**BLIND EYE:**

**HOW THE MEDICAL ESTABLISHMENT LET A DOCTOR GET AWAY WITH MURDER**

[Book Review by Major Matthew J. Ruane]{.smallcaps}[^1]

By dissecting dozens of failed investigations into the exploits of
serial poison-killing physician Michael Swango, Pulitzer Prize-winning
author James B. Stewart created a magnificent teaching tool for judge
advocates and other lawyers, investigators, and health care
professionals. The key lessons of *Blind Eye* are derived from Stewart's
meticulous analyses of flawed investigations conducted by medical school
faculty,[^2] senior administrators,[^3] experienced police,[^4] seasoned
district attorneys,[^5] and even a law school dean,[^6] throughout
Swango's seventeen-year poisoning spree. Stewart exposes embarrassing
and simple blunders in evidence gathering[^7] and other investigative
missteps that allowed Swango to kill approximately sixty patients while
practicing medicine in four states and three African countries over
almost two decades. Incredibly, despite repeated exposure of the facts
by the national media,[^8] it was only after publication of this book
that a prosecutor finally managed to convict Swango of murder.[^9]

Despite the valuable lessons *Blind Eye* offers, Stewart unfortunately
overreaches in concluding that Swango owed his successful avoidance of
the law for such a long period to the greed of the medical
establishment. Indeed, in his effort to indict the medical community,
Stewart often glosses over the key reason Swango eluded the law for so
long: Swango was an extremely intelligent psychopath who took advantage
of inefficient bureaucracies. Nevertheless, thanks to Stewart's
exhaustive research and superb attention to detail in evaluating the
investigations, *Blind Eye* presents a gold mine of lessons for
professionals.

This review provides an overview of the blunders that enabled Swango to
practice deadly medicine, as well as an analysis of two of the basic
lessons presented: the importance of early legal involvement in adverse
personnel actions and the danger of giving legal opinions without
carefully examining all of the relevant evidence. This review suggests
that *Blind Eye* would have been a better book had the author focused
more intellectual energy on the lessons learned in pursuing Swango and
less on his own elusive case against the medical establishment.

## I. Overview {#i.-overview .unnumbered}

In his childhood, Swango was above average socially and academically,
despite a home life strained by his alcoholic father's frequent
deployments to Vietnam and his mother's emotional distance.[^10] In
college, however, classmates noticed Swango's gradual social withdrawal,
starting in his sophomore year. As Swango withdrew, he began exploring
what was to become a lifelong past-time: avidly reading about cases
involving violent and gruesome death. He also began talking about going
to medical school.[^11]

At the end of his sophomore year, Swango withdrew from college and began
a short and unremarkable two-year stint in the Marine Corps. Following
discharge, he returned to college and pursued premedical courses
exclusively. He wrote his senior chemistry thesis on the subject of
ricin, a poison that kills without leaving any identifiable trace.[^12]

After obtaining his undergraduate degree in chemistry in 1979 from
Quincy College in Quincy, Illinois, Swango began his murderous odyssey
as a medical student at Southern Illinois University (SIU). From the
beginning, his classmates found it odd that Swango never expressed any
interest in patient well-being nor offered any particular reason why he
wanted to become a doctor. In fact, the only element of the curriculum
for which he showed any enthusiasm was toxicology, the study of
poisons.[^13] Additionally, many students noticed that an unusually
large number of patients unexpectedly died in whatever ward Swango was
assigned. This phenomenon was obvious enough to earn him the nickname
"Double O Swango," meant to imply that, like the famed fictional James
Bond, British Agent 007, Swango had a license to kill.[^14]

With his medical degree from SIU in hand, Swango pursued several
short-lived internships at various hospitals throughout the country.
Carelessness allowed the school that accepted him as an intern, Ohio
State University, to overlook a warning letter from Swango's medical
school cautioning the university's faculty that there had been concern
about his professional behavior.[^15] If only the letter in Swango's
application file had been read, Swango would have likely been either
denied employment in Ohio's internship program or watched closely enough
to prevent the five poisoning deaths that occurred during his
internship.

Here, Stewart overreaches and attempts to construe this tragic but
simple carelessness as evidence of some greedy conspiracy by the medical
establishment. He weakly supports this thesis by discussing the American
Medical Association's (AMA) political opposition to physician misconduct
reporting laws.[^16] However, this support is misplaced because there is
no nexus between the AMA's political agenda and Ohio State's
carelessness in overlooking the written warnings on Swango. Stewart's
view on this point should not distract the reader from the real lesson,
which is the critical importance of attention to detail in
administrative matters.

Despite a 1986 conviction and two-year prison term for nonfatal
poisoning of coworkers' soft drinks and donuts, Swango continued to gain
employment and access to patients in a succession of hospitals after his
release in 1988 through 1997. Blundering administrators at South Dakota
and New York hospitals accepted Swango's explanation that the 1986
poisoning conviction was actually a miscarriage of justice. As the
limited information that they received from the AMA and state licensing
authorities did not contradict Swango's excuses, he was accepted into
the South Dakota and later, New York residency programs. Had
administrators simply contacted the appropriate courthouse, they would
have learned that there was ample proof at trial that Swango had
repeatedly poisoned his ambulance service coworkers with arsenic-laced
soft drinks and donuts. Given the lack of courthouse contact, it was not
until network producers of the television show, "The Justice Files,"
aired an episode on Swango's past that South Dakota administrators
learned of Swango\'s misdeeds and ended his residency.

Despite the widespread publicity, at least some did not know about his
notoriety: Swango gained admittance to a New York residency without the
hospital administrators' knowledge of his story. To gain admittance, he
again lied about the poisoning conviction on his application, which
worked because the administrators failed to check with prosecutors or
the court for details of the case. The full truth of the Swango story
reached New York administrators only after their South Dakota
counterparts learned through informal contacts that Swango had obtained
new employment in New York. Upon learning of his new position, South
Dakota administrators phoned the New York hospital, effectively ending
Swango's residency there. If the administrators had taken the time to
call the district attorney who had prosecuted Swango, these hospitals
would have learned about Swango's gruesome past. Almost certainly,
several subsequent New York murders would have been prevented.[^17]

Following Swango's aborted South Dakota and New York medical
residencies, New York hospital officials contacted Federal Bureau of
Investigation (FBI) officials who opened an investigation. However,
Swango quietly left the United States for medical employment in Africa
before the FBI found sufficient evidence of murder to arrest him. The
tragedy is that while the FBI struggled to develop probable cause to
arrest Swango for murder, it overlooked the strong case it had against
him for submitting false statements to gain the position in the New York
hospital.[^18] Distracted by his premise that the medical
establishment's greed was to blame for Swango's gruesome crimes, Stewart
misses yet another opportunity to emphasize the importance of careful
and comprehensive legal analysis.

Initially, African hospitals fared much better in investigating Swango.
Immediately after suspicious deaths occurred in the rural Zimbabwe
hospital where Swango worked, the hospital staff suspended his practice
and contacted the police. The resulting search of Swango's quarters
yielded a large supply of poisons, including potassium chloride, a
deadly chemical compound that is undetectable in human bodies after
death. Although the Zimbabwean authorities reacted quickly, notifying
police who were able to preserve key evidence, authorities failed to
arrest him before he took his medical practice to another town.
Unfortunately, Swango was able to claim victims in another African
hospital before authorities closed in on him again. After the African
bureaucracy spread word of Swango's murderous medical practice and
closed other potential avenues for his employment in Africa, he began to
look elsewhere.[^19]

During Swango's sojourn in Africa, U.S. authorities finally devised a
strategy to prosecute him. The Justice Department issued a warrant for
his arrest for the false statements he had made to the New York
hospital, and he was finally arrested on June 27, 1997, while traveling
through the United States, on his way from Johannesburg, South Africa,
to accept a medical position in Saudi Arabia.[^20] Thereafter, Swango
was convicted and sentenced to jail for forty-two months, during which
time the Justice Department conducted an exhaustive search for evidence
of murder in the dozens of suspicious patient deaths that occurred under
his care.[^21]

*Blind Eye* offers many lessons relevant to legal and health care
professionals and to laypersons involved in employment-related adverse
actions. Two such lessons, particularly instructive to judge
advocates,[^22] are the importance of early legal involvement in adverse
personnel actions and the danger of providing legal opinions without
carefully reviewing all of the relevant evidence.

### II. Example Case Studies

#### A. Early Legal Involvement in Adverse Actions

In 1982, Swango's senior year at SIU, the medical staff attempted
unsuccessfully to expel him for cheating and endangering patients. The
school's administrative proceeding arose after Swango's obstetrics and
gynecology (OB/GYN) professor determined that Swango had submitted
fabricated reports on patients' progress.[^23] The OB/GYN professor
swiftly referred the matter to the OB/GYN faculty, and they agreed with
the professor's allegation.

The faculty was "appalled and angry at Swango's brazen misconduct and
dishonesty which very well may have posed a threat to patient
health."[^24] In particular, the faculty\'s departmental chairman
concluded that Swango was a "bald faced liar" and said that such
misconduct alone was sufficient grounds to expel him.[^25] If the school
expulsion committee had agreed with this assessment, Swango's path to
becoming a serial killing-doctor would have ended right there.

Unfortunately, the expulsion committee did not review the same evidence
because the OB/GYN faculty failed to preserve copies of the
incriminating reports. Incredibly, the faculty left the original and all
copies of the reports in the patient medical records, which Swango could
still access. Later, when the faculty sought to show them to the
expulsion committee, they were missing. Owing to the lack of evidence,
the expulsion committee did not unanimously agree that Swango had
cheated and thus, according to its own rules, Swango could not be
expelled.[^26] Sadly, some basic, early legal guidance on safeguarding
evidence in the faculty\'s proceeding might have stopped Swango's
murderous medical career before it got started.

In discussing this episode, Stewart unconvincingly implies that SIU did
not expel Swango out of a fear of litigation. A careful reading reveals
that, to the contrary, SIU took the allegations of cheating very
seriously and took immediate steps to investigate. Once convinced that
the charges were valid, the staff proceeded deliberately, though
unsuccessfully, against Swango through its established hearing process.
Although Stewart attempts to make much of the fact that Swango hired an
attorney, he fails to acknowledge that the attorney did not stop SIU
from seeking the maximum punishment, expulsion. Upon having failed in
its expulsion attempt, the school devoted significant resources to keep
Swango under close scrutiny for the remainder of school term and gave
him extra assignments with the faculty's strictest professors.[^27] The
school\'s response was not that of a lazy or litigation-fearing medical
system as Stewart argues; rather, the institution simply lacked legal
acumen on the matter.

**B. The Danger of Giving Legal Opinions without Carefully Reviewing All
of the Facts**

In 1984, another opportunity to stop Swango was lost when attorneys
reviewing accusations of poisoning failed to aggressively seek out and
review all of the relevant evidence. At this time, Swango was a general
surgery intern at Ohio State University Hospital. A nurse and two
patients saw Swango administer an unscheduled injection to one of the
patients, Mrs. Cooper. Within minutes, Mrs. Cooper suffered a
respiratory arrest and might not have survived the episode without the
quick actions of the nurse. The nurse immediately informed the staff of
what she had seen, and Mrs. Cooper accused Swango of poisoning her. For
his part, Swango gave conflicting stories to the staff, first denying
being in the room, and later stating that Mrs. Cooper had complained
that her feet were cold and that he was putting her slippers on them.

Another disturbing fact is that a second nurse saw Swango discard a used
syringe in a vacant room a few minutes after the episode. She wrapped it
in paper and gave it to the hospital's chief nurse who put it in a desk
drawer.

The medical staff convened an emergency meeting to consider the
accusations and requested an attorney attend as well. Despite strenuous
objections by the nurses, the attorney disregarded the eyewitness
accounts and the potential evidentiary value of the syringe. He
incorrectly reasoned that because hospitals routinely use syringes for
many types of legitimate medical purposes, the syringe that had been
kept by the chief nurse had no particular significance; thus, he
overlooked the fact that testing of this particular syringe may have
produced useful evidence of the crime and that the syringe may have been
used to corroborate eyewitness testimony. Rather, the attorney simply
concluded that there "wasn't any credible evidence of a crime" and did
not recommend contacting the police.[^28] With this hasty opinion and
recommendation, the attorney lost the opportunity to collect and analyze
potentially critical evidence when the trail was fresh.[^29]

Unfortunately, the attorney's advice did not get any better when the
staff meeting reconvened a few weeks later. The staff reviewed the
evidence collected in a cursory in-house investigation conducted by one
of the physicians. This time, scant attention was paid to three
eyewitnesses. The investigator inexplicably disregarded one of the
eyewitnesses, a patient who witnessed Swango injecting Mrs. Cooper. He
described the two remaining witnesses as "a crazy patient who had an
unusual episode and a nurse who saw something." He asked, "Is that
enough to prove anything?"[^30] Maddeningly, with only this information,
the lawyer then opined that there was "no legal basis for accusing
Swango of a criminal act or, for that matter, even removing him from the
intern program."[^31]

This legal opinion was harshly criticized by the Dean of the Ohio State
University Law School who reviewed the case after Swango was implicated
in other poisonings. The Dean concluded that based on the testimony of
the witnesses alone, the situation should have been investigated
further. Additionally, he said "assuming hypothetically that all three
witnesses to an event are psychotic, the fact that they report the same
basic fact would preclude rejection of all three versions due to the
psychosis of each individual witness."[^32] This incident provides a
superb lesson for attorneys to vigorously investigate and rigorously
evaluate available evidence before rendering a legal opinion.

Stewart analyzes this episode quite deftly. He notes that the fact that
the investigator was a staff member probably colored the investigator's
conclusions, which, in turn, handicapped the lawyer. Additionally, he
concedes that the first lawyer who evaluated the case on short notice
was out of his element because he was a probate law specialist. Finally,
Stewart questions the objectivity of the hospital's primary legal
advisor (from the office of the state attorney general) because the
state funded the hospital's self-insurance program. In sum, Stewart
makes a convincing case that the university's obsession with its image
and concern for its self-insurance coffers inhibited the kind of
critical, objective analysis that was necessary in building a case
against Swango.

### III. Conclusion

*Blind Eye* contains a treasure trove of important lessons for medical
professionals, investigators, and attorneys. Unfortunately, Stewart's
attempt to assign blame on the medical establishment somewhat obscures
several of these important points. Nevertheless, *Blind Eye* is an
excellent review of seventeen years of investigative work so inadequate
that it allowed one of the world's worst serial killers to use his
status as a doctor to readily take many lives in medical institutions on
two continents over the course of almost two decades.[^33]

[^1]: ^\*^ *Major Matthew J. Ruane (B.S., University of North Carolina;
    J.D., University of Nebraska; LL.M., The Army Judge Advocate General
    School) is the Deputy Chief, Technology and Operations Division, and
    Program Counsel, Air Force Security Assistance Center, Air Force
    Materiel Command, Wright-Patterson AFB, Ohio. He is a Member of the
    Bar of Nebraska.*

[^2]: S[tewart, James B., Blind Eye: How The Medical Establishment Let A
    Doctor Get Away With Murder 51]{.smallcaps} (1999), \[hereinafter:
    [Blind Eye\].]{.smallcaps} In 2000, a paperback version was
    published under a slightly different title: [Blind Eye: The
    Terrifying Story of a Doctor Who Got Away With Murder.]{.smallcaps}

[^3]: *Id.* at 81.

[^4]: *Id*. at 106, 109.

[^5]: *Id.* at 124, 151-2.

[^6]: *Id.* at 122, 129.

[^7]: *Id.* at 51, 72.

[^8]: *Id.* at 153, 161, 305.

[^9]: David Woods, *US Doctor May Have Killed 60*, 321 [British Med.
    J.]{.smallcaps} 657 (2000).

[^10]: [Blind Eye]{.smallcaps} at 25.

[^11]: *Id.* at 26.

[^12]: *Id.* at 27.

[^13]: *Id.* at 29.

[^14]: *Id.* at 34.

[^15]: *Id*. at 56, 60.

[^16]: *Id*. at 168. Here, the author presents useful background
    information on the system used to facilitate a comprehensive review
    of health care practitioners' professional credentials, the National
    Practitioner Data Bank (NPDB). Authorized by the Health Care Quality
    Improvement Act of 1986, 42 U.S.C. § 11101 *et seq*., it was not
    inaugurated until 1990 and was not retroactive to the period
    involving the Swango's early identified medical school deficiencies,
    suspicious patient deaths, and the resulting investigations.
    Therefore, it had no direct bearing on the Swango case.
    Nevertheless, [Blind Eye]{.smallcaps}'s discussion is instructive
    for anyone with an interest in medical provider credentialing and
    privileging. In the Department of Defense (DoD) health care system,
    NPDB reporting is governed by DoD Instruction 6025.15,
    *Implementation of Department of Defense Participation in the
    National Practitioner Data Bank*, Oct. 12, 2000. In the Air Force,
    the following regulations are relevant to NPDB reporting and medical
    provider competence determinations: Air Force Policy Directive 44-1,
    *MEDICAL OPERATIONS,* Sept. 1, 1999; Air Force Instruction (AFI)
    44-119*, Medical, CLINICAL PERFORMANCE IMPROVEMENT*, Aug. 1, 2000;
    and AFI 51-302, *Law, MEDICAL LAW*, Dec. 1, 1995. *See also*
    *National Practitioner Data Bank* at
    <http://www.npdb-hipdb.com/npdb.html> (last visited Feb. 27, 2002).

[^17]: [Blind Eye]{.smallcaps} at 172, 206.

[^18]: *Id*. at 217. Swango lied to New York administrators, telling
    them that the circumstances surrounding his 1986 "assault"
    conviction involved a "bar fight" when, in fact, the truth was that
    he had poisoned coworkers' snacks and drinks with insect poison.
    Since the hospital was a Veterans Affairs facility, Swango violated
    18 U.S.C. § 1001, generally prohibiting false representations to the
    federal government. United States v. Swango, 172 F.3d 39 (2nd Cir.
    1999).

[^19]: [Blind Eye]{.smallcaps} at 280. When Air Force medical facilities
    are asked to provide "references" for staff or former staff with
    practice privileges and the subject of the records does not give
    permission for access to records, the medical facility staff may
    refer to the "routine uses" provision of rules governing the
    releasability of Air Force medical provider records to third
    parties. These rules are contained at 62 Fed. Reg. at 61495 (Nov.
    18, 1997), and provide, in pertinent part, as follows:

    > \[Medical provider\] credential review files...including
    > curriculum vitae, list of approved privileges, copies of diplomas
    > and certificates, records of continuing health education training,
    > letters of evaluation, summaries of special activities or other
    > information, including malpractice claims reports**,** furnished
    > or solicited in order to fully evaluate the professional
    > qualifications of individuals**,** and the records of any actions
    > taken on the individual\'s credentials...and...health education
    > records...including applications for training, training reports,
    > Faculty Board reports, photograph or negative, and personnel
    > documents related to training may be disclosed outside the
    > Department of Defense as a routine use pursuant to 5 U.S.C. §
    > 552a(b)(3)...to a governmental board or agency or health care
    > professional society or organization if such record of document is
    > needed to perform licensing or professional standards monitoring
    > related to health care practitioners who are or were formerly
    > members or employees of the Armed Forces, and to medical
    > institutions or organizations wherein such member or employee has
    > applied for or been granted authority or employment to provide
    > health care services if such record or document is needed to
    > assess the professional qualifications of such member or employee.
    > Additionally, records concerning civilian consultants or
    > contractors who engage in direct patient care may be released to
    > civilian organizations employing said civilian consultants or
    > contractors providing direct patient care to eligible
    > beneficiaries if such records are necessary to evaluate the
    > civilian consultant or contractor in accordance with 10 U.S.C. §
    > 1102(c)(E).

[^20]: [Blind Eye]{.smallcaps} at 285.

[^21]: *Id*. at 303.

[^22]: Air Force Judge Advocate practice is very broad, with a typical
    military attorney's assignment including responsibilities in both
    criminal prosecutions and administrative employment actions.
    Department of the Air Force, *Air Force Online Recruiting Brochure*,
    at http://www.jagusaf.hq.af.mil/FAQs/lawtypes.htm (last visited Oct.
    18, 2001) (FAQ: What Types Of Law Do Air Force Judge Advocates
    Practice?).

[^23]: These patient reports are the staple of medical student learning
    and a record of hospital inpatient progress. While other students
    devoted a great deal of effort to patient interviews and physical
    exams that served as the basis for their patient reports, Swango
    never performed such exams; rather, he simply fabricated them in his
    reports.

[^24]: *Id.* at 49.

[^25]: *Id.* at 52.

[^26]: *Id*. at 52.

[^27]: *Id*. at 53.

[^28]: *Id*. at 76.

[^29]: *Id.* at 72. Apparently, the doctor who conducted the
    investigation did not focus on the syringe because he believed the
    nurse had found it in the hospital the morning after Cooper's death,
    believing it used in routine hospital care, with no nexus to the
    crime. This makes no sense, given the then existing allegation that
    in the same hospital location, an unscheduled injection administered
    by a person not ordinarily in the patient's room had almost killed
    the patient, and given that a syringe used in the crime might have
    distinguishing characteristics that could link it, from an
    evidentiary standpoint, to the crime, or, alternatively, might
    somehow be tied to the crime by the testimony of the nursing staff
    who indeed had already discussed with the hospital\'s attorney
    events surrounding a discarded syringe.

[^30]: *Id*. at 83.

[^31]: *Id*. at 80.

[^32]: *Id*. at 127-8.

[^33]: *Id*. at 306.