drug diversion by the defendant. The medical literature contains several examples of situations where health care workers transmitted Hepatitis C by stealing fentanyl, injecting the drug into their body, refilling the syringe with saline, and then allowing the contents of the saline-filled syringe (which was tainted with the Hepatitis C virus) to be injected into the patient…
He also admitted that while working at Exeter Hospital, he would "swap out" fentanyl by taking a syringe of fentanyl and replacing it with a syringe of saline. He would use the fentanyl by injecting it into his arm. Afterward, he would refill the used syringe with saline and then perform another swap…
The defendant admitted that he had been diverting controlled substances, including fentanyl, since approximately 2002…
As a result of the defendant's actions, public health departments and the Centers for Disease Control and Prevention ("CDC") conducted a massive public health investigation. Public health authorities recommended that over 11,000 people get tested for possible Hepatitis C infection as a result of the defendant's conduct.
The CDC has conducted genetic testing known as quasispecies analysis that can determine the genetic relatedness between different samples of the Hepatitis C virus. That testing has determined that at least 32 patients who were treated at Exeter Hospital, six patients from Johns Hopkins, one patient from the VA Medical Center in Baltimore, and six patients from Hays Medical Center all share the same strain of Hepatitis C as the defendant. Based upon the defendant's admissions and the scientific and epidemiological evidence, the defendant's drug diversion conduct resulted in each of these infections. Several of the victims who were infected with Hepatitis C have experienced very serious health complications.”
The U.S. Attorney who is prosecuting this case in New Hampshire had the following to say about the lack of reporting by his previous employers;
"I can tell you that based on information we've derived so far, his conduct should have been reported to law enforcement authorities — conduct in diverting drugs and acquiring controlled substances," Kacavas said Tuesday. "I think that had he been stopped from diverting drugs some years ago, maybe this would not have happened."[8]
His remorse is limited. He had the following to say;
“You know, I’m more concerned about myself, my own well-being,” he told investigators. “That’s all I’m really concerned about and I’ve learned here to just worry about myself and that’s all I really care about now.”[9]
Many hospitals had the opportunity to stop Mr. Kwiatkowski before he infected all of these people, including the University of Michigan Medical Center. There seems to be an oft repeated pattern of employers who do not want to risk a lawsuit from an employee, who were perfectly willing to allow that employee to resign without any warning to future employers about the circumstances of their firing.
Mr. Kwiatkowski was accredited by the American Registry of Radiologic Technician until his accreditation was revoked after his arrest in September 2012[10]. One of the ethical requirements of accreditation is that any technologist who is accredited by ARRT must report any violations of ethical standards by another accredited technologist to the ARRT. Apparently, no one reported Mr. Kwiatkowski to ARRT.
The Centers for Disease Control in Atlanta has investigated 6 outbreaks of Hepatitis C that were the result of hospital workers diverting drugs from patients[11]. All but one of those cases involved multiple infected patients. The long delays in reporting and the difficulty of linking the cases to an individual make it all the more important that hospitals aggressively investigate and report cases of drug diversion by employees.
This case also illustrates the problems that have been evident between the Hospital Security Department and the Campus Police. Hospital security took responsibility to investigate what was a crime, the theft of narcotics. They did not report any of the incidents to the campus police until the third theft. Other employers performed drug testing on Mr. Kwiatkowski after suspecting him of diverting narcotics. Why didn’t the University of Michigan? When he was finally caught by New Hampshire police, they conducted a search and found multiple syringes marked “fentanyl”. Why didn’t the campus police ask for a search warrant? Once he resigned from UM, the campus police closed the case, with no regard for the risk that he posed to future patients. Diane Brown, spokesperson for the UM Dept. of Public Safety said last year in an article in AA.com as follows;
Kwiatkowski, formerly of Canton, was interviewed by U-M’s Department of Public Safety as a part of the investigation Dec. 15, 2006, but was never considered an official suspect because there wasn’t enough information to turn the case over to the prosecutor’s office, Brown said.
It even appears that he learned at UM that taking the vials would alert others to the missing drugs, which lead him to refine his method to replacing the syringes with ones containing saline tainted with his own blood.
This case should provide an object lesson and should be taught in every hospital management program and to every campus police department in the nation.
[1] 01 Kwiatkowski resume
[2] http://www.nydailynews.com/life-style/health/hospital-tech-pleads-guilty-infecting-patients-hepatitis-article-1.1426542
[3] 02 Kwiatkowski department personnel file
[4] 03 Investigation report of the first incident
[5] 04 Investigation report of the second incident
[6] 05 Investigation report of the third incident
[7] 06 Plea Agreement
[8] http://www.fosters.com/apps/pbcs.dll/article?AID=/20120725/GJNEWS_01/707259933
[9] http://theblondepharmacist.com/2012/07/28/who-is-david-matthew-kwiatkowski/
[10] 07 ARRT Certification
[11] http://www.concordmonitor.com/news/4220717-95/story.html
| 01_david_kwiatkowski_resume.pdf |
| 02_kwiatowski_personnel_file_dept.pdf |
| 03_kwiatowski_security_dept_report_01.pdf |
| 04_kwiatowski_security_dept_report_02.pdf |
| 05_kwiatowski_security_dept_report_03.pdf |
| 06_david_kwiatkowski_plea_agreement.pdf |
| 07_david_kwiatkowski_arrt_certification.pdf |
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