by John Foxjohn
Since he didn’t have a clue as to what he was about to walk into, Sergeant Abbott went looking for another detective to take with him. By that time of day, most of the detectives were out of the office, but as luck would have it, he found Corporal Mike Shurley, another supervisor. Like Sergeant Abbott, Corporal Shurley also had additional duties other than investigations; he’d spent the day at SWAT practice and was still in his SWAT uniform. He’d just dropped by the office for a moment to check his messages when Sergeant Abbott stuck his head in and asked him to come along to DaVita.
On the five-minute drive from the police department to DaVita, Sergeant Abbott filled Corporal Shurley in on what he knew, which wasn’t much. Shurley wasn’t as large as Abbott, but he looked imposing in his SWAT uniform. As the two detectives walked into the dialysis center (still full of patients) that evening, they still had no real idea why they were there.
Jerry McNeill, DaVita divisional vice president, met the detectives and explained the horrific situation to them. McNeill told them that two patients had claimed to see a DaVita nurse purposefully inject bleach into the lines of two other patients and then dispose of the syringes in two sharps containers. He told them that after Saenz was dismissed for the day, Amy Clinton and Giselle Frenette, another RN whom Clinton had brought in to help her monitor DaVita, went into the reuse room and used a screwdriver to pry the lids off the two sharps containers. They dumped all of the syringes from one container on a piece of paper and from the other container on a different piece of paper to ensure that they didn’t get the contents of one container mixed with the other.
Now Clinton used the same test strips they used on the dialysis machines to check the syringes.
Clinton soon found a syringe that wasn’t labeled but appeared to have a little clear liquid inside. She pulled the syringe apart and used the strip to test the inside of the syringe. When the strip turned purple—an indicator of bleach, her heart sank. “Oh, my goodness,” Clinton said.
As the two RNs continued to test, they found four syringes in the two containers that tested positive for bleach. That just happened to be the exact number of syringes the two witnesses claimed Kim had used and put in the containers.
Frenette said that she was shocked when the syringes tested positive—so much so that she uttered a “bad word,” which was something she just didn’t do.
Even with the test results now in front of them, both detectives were still doubtful. Sergeant Abbott said later, “I was skeptical. Witnesses don’t always know what they saw.” Corporal Shurley echoed those thoughts.
In truth, no one really wanted to believe that a medical professional would do something to deliberately harm patients. As Jessica Cooley, The Lufkin News crime reporter, later told E!, “It seemed like such a wild accusation. A nurse would inject someone with something that was used for cleaning. It just didn’t make any sense.”
Despite his doubts, however, Sergeant Abbott called for the crime scene unit to come to DaVita, while McNeill filled the two detectives in on some back story. He gave them a list of patients who had died while on the dialysis machines, but stressed that it was extremely rare for patients to die suddenly on the machines while doing dialysis—however, as April 2008 drew to a close, the DaVita Lufkin Dialysis Center had experienced an unusually large number of deaths and injuries to patients, totally perplexing the company. After a thorough investigation that had focused on four areas—the water, the machines, the policies and procedures, and the patients themselves, all of which had come back clean—the company had been left as confused as ever. DaVita’s investigators simply could not find anything to explain what was causing the fatal issues, yet clearly, the deaths and injuries had continued.
But, McNeill told them, two patients had come forward that very day with disturbing information. Both claimed to have seen Kimberly Clark Saenz, a nurse, fill a syringe with bleach from a container used to sterilize the equipment and inject the fluid into the IV port of Carolyn Risinger, and then Marva Rhone. Thankfully those patients had both survived, but now DaVita had a full-blown criminal investigation on its hands.
Sergeant Abbott said later that DaVita had only one request: to let the rest of the patients finish their treatments and leave the clinic before the police began the main part of their investigation. Although defense attorney Ryan Deaton later claimed that DaVita had its hooks into everyone, including the police department, Sergeant Abbott said, “In my experience, there was never any interference in the investigation from DaVita or their attorneys.” He added, “Besides that, I’m not the type to allow interference in my investigations.” Coming from Sergeant Abbott, it was a simple statement of truth.
As the detectives waited for the crime scene unit to arrive and the patients to leave, DaVita gave them a crash course on how dialysis worked, and the procedures that the PCTs and nurses had to follow. Like most police officers, other than basic lifesaving skills—CPR and things like that—Abbott and Shurley knew little about medical procedures, and absolutely nothing about the dialysis process.
As the nurses took the detectives through the medical procedures and patient care, Sergeant Abbott asked questions and had them go through things again and again. As a colleague said of Abbott, “He always goes the extra mile to prepare himself for the investigation.” That proved to be an understatement.
Once the crime scene unit arrived, they were directed to the reuse room to examine the evidence that Amy Clinton and Giselle Frenette had found. In the room were two sharps containers in biohazard bags, and Corporal Shurley, still dressed for battle, guarded the door to make sure no one could tamper with any evidence as the crime scene techs began to do their jobs.
Although the DaVita inquiry later turned into a murder investigation—the first one Sergeant Abbott had ever headed—that night, all they were looking at was the injection of two patients with bleach. Since both patients had lived, the most anyone could be charged with in Texas was aggravated assault with a deadly weapon—bleach, if it proved true—and at that point, both detectives had entertained some healthy skepticism about what the witnesses had said.
One important thing the detectives learned was that DaVita had been keeping all the bloodlines used for the patients who suffered cardiac arrests while undergoing treatment on a dialysis machine. They kept the individual lines in marked biohazard bags in a freezer. Sergeant Abbott didn’t have a clue what to do with the bloodlines, but he instructed CSU to collect all of them and take them in as evidence. These later became the most important evidence in the entire case.
In addition to the two sharps containers from the reuse room that Corporal Shurley was guarding, the two investigators also confiscated every sharps container in the clinic as evidence. Sergeant Abbott had the crime scene unit number and label every container based on the patient station numbers that were on the walls. They also made a chart of where each container had been before they took it into custody. Corporal Shurley said later that this was hugely important in the long run and defused a defense theory that DaVita was merely trying to cover up their own negligence by blaming a single employee. There was no way DaVita could have known in advance that the investigators would take all of the sharps containers.
Next to the bloodlines, these sharps containers proved the most important evidence collected. They didn’t point to aggravated assault. They pointed to murder.
PART II
SEARCH FOR JUSTICE
Neither evil tongues, rash judgements, nor the sneers of selfish men, nor greetings where no kindness is, nor all the dreary intercourse of daily life, shall e’er prevail against us.
—WILLIAM WORDSWORTH
CHAPTER 8
THE HAND GRENADE
Sergeant Steve Abbott, Corporal Mike Shurley, and the crime scene techs stayed at DaVita until around ten thirty that night collecting all the evidence, taking pictures, and speaking with members of DaVita’s hierarchy—namely, Jerry McN
eill and Amy Clinton.
After hearing what DaVita had to say, Sergeant Abbott called his immediate supervisor, a lieutenant who was off that day, and then the assistant and chief of police to inform them of what he had. His supervisors didn’t offer him any advice or tell him how to proceed. After all, he was the one who cleaned up the messes, not them, and this kind of situation had never come up before. Sergeant Abbott said later, “That first day we didn’t know enough to know what made sense or what didn’t.”
But meanwhile at DaVita, Sergeant Abbott was still finding out plenty.
Sergeant Abbott had the CSU sit in Ms. Hall’s and Ms. Hamilton’s chairs and take pictures of people sitting in the alleged victims’ chairs. These pictures along with the measurements offered valuable insight into what kind of sight lines the witnesses could have had.
While the CSU was taking the containers and making the chart, Sergeant Abbott decided to test what he’d been told about procedures by Clinton and McNeill. He stopped an employee at random to question about the process of getting the two pails of bleach water, and policies they had to follow. The employee, who turned out to be Yazmin Santana, a PCT, told him the same thing the DaVita administrators had. Abbott specifically asked her about the practice of using a syringe to measure bleach, and Santana responded that they always used a cup to measure the bleach. She was emphatic that it was never acceptable to use a syringe to measure bleach—though she did tell him that a week earlier in a meeting, a teammate, she couldn’t remember who, had suggested using a syringe. However, no one agreed that this was a proper method, and they had all agreed to continue using the measuring cups.
Santana also emphasized using a syringe to measure bleach would require one to pour the bleach into something first before drawing it into a syringe. The best thing they had for that was the measuring cup they were supposed to use to start with. So what would be the point of using a syringe?
Before Sergeant Abbott left that night, state health officials gave him a report on the blood samples taken from Ms. Risinger and Ms. Rhone—the two patients whom the witnesses claimed Saenz had injected with bleach. The report confirmed that both patients had been exposed to bleach poisoning.
Sergeant Abbott also learned that Clinton had arrived on April 2 and brought several specialists with her to inspect all aspects of the clinic. In April, Clinton spent 90 percent of her time at the clinic. After the two patients died on April 1, DaVita didn’t have another documented occurrence, one they kept bloodlines on, until April 16, when Mr. Kelley coded while on the machine—likely because of all the monitors and Clinton’s near constant presence. At that point, even though DaVita investigators didn’t believe reuse dialyzers were causing the problems, they stopped using reuse dialyzers.
Then Clinton passed along what two employees had said to Sandy Lawrence, who was the facility administrator prior to Clinton’s arrival, that it had to be an employee who was harming the patients. As badly as Clinton didn’t want to believe Ms. Hall’s and Ms. Hamilton’s stories, in the back of her mind, she realized they now had the answer they’d been searching for.
Before the detectives left that Monday night, Clinton confirmed what Yazmin Santana had already told them: at no time were the employees—or anyone else, for that matter—supposed to use a syringe to measure bleach. There was no reason for the syringes to come in contact with bleach at all. The bleach solutions DaVita used for cleaning and disinfecting were mixed in the back, not at the patient care stations, and with abundantly available measuring cups. It didn’t make any sense to try to use a syringe.
* * *
The next morning, Tuesday, April 29, Sergeant Abbott and Corporal Shurley received a call from an unexpected source, an attorney by the name of Robert Flournoy, who at that time was also the attorney for the City of Lufkin. He had a client in his office who wanted to talk to them.
The client’s name raised some eyebrows with the detectives. It was Mark Kevin Saenz, Kimberly Clark Saenz’s husband.
Corporal Shurley left the police department and went to the attorney’s office, where he met Kevin, who told Corporal Shurley that he was in the process of filing for a divorce. The reason he’d called the meeting was to inform the police that he’d seen some Internet searches on Kim’s computer that had disturbed him. Kevin told the detectives that he had found records of searches done on bleach poisoning. He also told Corporal Shurley that he didn’t want to see Kim get into trouble for something that she didn’t do, and Shurley assured him if his wife hadn’t done anything wrong, she wouldn’t get into trouble. The detectives said that Saenz continued to completely cooperate with police after the initial interview, until he began to see all the evidence piling up against her, and then he refused to cooperate anymore.
After Corporal Shurley returned to the station, the two detectives made arrangements to speak with the two eyewitnesses. The first one was Ms. Hall, the sixty-four-year-old mother of three who had worked at Memorial Hospital as a nurse’s assistant for seven and a half years prior to becoming ill. She told them that she always took a book to read and sat in the same place, a corner seat in Bay B with a machine between her and Ms. Hamilton. On April 28, LVN Kim Saenz was the nurse for both Ms. Hall and Ms. Hamilton. Ms. Hall told the detectives that Saenz was always a nice person. They laughed and talked together, and they’d even discussed the Lord that day.
What caught her attention and made her stop reading was the way Saenz was acting. “She was fidgety—not acting like herself,” Ms. Hall recalled. She watched as Saenz went to the drawer of the desk at the nurses’ station and took out some syringes and dropped some paper in the trash. Saenz glanced all around as if she was checking to see if anyone was observing her, then set the bleach pail on the floor. Before squatting next to it, Kim again looked around as if making sure that no one was watching her.
Ms. Hall told them that Kim then stuck the syringe in the bleach water and drew some of it up. She stood at the station a minute looking around and then walked to Ms. Marva Rhone’s station and injected the bleach into her saline port. Just as Ms. Hall was wondering if she was really seeing what she thought she saw, Ms. Hamilton became very upset. She heard Ms. Hamilton say she saw something, and Ms. Hall responded, “Lord, I did, too.”
Ms. Hall told the detectives that she begged the nurses not to let Kim touch her.
Ms. Hamilton’s statement was similar to Ms. Hall’s. There were some minor variations because they were sitting in different places, at different distances, and had different angles. Ms. Hamilton echoed Ms. Hall’s description of Kim’s unusual behavior. This was what had originally captured the attention of both of them.
When Kim put the pail on the floor, Ms. Hamilton said to herself, “What is she doing?” Ms. Hall had been a dialysis patient for a year, but Ms. Hamilton had been one for eight years. She was by far more experienced than Ms. Hall, and she knew they never put anything on the floor.
In a deposition later, Ms. Hamilton related how she saw Kim pour the bleach from a Clorox bottle and she’d smelled the bleach. Both witnesses had seen her inject the bleach not only into Ms. Rhone’s lines, but also into Ms. Carolyn Risinger’s.
Every detective has that aha moment. For Corporal Mike Shurley, that moment came when they interviewed those two women. He said that he had an open mind going into an investigation and, as always, would let the evidence and not his preconceptions lead to guilt or innocence. He’d interviewed thousands of people by the time they talked to Ms. Hall and Ms. Hamilton, and he was leery of eyewitnesses, but what the witnesses said matched up to everything the detectives had seen and found.
Besides that, the detectives had spent an inordinate amount of time investigating the witnesses themselves—they looked to see if either Ms. Hall or Ms. Hamilton might’ve had an ax to grind with Saenz, if either had ever complained about her before, or said or did anything that would make them report false allegations about her. But investigators found
that not only did neither of the women have any reason to lie, until this incident, they had both really liked Saenz. Far from being vindictive, Ms. Hall and Ms. Hamilton were simply stunned and scared to death to think that Saenz could’ve done something like that.
Another thing that helped seal the deal for Shurley: both witnesses had similar but not identical stories, which spoke volumes for their validity. Most of the time, if people collude on a story, there aren’t any differences. Also, the women were absolutely positive of what they’d seen and there wasn’t anything or anyone that would ever sway them from it.
Next up for the investigators was their most illuminating interview yet—Kimberly Clark Saenz.
CHAPTER 9
TELL NO LIES
In any investigation, it is imperative that investigators speak with potential suspects as soon as possible, especially when the crimes are of a serious nature. The sooner suspects are interviewed, the more likely they will speak, even with their rights read to them. In many cases, suspects—whether innocent or guilty—want to tell their side of the story. Often, guilty suspects believe they can spin a story in their favor, explain away things that might be incriminating, actually learn what the police have, and in some cases mislead or divert the investigators.
And in this case, the two witnesses’ poor health made it even more imperative to get the suspect talking. Young, healthy witnesses don’t always do well on a stand in the courtroom, but it would be a lot easier to confuse or discredit the accuracy of elderly, ill witnesses.
