VILE Podcast: Nurse 32 and the 'epidemic' of infant deaths
Author: Stacey Welsh
Published: 12:48 PM CST February 22, 2018
Updated: 12:48 PM CST February 22, 2018
VILE-PODCAST 5 Articles

The Centers for Disease Control and Prevention studied an epidemic in San Antonio that occurred at Bexar County Hospital between April 1981 and June 1982.

The study centered on deaths in the pediatric intensive care unit, and it was prompted by an "unusual increase in mortality associated with the evening shift."

The purpose of the CDC's investigation, according to the study's written report, was to "determine whether excess deaths had occurred in the period in question" and to "identify the factors associated with any increased occurrence of death."

The CDC stated in the report that Bexar County Hospital, later renamed Medical Center Hospital, was a 600-bed county teaching hospital and was administered by the Bexar County Hospital district. The PICU was an eight-bed unit, which was separate from the 48-bed neonatal intensive care unit.

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"The deaths had increased over a period of, I think, four or five months that we noticed. For some reason, the month of December sticks in there. It was around those months. We were saying that around the holiday time, it is kind of typical that there are more intensive patients. Sometimes there is a wave of higher mortality happening. Then it seemed to be more concentrated on the 3-11 p.m. shift," nurse Cheri Pendergraft said.

The CDC study attributed a sharp increase in deaths to one nurse. She was labeled "Nurse 32."

EXPLORE

VILE Podcast: Nurse 32 and the 'epidemic' of infant deaths

VILE-PODCAST
Chapter 1

An intense person

Genene Jones started working as a licensed vocational nurse, or LVN, at Bexar County Hospital in San Antonio's Medical Center in late 1978.

About a year later, the number of deaths occurring during the 3 to 11 p.m. shift started increasing. It became known as "The Death Shift."

In his book of the same name, author Peter Elkind recalls how the troubling pattern emerged.

"There was already a very clear pattern that kids under Genene Jones were having surprising emergencies, were taking a turn for the worse and dying when they weren’t expected to die… She seemed to be excited and drawn to the excitement and crisis of a medical emergency," Elkind said.

Pendergraft was one of the first people to meet Jones when she was working at Bexar County Hospital, and she said she also picked up on the pattern.

“In the beginning when I first met her, I was the charge nurse on the 11-7 shift. I was an RN, she was an LVN. She was hired, and I was tasked with orienting her to the pediatric ICU.

She was a very intense person. She had a fun side, too, but she was very intense and very intense with her patients... The thing about it was she seemed to be in the middle of a crisis. She always wanted the most intensive patients. It was always dramatic with her in her patient care and the patients she wanted. If she was challenged in any way, she would react very strongly," Pendergraft said.

At the time Jones and Pendergraft worked in the PICU, the nursing staff was broken down into three shifts: 7 a.m. to 3 p.m., known as the day shift, 3 p.m. to 11 p.m., or the evening shift and 11 p.m. to 7 a.m., the night shift.

While she said she had no reason to suspect there would be any trouble with Jones when she first started, Pendergraft witnessed incidents at the hospital that raised red flags for her.

Genene Jones walks outside of Bexar County court during her 1984 trial for 'injury to a child.' (PHOTO: KENS-TV archives)

“The very first bizarre incident that I can recall when I was orienting her was the first night she was there in the ICU. A little preemie was admitted. It was very sick. I ended up taking care of it, but it did end up dying on the shift. [Jones] started crying, and she asked if she could hold the baby. I thought that was kind of odd because [Jones was] not attached to this baby in any way. So, she sat in a rocking chair that we had in the unit and just sobbed over this baby. I thought wow, that’s kind of weird because she had no time to form any type of attachment. That was the very first incident that kind of caught me off guard,” Pendergraft said.

As these strange and unexpected incidents loomed over the ICU, Pendergraft said Genene Jones had other ways of causing tension at work.

"The other thing I noticed about her that I didn’t really like, or it didn’t really appeal to me, was she had a potty mouth," Pendergraft said.

Jones' former fiancé, Ron English, agreed, and said this behavior bothered him as well.

"If there was a sexual joke, I mean Genene knew it, and she could tell it very well. She made sex into a very vile and dirty thing. She was very foul-mouthed," English said.

Pendergraft said Jones was known as a skilled nurse, and for that reason, their supervisors at the time respected her, even as Jones’ actions rattled other staff members.

“I went to the head nurse about it, saying that we had noticed this trend and saying it was disconcerting. I think we might have mentioned Genene’s name at the time, I’m not sure about that conversation, but [the head nurse] did say that ‘this is something that happens cyclically. I don’t think it’s anything to worry about.’ She resented the fact that Genene’s name was mentioned.

I had mentioned her name on another occasion when I went to [the head nurse]. I don’t know if it was before or after that, but she got really incensed. She was very fond of Genene. Genene was a very intelligent nurse. She knew a lot, more than most LVN’s knew. She was very good at patient care,” Pendergraft said.

Former Kerr County DA Ron Sutton, who prosecuted Jones' 1984 murder trial, backed up this claim.

"I made a remark at some point to the press that she could put an IV in a fly," Sutton said.

Chapter 2

Code Blue: The center of attention

Among the most troubling behaviors Jones exhibited in the ICU, according to Pendergraft, was her penchant for taking charge and even stepping out of bounds to assert her authority.

Pendergraft described one incident when Jones was treating a near drowning victim.

“She was doing CPR, and she had been on duty already for two shifts, so 16 hours. I put my stuff down, and I went in and said, 'I will take over, and you need to go home and get some rest.' She was coming back the next day. She burst out with, ‘I’m not gonna leave my patient.' I said, ‘You need to. You need to go home and get some rest.’ She said no, ‘I’m not going to leave my patient.’ I called the nursing supervisor and said she was refusing to leave, this is the situation and the supervisor came in and told [Jones] she had to leave.

Then she went to the locker room, got her stuff and stormed out of the ICU. She was just really angry, cussing and all of that. That was the end of that. She was really angry that we interrupted her," Pendergraft said.

She said it was unbelievable at the time to think a coworker would be deliberately harming children under her care.

"It was just unfathomable that we could believe that any of our nurses could be capable of something like that," Pendergraft said.

KENS 5 obtained a copy of the CDC's study on the PICU through an open records request. It states that each PICU nurse was "generally assigned to only one patient per duty shift, and, when practical, continued to care for that patient through his or her stay in the PICU."

Click here to read the full report:

In researching the book, Elkind spoke with people Jones worked with, like Pendergraft, who became suspicious of Jones' actions.

He described one incident with a doctor who was called into the ICU in an emergency.

“He needed someone to babysit. He called the ICU and said ‘I’m coming in, is there someone who can watch my kids. Genene Jones picked up the phone and said ‘I’ll do it. I’ll be right over.’ This really would not have been his first choice, but he didn’t feel like he could tell her no. He had to come in to take care of the kid who was having a crisis.

She was getting off duty. He went in, handled the emergency involving the child in the ICU and returned home holding his breath that his kids were OK. He went upstairs and checked on them, and they were fine. It was a troubling and scary moment for him and kind of a gut-check moment for ‘What does he really think about her?’"

In its study, the CDC looked into deaths in the pediatric ICU, when they occurred, when patients arrested and operations at the hospital. In studying general procedures in the ICU, the CDC determined that when cardiopulmonary arrests happened, someone would announce the need for immediate assistance over the hospital paging system, and those events are called “Code Blues.”

“Whenever there was a code blue on her shift, she was in the middle of it. [Jones] insisted on and forced her way into the center of codes. She clearly got a thrill out of being in the middle of a medical emergency. She was described by many people as almost seeming high in that situation. Obviously there’s a lot of adrenaline. It is a crisis, but they were struck by how excited she seemed to be in that setting. There’s no question that there was an element of liking the attention, wanting to be the hero, to save kids. That’s also how she cast herself in my conversations with her," Elkind said.

Chapter 3

The study: 'An Investigation of Infant Deaths in a Hospital'

The CDC’s report states that the consultant conducting the study did not know the identity of the hospital employees involved, so they were given number labels.

The study ultimately came to the conclusion that the increase in mortality was associated with an increase in deaths on the evening shift.

Among the key findings:

  • Nurse 32’s assignment and duty schedule were associated with deaths on the evening shift.
  • Nurse 32 was associated with the increase in cardiopulmonary arrests on the evening shift.
  • Nurse 32 also was associated with the quote “unusual recurrence” of cardiopulmonary arrests among the same patients during the epidemic period.

Court testimony later revealed that Nurse 32 was Genene Jones.

Deaths in the pediatric ICU increased a staggering 178 percent from 1980 to 1981, when the so-called “epidemic period” began.

The CDC came up with statistics to explain the pattern of what happened in the ICU where Jones worked. The study was commissioned in 1983.

“They were brought in by the Bexar County District Attorney's Office, by the prosecutors. They looked at what had happened and did a study as if it were an epidemic. They treated it like an infectious disease to try to understand the epidemic, what had happened and to quantify it. They discovered that when Genene Jones was on duty, kids were 25 times more likely to suffer a medical emergency than any other time in the ICU, and when she was on duty, they were 10 times more likely to die," Elkind said.

The report identifies this as a "relative risk of 10.7," meaning that "a death was more than 10 times as likely to occur during a shift Nurse 32 was working than during a shift she was not working."

Chapter 4

Rolando Santos

Rumors about Jones' effect on the ICU came to a head when a 1-month-old child's bleeding wouldn't stop.

“Rolando Santos was the most clear-cut case, and provided the most clear-cut evidence that Genene Jones was harming kids," Elkind said.

Rolando Santos suffered severe bleeding episodes on multiple occasions in the PICU.

"He would have terrible bleeding episodes where blood would ooze out of his mucus membranes and blood would ooze out of where he had been stuck with needles. He was having terrible bleeding problems that threatened his life. It happened time and again on the 3-11 p.m. shift. As this was happening, there was a concern that he was getting an overdose of heparin, a blood thinner that is used routinely in the hospital’s ICU setting to avoid blood clots and for medical reasons," Elkind said.

Genene Jones was accused, tried and eventually convicted of ‘injury to a child’ in the case of Rolando Santos.

Genene Jones was convicted of giving Rolando Santos an overdose of Heparin. She was convicted of 'injury to a child' in this case.

The trial centered on Rolando Santos' case happened later in 1984, after Jones already had been sentenced to 99 years in prison for the murder of Chelsea McClellan in Kerrville. The CDC study was used as evidence in the Bexar County trial.

Jones was sentenced to 60 years in prison to be served concurrently with her sentence for Chelsea McClellan’s murder. Santos ultimately survived the severe bleeding incidents, but Elkind explained there was chaos surrounding the baby’s care.

"They first of all ordered all heparin discontinued from Rolando Santos, then they ordered Heparin removed from the room altogether. Still, he continued to have these problems several days in a row on the 3-11 p.m. shift. Finally, another time when Genene Jones was on duty, Rolando Santos had another terrible bleeding episode, and he was about to die.

Blood was pouring out of all of his pores and mucous membranes. He was on the brink of death. This attending physician, Dr. Ken Copeland, who had been suspicious of Jones and was very conscious of this issue, ordered a drug called protamine, which specifically counteracts the effects of heparin, and he ordered that be pushed into the child’s body. He pushed one dose of protamine, and nothing happened, He gave another dose, and the bleeding suddenly stopped," Elkind said.

Court documents state that at one point during Santos’ care, Copeland “ordered the removal of the arterial line from Santos so there could be no miscalculation of a [Heparin] dose.”

"It’s specific evidence that this kid had gotten a terrible overdose of heparin when there was not supposed to be any heparin in his body or in the room. That is the case, the one case, which [past officials in the] Bexar County DA’s office brought against Genene Jones and got a conviction against her for injury to a child," Elkind said.

As we reported, Genene Jones now faces five Bexar County murder charges brought against her in 2017 for cases dating back to that epidemic period at Bexar County Hospital in 1981 and 1982.

In August 1982, Jones began working at the Kerrville clinic where Chelsea McClellan was killed. While Jones was there, prosecutors alleged that eight kids suffered nine medical emergencies in less than a month.

Chapter 5

Puzzle pieces

The pattern described in the CDC study in San Antonio had re-emerged in Kerrville. Prosecutor Ron Sutton said he wracked his brain to figure out what was behind the cases in his jurisdiction.

“The whole time I’d been investigating this thing, I kept thinking to myself that there’s bound to be something I’m missing on this. There’s bound to be something that linked these cases together. There had to be something. One cold and rainy Sunday afternoon in Georgetown, I was working on it. I had the files of the other kids that had suffered at the hands of Genene Jones.

I got to looking at them, and I discovered that all of them were non-speaking. They were too little to talk, or they had some other defect that prevented them from speech.

You put all these things together, it sounds like a puzzle, and they all begin to kind of fit together. Circumstantial, probably, but you fit all these pieces of the puzzle, and you’ve got a complete picture of what was going on. Plus, with Genene, when they got to Kerrville, there was no pediatric intensive care unit such as the one she worked at in San Antonio. She was trying to develop through the hospital a plan to establish an intensive care unit for babies and little kids, and everybody told her the demographics are not such that you need that here. If it’s a rare emergency, you go to San Antonio which is not very far, but there’s just no need for a pediatrics unit here at the hospital [in Kerrville]. She told one of her nurse friends down there, a nurse friend had confronted her with that, that there’s not enough babies to justify that.

[Jones] told her, ‘Yes there is. You’ve just got to go out and find them.’ You’ve just got to go out and find them... That’s how I closed my argument in Georgetown. You’ve just got to go out and find them, and she found them," Sutton said.

Genene Jones had permission to leave the hospital where the epidemic of unexplained infant deaths occurred and go on practicing as a nurse. As KENS 5 reported, no action was taken against her at the time she left Bexar County Hospital. Her position was simply eliminated.

In the next episode of Vile, we look into what hospital officials knew and when they knew it.

KENS 5 is taking a look back at the history of the Genene Jones case and following new developments in the Vile podcast. This is an ongoing project. If you are connected to the case, and you would like to speak with us, email swelsh@kens5.com.

Stick with KENS5.com/Vile for the latest updates in our podcast series, plus photos, videos and audio recordings related to the story.