This is not primarily a story about a killer. It is a story about two nurses who were nearly destroyed for a killer’s crimes — and about a case that, almost fifty years later, has still never been solved. I want to say that out loud at the start because the way this case is usually told buries the wrong people.
Filipina Narciso and Leonora Perez were two Filipino nurses working the intensive care unit at the Veterans Administration Hospital in Ann Arbor, Michigan. In the summer of 1975 something began happening on their ward that no one could explain. Then someone decided they were the reason. They were not.
Summer 1975: The Ward Where Patients Stopped Breathing
Between July and August of 1975, patients at the Ann Arbor VA Hospital began going into sudden respiratory arrest. Men who had been stable, recovering, sometimes days away from discharge, would suddenly stop breathing. Some were revived. Ten of them died. By the time it peaked, on the afternoon of August 15, three patients arrested in a twenty-minute window on the same ward.
The hospital’s chief anesthesiologist, Dr. S. Martin Lindenauer, was the one who figured out what the pattern looked like. The failures resembled the effects of Pavulon — the brand name for pancuronium, a powerful synthetic muscle relaxant that works, essentially, by paralyzing the body from the inside. It is a synthetic form of curare, the plant-derived poison that South American peoples used on hunting darts. In the right controlled dose, an anesthesiologist uses it during surgery. In the wrong dose, injected into an IV line, it stops the diaphragm. The patient cannot breathe.
Someone was putting Pavulon into IV bags on the ICU ward. That much is not in dispute. That is where the certainty ends.
The Investigation That Landed on the Wrong People
The FBI was called in. Agents built a schedule matrix — every incident of respiratory arrest, cross-referenced against every hospital staff member on duty at the time. On paper, Filipina Narciso was the only nurse present during every single incident. That was the evidence. That was, essentially, all of it.
Let me say what needs to be said here. Two Filipino women working night shifts on an ICU with a rotating staff were the ones singled out. There were no eyewitnesses. There was no confession. There was no motive that ever made sense — not money, not personal grudge, not ideology. There was a schedule pattern that turned out, on cross examination, to be much thinner than the prosecution had implied. And there was, running underneath the whole thing, the low steady hum of institutional racism that made two immigrant women a much easier story than a systemic failure at a federal hospital.
The Trial: Four Months of Prosecution, Thirteen Days of Deliberation
In June of 1976, a federal grand jury indicted Narciso and Perez. Ten counts of poisoning. Five counts of murder. One count of conspiracy to commit murder. The trial began in February 1977 at the Theodore Levin U.S. Courthouse in Detroit and ran for four months, which is a long time to sit in a federal courtroom being told you are a serial killer. The jury deliberated for thirteen days — the longest jury deliberation in federal court history up to that point.
The verdict was not clean. The jury acquitted them of the one murder count that had been narrowed down to actually reach the jury. They convicted them of three counts of poisoning and one count of conspiracy. It was the kind of split verdict that tells you nobody — not the jury, not the prosecutors themselves — was sure what actually happened.
Overturned: What Judge Pratt Actually Said
Seven months after the conviction, the presiding judge — Judge Philip Pratt — granted the defense a new trial. His ruling did not use polite language. He wrote that the prosecutors had created “overwhelming prejudice” against the nurses by (a) withholding information from the defense and (b) making improper statements in open court. This was not a technicality. This was a federal judge saying, in as close to plain words as a judge is allowed to use, that the prosecution had run an unfair trial.
A new U.S. attorney was assigned. He decided not to retry them. The charges were dropped. Narciso had already served about three months. Perez had served about two years. They walked away with no convictions on their record and the rest of their lives to try to rebuild, which they did — both of them went back to nursing.
The Question Nobody Answered
Someone poisoned those patients. Ten men died. That part is real, and it has never been solved.
The FBI closed the case after the retrial was declined. No other suspect was ever charged. No further investigation, as far as the public record shows, has ever been reopened. The theory that emerged over the years — laid out most fully by Dr. Lindenauer in his 2015 book Paralyzing Summer, co-authored with Elizabeth Oneal — is that the killer was almost certainly a member of the hospital staff who had both the access and the knowledge, and who was never seriously investigated once the case had settled on Narciso and Perez.
That is the shape of the case. Ten men murdered. Two innocent women prosecuted. One killer, still nameless, still uncharged, almost certainly dead of old age by now.
Why This Case Still Matters
I keep coming back to a specific thing about this case, which is that the injustice done to Narciso and Perez was made possible by two structural failures at the same time. The first is the one everyone talks about — the racism that made two Filipino women a satisfying story for a court and a public that wanted a face for the crime. The second is the one nobody wants to talk about — the hospital itself, a federal institution that ran an ICU where someone could tamper with IV bags undetected for weeks, and then handed the FBI a suspect list rather than a systemic accounting of its own security. The prosecution of the nurses did the hospital a favor. It gave the public a story with people in it, rather than a story about how a VA hospital was structurally unsafe.
Federal hospital drug protocols did change after this case — that part of the article’s original framing was accurate in spirit if not in cited detail. Chain-of-custody requirements for controlled substances tightened. IV bag storage was locked. But the specific human cost, which was the two years Leonora Perez spent behind bars for a crime she did not commit, is not a policy note. It is a debt this country owes and never paid.
Sources
- Dr. S. Martin Lindenauer and Elizabeth Oneal, Paralyzing Summer: The True Story of the Ann Arbor V.A. Hospital Poisonings and Deaths (University of Michigan Press).
- “The Murders at Ann Arbor’s Veterans Hospital” — Society of Former Special Agents of the FBI (case story).
- “VA Murders Revisited” — Ann Arbor Observer.
- United States v. Narciso, 446 F. Supp. 252 (E.D. Mich. 1977) — Justia (Judge Pratt’s ruling on the motion for new trial).
- “Judge Rejects Some Charges in VA Nurses’ Poisoning Trial,” The Washington Post, June 9, 1977 (archived).
- Ann Arbor District Library, contemporaneous news coverage of the trial, June 24, 1977.