Published April 19, 1992|Updated Oct. 11, 2005

At first, it resembled any other humid August morning. Pinellas Medical Examiner Joan Wood, just back from a forensic convention in St. Louis, counted on finding the usualfrenetic workload when she walked into her Largo office.

But she didn't expect a greeting committee.

"You better get some coffee and sit down," said investigator Tim Moran. "We may have another nurse murdering people."

As Moran and Pinellas Sheriff's Deputy Chuck Vaughn briefed her on unsettling events at Rosedale Manor nursing home, Wood listened with growing fascination and dread.

Two aides had spotted a nurse named Brian Rosenfeld pouring a strange liquid down an elderly widow's feeding tube. Within minutes, the woman had died. Investigators who interviewed Rosenfeld's co-workers were picking up bizarre tales of sadistic behavior toward patients and co-workers.

"Alarm bells went off everywhere," Wood recalled recently.

In the realm of serial killers, nothing challenges a medical examiner like homicidal nurses. They are surrounded by helpless targets who everyone expects to die. They have easy access to powerful medication. They can kill for years and leave nary a trace.

Wood, 47, knew about killer nurses.

Five years earlier, her office had teamed with St. Petersburg police to catch a nurse named Bobbi Sue Dudley, who injected lethal doses of insulin into at least four nursing home patients.

The Dudley investigation had required a laborious search of medical records. Twelve bodies were exhumed. In Wood's 17 years of medical examining, the staff had never worked harder.

Now it was 1990, and Sheriff's Deputy Vaughn was calmly briefing her on Brian Rosenfeld: worked at nursing homes all over the county. Long history of abuse. Multiple firings. Drug use. Criminal record. Lying on medical charts _ like he had something to hide.

"Oh my God," thought Wood. "Here we go again."

A veteran cop at 43, Chuck Vaughn is no stranger to homicide. But by his own recollection, he originally viewed Rosenfeld as just another case. He was clueless about what lay ahead.

Over the next four months, the investigative team would dig up bodies in five states, pore over boxes of mind-numbing medical charts, track down witnesses from dozens of nursing homes and concoct a special computer program just to sort through the evidence.

The team would experience moments of exhilaration _ like the day a jailhouse snitch reported that Rosenfeld was spilling details about murdering 23 patients.

Other times, they would go home drained _ like the day they discovered Rosenfeld had probably slipped through their fingers a year earlier in a suspicious Kenneth City death.

Eventually, the case would consume Chuck Vaughn.

In the field, he would put in overtime. At home, he would retrace his steps and plot strategy for hours. He couldn't get Rosenfeld out of his mind.

But that passion took time to develop. It's not that Vaughn mistrusted Wood's instincts in their first meeting; he just lacked her experience with nursing home killers. Nevertheless, he dutifully went to his supervisor, Gary Herbein, to request full-time assignment to the case. He carried a message:

"According to Dr. Wood, life as we know it is about to end."

"Injuns' and engines

Right off the bat, here's what the medical examiner's office asked of investigators:

Find out every place Brian has worked the past 10 years. Identify all his working shifts. Identify every patient who died on that shift or soon after. Get every medical chart from every one of those patients. Subpoena them if you must.

And get ready to dig up bodies.

Larry Bedore, chief of operations for the medical examiner, sat down at his MacIntosh computer and wrote a program to help the team keep track of information as it trickled in.

Bedore, 43, is a precise man with a fondness for metaphor and small jokes. He labeled his database Little Red Engine. That stemmed from Vaughn's first tentative interview with Rosenfeld, before the arrest.

As Vaughn tells it, Rosenfeld said something that sounded amiss. Vaughn replied, "Oh, really?" Rosenfeld raised his hand, like a witness swearing to the truth, and said, "Little Red Injun."

For a while, investigators puzzled over that response. Might this be some clue, like Citizen Kane's "Rosebud?" Did Rosenfeld mean Honest Injun? Was he citing the popular children's tale The Little Engine That Could?

They never did decipher the Little Red Injun, but Bedore had a title for his database.

The database eventually would juggle information from several nursing homes, but for now investigators honed on the suspicious death at Rosedale.

The victim was 80-year-old Muriel Watts, a former New York socialite who was comatose. Just minutes before she died, two nursing aides saw Rosenfeld take a large syringe and inject a strange brown liquid down her feeding tube.

Rosenfeld then insisted on personally cleaning her body _ a chore that usually falls to aides. As the aides later told a supervisor, Rosenfeld took a rag and wiped the body from head to toe with mouthwash, an unheard of procedure.

Rosenfeld's nursing notes reported that Watts had bled profusely from her mouth, bowel and urinary tract. Yet the aides had seen no blood. So Rosedale officials called in the authorities.

An autopsy showed that Watts had ingested Mellaril, a potent tranquilizer. At first, investigators didn't know if the dose was lethal. That required a more sophisticated test in a Philadelphia laboratory. But they knew that Mellaril can kill, and that no doctor had prescribed it for Watts.

Another thing was clear _ this was no mercy killing. Co-workers plied Vaughn with anecdote after anecdote of Rosenfeld's sadism. He would bend fingers back until patients screamed, snap their catheter tubes, jerk their legs. When he got angry at nursing aides, he would feed laxatives to patients to add to the aides' cleaning duties.

Investigators' first chore was pinpointing where Rosenfeld had worked. In theory, just about any job application form should provide his employment history. Except that Rosenfeld routinely lied.

He was fired from most jobs, or left under a cloud. Often for abusing patients. So when he applied for a new job, he left large gaps in his employment history or made up phony employers.

At one time, the list of possible employers reached 20 nursing homes, three hospitals and six other health-related companies.

Some nursing homes didn't keep timecards, so Wood and one of her investigators, Jackie Martino, scanned patient records looking for Rosenfeld's handwriting. One nursing home's records had him fired on May 18, 1988. Yet his handwriting showed up on patient charts the next day.

Planning for exhumations

Although some records were missing or unavailable, the investigative team identified 201 people who had died while Rosenfeld worked at various nursing homes. The next step was to search for patterns.

For example, Rosenfeld's handwriting on medical charts varied dramatically from shift to shift.

"It went from this big, flowery, almost flamboyant handwriting, to very small, precise, easily read notes," Wood said. "Then there were times that his signature was almost illegible, other times it was very precise."

Maybe the notes were precise during the act of murder, Bedore speculated, because Rosenfeld knew people would look closely at that day's chart?

Investigators also noticed that three dead patients had the same birthdate. So they searched for astrological signs. Was there an abundance of Taurus deaths, or Leos?

None of these patterns proved fruitful. Ultimately, the investigators fell back on one simple route for finding more victims. They looked for Rosenfeld's patients who had been buried in northern states. That's where cool weather and lower water tables preserve bodies.

This selection process meant abandoning the trail on several suspicious deaths. For example, three days before Watts died at Rosedale, 77-year-old Albert Crichlow had also died on Rosenfeld's shift. Just as he had done with Watts, Rosenfeld mysteriously washed Crichlow's body down with mouthwash.

Crichlow, the first black person to serve on the Christian Science Board of Lectureship, had been murdered, investigators agreed. But they couldn't prove it because Crichlow had been cremated.

Pinellas County has the highest rate of cremation in the state. From the initial Rosenfeld death list of 201 patients, only 73 had been buried. To further narrow candidates for exhumation, Bedore's database listed 35 patients who had died on Rosenfeld's shift or within eight hours. The team's working theory was that anyone poisoned with Mellaril probably would have died within eight hours.

The first exhumation was obvious.

Alphonse Silva, 76, had died at Rosedale just 10 weeks before Watts. Rosenfeld had just gone off his shift. Silva was buried in Pawtucket, R.I.

Three other patients fit the profile for a fruitful exhumation. They had died within three years of Rosenfeld's arrest. They were buried in Michigan, Wisconsin and Pennsylvania.

The team would exhume Silva first, then swing through the Midwest and do the others. Spurring them on was new and disturbing information.

Final lab results had returned from Philadelphia in the Watts case. Her stomach not only contained Mellaril. It was a huge dose _ enough to kill her many times over.

Something else had happened.

Tim Moran, one of Wood's investigators, kept thinking that the name Brian Rosenfeld sounded familiar. It had come up before. Moran plunged into old medical examiner files and retrieved a report that, as Bedore put it, "wrenched your gut."

On Sept. 25, 1989 _ almost a year before Watts died _ an aide at Colonial Care Nursing Home had called the abuse hot line at the Department of Health and Rehabilitative Services (HRS). The aide reported that a nurse named Brian Rosenfeld had murdered 93-year-old Henry Schrader.

The aide had seen Rosenfeld behave suspiciously when he poured medicine down Schrader's feeding tube. Then Rosenfeld talked about how Schrader would die soon.

Kenneth City Police investigated, and the medical examiner even put a hold on Schrader's scheduled cremation for one day. But then the police and medical examiner concluded that Schrader had died a natural death. The aide was a troublemaker, nursing home officials said. No need for an autopsy. The cremation proceeded.

The 1989 report also made clear how vigorously HRS had pushed for further investigation. HRS investigator Cecil Odom "is very upset that this office has not done an autopsy," the report said. Odom found a second aide who said Rosenfeld had over-medicated a patient into a stupor for an entire day.

Nevertheless, the report concluded, with police not suspecting foul play, "we cannot make this medical examiner's case." The report was filed away under miscellaneous investigations.

A year later, the Rosenfeld investigative team reviewed the 1989 report and saw striking parallels to the Watts case.

"It was a chance to catch him, but we missed," Wood recalled recently. "It drove us."

The road trip

A month into the investigation, Wood, Bedore, Moran and Vaughn flew to Pawtucket to exhume Alphonse Silva. To their surprise, they ended up at St. Francis Cemetery, where two grave-diggers looked at Joan Wood in disbelief.

By coincidence, Wood had exhumed a body in the same cemetery, five years earlier, while investigating Bobbi Sue Dudley. A forceful, energetic woman, Wood often leaves an impression. The grave-diggers remembered, they just didn't understand.

"Do you go travel around the country digging people up?" they asked. "Is this what you do for a living?"

While awaiting autopsy results on Silva, the team headed for the Midwest. Over nine days, they traveled by airplane and van through six states, exhuming the bodies of three women who had died in three different nursing homes. They would perform an autopsy, Federal Express the specimens back to Pinellas County, then pile into the van and head for the next state.

The trip was exhausting, fueled with drab roadway food and hotel rooms without water. But unless they moved quickly, winter would freeze the ground and put their exhumations on hold.

"It's depressing work," said Wood. "You're spending a lot of taxpayer's money. You don't know if you are going to find anything. We don't know what all the results are."

For relief, they played card games and word games, often Wood against the others. Other off-hour activities included what you might expect from a medical examiner: Dinner at the Detroit restaurant where Jimmy Hoffa disappeared, Pet Semetary on the VCR, a Sunday visit to the Gettysburg battlefield and national cemetery.

Even snooping newspaper reporters inadvertently helped lighten the load.

The St. Petersburg Times had gotten wind of the exhumation odyssey and had published a Sunday story describing how Wood was in Pennsylvania, about to dig up the body of Hazel DeRemer.

Rosenfeld's father telephoned him in the Pinellas County jail and reported the news. Depressed, Rosenfeld told cellmate David Greenway that he had murdered numerous nursing home patients, Greenway told investigators.

Greenway, in jail for grand theft, listened carefully and went straight to prosecutors. In a deposition, he described his jail cell conversation with Rosenfeld:

The Pennsylvania autopsy frightened Rosenfeld, said Greenway, "because he knew that was one of the persons he had OD'd. And he was scared about that.

"I said, "How many have you done?'

"And he said, "Probably 20, 21, 22, 23 of them."

Rosenfeld even named individual victims, Greenway told prosecutors. When the conversation ended, Greenway hastily wrote down all the names he could remember _ five or six names _ on a letter he was writing to his girlfriend. All but one name matched people who had died under Rosenfeld's care.

The exhumation team in Pennsylvania had just finished the DeRemer autopsy when they heard about the snitch.

"We were ecstatic," Wood recalled. Now they knew that Rosenfeld was worried about the very specimens they held in their hands.

For the next month, they anxiously awaited the autopsy results. Would they find more unprescribed Mellaril? Could they establish a pattern?

First indication would come from the Silva autopsy. Wood recalled how she waited for Silva's results with mixed emotions.

In seeking permission for the exhumation from Silva's son, investigators had discovered that the two men had been estranged for years. The son had planned a reconciliation, and even held a plane reservation to Florida. But his father had died a day before he could arrive.

If Rosenfeld murdered Silva, then father and son were cheated out of their last moments.

In that way, Wood didn't want to learn that Silva was a victim. On the other hand, her gut was telling her that Rosenfeld had killed many times.

Wood needed evidence, and the Silva autopsy could give it.

Those feelings hung in the balance Dec. 7, when Larry Bedore came to work and found Wood waiting. She was waving Silva's autopsy results in her fist, Bedore recalled, and was grinning like a wild woman.

Her greeting was succinct: "We've got him."