One doctor. 25 deaths. How could it have happened?

Allen’s family was stunned. He had suffered a heart attack and was on a ventilator in the hushed intensive care unit of Mount Carmel West, a Catholic hospital in a working-class corner of Columbus. But Allen, 80, had been stabilized, his family said. He could squeeze his son’s hand. His family still believed he would return home to his bedridden wife and his backyard tomatoes.

But as the graveyard shift began that night in May 2018, the new doctor who had taken over, William Husel, said Allen was in complete organ failure, his family said. Husel offered to give Allen comfort medication and said he would “go quickly” after the family agreed to remove him from a ventilator, Allen’s daughter, Lisa Coleman, said. Then, prosecutors said, the doctor ordered up a fatally large dose of the powerful opioid fentanyl.

Now Husel is charged with killing 25 patients, including Allen, with overdoses of fentanyl, a drug that has led to tens of thousands of deaths on the streets but is also a potent, effective painkiller for critically ill patients. The prosecution is one of the largest medical-murder cases in years, and it has exposed glaring lapses that patients’ families and lawyers said allowed the deaths to continue undetected for years.

“We felt like we had no other choice,” Coleman said. “They never said anything about a lethal dose.”

Husel, 43, has pleaded not guilty. His lawyer, Jose Baez, criticized the prosecution as “an indictment on comfort care,” and said Husel had provided medication to ease the suffering of dying patients.

“He dedicated his life to medicine, to helping others, to helping these specific patients,” Baez said. “He exercised livesaving procedures for many of these patients that he’s now accused of killing.”

The doctor’s trial, set for next spring, is likely to be fought along the murky borderlands between life and death, where medical and legal debates still rage over how to treat the dying.

Opioids are widely used at the end of life to treat pain and shortness of breath, and experts in critical care said they are intended to be prescribed carefully and only in response to a patient’s symptoms.

“I do not want to hasten death,” said Ryan Nash, director of the Center for Bioethics at The Ohio State University College of Medicine. “We try to care for the dying. We don’t try to control the dying process.”

Prosecutors have not publicly discussed any motive but said Husel clearly intended for his patients to die. They argued that the amounts of fentanyl he prescribed were five to 20 times higher than recommended doses, and had no medical purpose.

But Husel’s lawyer said the proper doses are not so black-and-white in such cases, and can vary depending on a patient’s drug tolerance, level of pain, weight and response to medication.

Already, the case has added to a roster of nearly 150 medical providers around the world who have been accused of killing or assaulting multiple patients since 1970. About 30 have been convicted in the United States, according to researchers.

While the cases affect a statistically tiny number of patients, they reveal how medical professionals can exploit blind spots in health care systems.

In Husel’s case, a federal investigation found that there were few safeguards to prevent excessive doses. The hospital said it had never learned of a criminal incident in his past, and questions remain about whether he met the hospital’s requirements to be a critical care doctor.

“It’s got red flags all over the place,” said Gerald Leeseberg, a lawyer representing 17 families in wrongful-death lawsuits against Mount Carmel. The hospital has already paid $13 million in settlements, and its chief executive and chief clinical officer have stepped down; more than 20 employees have been fired.

Beginning in September 2014, prosecutors said, Husel prescribed oversize doses of fentanyl to patients — most of them gravely ill — at two hospitals in the Mount Carmel Health System in central Ohio. One patient, Melissa Penix, was given 20 100-microgram vials, about 20 times the upper end of a dose recommended by Food and Drug Administration guidelines. Allen was given an injection of 1,000 micrograms.

Prosecutors said the deaths did not stop until November 2018, when Husel was pulled from duty and later fired after two hospital pharmacists raised concerns. Three patients died in the interval between when Mount Carmel received its first official complaint and when it removed Husel. In all, the hospital said 35 patients were “affected by Dr. Husel’s actions.”

Hospital knew of problems and patients kept dying

For years, at least two dozen nurses administered dangerously large doses of fentanyl and other drugs prescribed by Husel, according to medical and court records. The hospital did not audit how the drugs were being used, according to Ron O’Brien, the Franklin County prosecutor.

They were not rich or powerful, the patients who died in intensive care. Some had long histories of health problems. Others struggled with chronic drug and alcohol use.

Some had spent all their lives in the racially diverse Franklinton neighborhood west of downtown Columbus, where Mount Carmel West was the primary source of care in an area where the average income hovers at $10,000 and the average life expectancy is 60 years, the lowest in Ohio. Court records show that Allen had just $25,400 in property.

The Mount Carmel Health System is part of Trinity Health, a Michigan-based Catholic health system that has hospitals across the country. Its death rate was in line with national averages.

Most of the patients named as victims were, according to the hospital, near death when their paths crossed with Husel, but Mount Carmel has tentatively identified five whose conditions might have improved without the drugs. Husel’s lawyer, Baez, said the suggestion that any of the patients might have recovered was “absolutely false.”

Ohio does not allow doctor-assisted suicide. And even if it did, family members said they never consented to potentially fatal doses of opioids.

“No one has the right to take even a second of life,” Allen’s son, John, said. “My dad was alive.”

Other staff members in the intensive care unit liked Husel, prosecutors said. He was friendly and explained his treatments as if he were leading a class. Sometimes they all went out to breakfast after an overnight shift.

He started working at Mount Carmel in July 2013 after completing a residency at the Cleveland Clinic, where two doctors endorsed him as “excellent” and “exemplary.” The clinic said it had received no patient complaints and found nothing abnormal about his prescribing.

But his past held a darker episode that Mount Carmel missed when it ran standard background checks.

In 1994, as a freshman attending Wheeling Jesuit University in West Virginia, Husel and a friend started stealing car stereos, court records show. When a classmate complained to authorities, Husel and the friend made plans to plant a pipe bomb under the classmate’s car, though the classmate was warned and the plan was never carried out. The bomb was instead detonated in an outdoor trash can. No one was hurt.

Husel pleaded guilty to a misdemeanor charge and reported the incident to the State Medical Board when he was applying for his license in 2013. In a letter to the board, he blamed the crime on peer pressure and called it a life-changing mistake that set him on a better path.

The classmate whose car was targeted said the incident changed his life, too. He was so afraid that he abandoned the first name he used in college. Some former Mount Carmel employees have questioned whether Husel met the hospital’s standards to work in the intensive care unit.

He had trained as an anesthesiologist, not an internist, having done a four-year residency in anesthesiology at the Cleveland Clinic. Mount Carmel’s application for critical care privileges requires that those doctors complete a residency in internal medicine.

The hospital system said Husel met the hospital’s standards because he completed a fellowship in critical care at the Cleveland Clinic.

Mount Carmel began an investigation after receiving a report about Husel last October, though it now says it should have moved faster to consider removing him. The hospital said it has made changes to improve patient safety and to “ensure this never happens again.”

At hospitals across the country, vials of drugs sit inside machines with locking drawers that pop open when a nurse picks up a prescription. They are basically automated medicine cabinets, equipped with alert systems to flag any large or inappropriate drug order.

But an investigation ordered by the Centers for Medicare and Medicaid Services found more than a dozen cases at Mount Carmel in which that alert system was overridden, allowing orders for 500 or 1,000 micrograms of fentanyl to be filled, often without prior approval from the pharmacy.

Although federal regulators track opioid prescriptions and the flow of pills to outpatient pharmacies, there is little oversight of fentanyl use inside hospital intensive care units.

More than two dozen nurses at Mount Carmel administered large doses of fentanyl and other drugs, according to disciplinary charges by Ohio’s Board of Nursing, even though they “knew or should have known that the order was harmful or potentially harmful.”

O’Brien, the prosecuting attorney, said that two pharmacists had reported their concerns about Husel in the summer or fall of 2018, and that some nurses had directly questioned the doctor’s prescriptions.

“Dr. Husel had a response,” O’Brien said. “He was the doc and they were the assistant. ‘I’m the smart guy in the room, and stand at ease.’ ”

More than a year after Troy Allison, 44, died at Mount Carmel after getting treated for trouble breathing and a skin infection, his widow, Christine, keeps him close. His ashes sit in their living room, tucked above family photos.

Allison had been in and out of Mount Carmel for the infection, and his widow thought that night last July would be another routine visit. She played solitaire in the lobby as she waited. But then a hospital chaplain told her Allison’s heart had failed, and he was whisked up to intensive care.

She said Husel told her there was a “99.9% chance” her husband was brain-dead, and he was given a 1,000-microgram dose of fentanyl at 1:25 a.m., medical records show. He was declared dead three minutes later.

“He didn’t even try to help him,” Christine Allison said.

Mount Carmel West is being demolished now as part of a long-standing plan to move its services to a new building. But its sign still looms over the neighborhood, visible from Allison’s front porch.

“You don’t know how bad I want to take that night back,” she said. “You always trust your doctor. If you can’t trust them, who can you trust?”