Hundreds of ICU patients at San Francisco hospital given saline instead of opioid painkillers, it emerges, as STILL WORKING junkie nurse who stole drug is sentenced
A San Francisco hospital nurse who stole ICU patients’ opioid medication for 18 months, secretly replacing it with saline that was administered instead, all to feed his morphine addiction, was sentenced to 10 months’ imprisonment today at the city’s federal courthouse.
Clinton Christian swapped more than 600 vials of painkiller Dilaudid across 2022 and 2023. It took bosses at Sutter Health’s CPMC Davies Hospital until September 2023 to catch on and launch an investigation.
Christian was eventually fired in February 2024.
“This was not just the taking of drugs but taking them in a health field in a setting where patients are so dependent on others,” said U.S. District Judge Edward Chen. “And this happened over a period of over a year, over several hundred times and it wasn’t just a straight theft, it was a cover up.”
Christian, 38, still works as a nurse because, the court was told, the California Board of Registered Nursing does not automatically revoke licenses for felony convictions.
Questions remain about how California Pacific Medical Center managers failed to spot the thefts sooner despite a monitoring system that recorded Christian’s suspicious access patterns.
The court was told the hospital has not identified individual patients whose care was compromised.
Hospital owner Sutter Health declined to respond to inquiries about whether it has since identified or contacted affected patients.
Beginning in 2022, the court was told, Christian began siphoning Dilaudid from each vial of the drug, intended for critically ill patients in the intensive care unit of CPMC Davies in San Francisco.
He replaced the opioid painkiller with saline – salt water – and then resealed the medicine package using a portable heat sealer he had brought to the hospital.
“Christian stole the contents of over 600 vials of Dilaudid in his role as a nurse,” wrote assistant U.S. attorney Sailaja Paidipaty, “and in the process deprived his patients of their much-needed pain relief.”
The theft and its consequences for patient wellbeing went unnoticed for around a year and a half.
In September 2023, hospital administrators noticed a drastic increase in the number of times the locked controlled substances drawer was opened, but the drug was still accounted for and no vial appeared to have been taken out or used.
In the intensive care unit this had happened 18 times in all of 2021. In 2022 this rose to 117 and, in 2023, the number of instances soared to 506 – the vast majority of which involved Dilaudid.
Manufacturers’ tests of a sample of drugs whose integrity had been called into question revealed them to contain saline.
“Christian acted with reckless disregard for the risk that another person would be placed in danger of death or bodily injury and under circumstances manifesting extreme indifference to such risk,” federal prosecutor Sailaja Paidipaty told the court in her sentencing memorandum.
“Working in an intensive care unit, Christian knew that patients who received saline instead of that Dilaudid would continue to experience physical pain. Indeed, for affected patients, the physiological impact of being deprived of the pain medication they need would have been severe.”
“As a trained nurse, Christian knew he was placing his patients in danger of severe adverse consequences yet, for a year-and-a-half, he continued stealing necessary drugs from them showing an extreme indifference to the consequence of his actions.”
She asked for a 12 month sentence, putting the lenient recommendation down to Christian’s acceptance of responsibility and continued sobriety.
Christian’s attorney, Ana Botello, told the court that her client’s back problems led him to abuse painkillers, then develop an addiction, then begin stealing from the hospital where he worked.
She alleged that, remarkably, the hospital has not since reviewed individual patient records to discover who had been treated with the compromised medicine. Because this information was not available, she said, he ought not to be sentenced on the basis that any individual was harmed.
“Had the hospital or the government reviewed the medical records of the patients who received medication from the particular vials of medication listed [in] the complaint, we could know precisely whether any patient experienced more pain than necessary as a consequence of Mr Christian’s actions,” she wrote in her sentencing memorandum.
She asked that Christian be given a time-served one-day sentence and then probation.
This morning in courtroom five of San Francisco Federal Courthouse Judge Chen imposed a 10 month sentence.
“The seriousness of this offense, [put] patient’s safety and health in jeopardy, some several hundred times given the number of extractions that were made of the medication, the fact it was done with deliberation and with planning and with methods of deceit and the grave danger to public health,” the judge remarked.
“I take full accountability for this,” Christian told the judge. “I know what I did was heinous and it’s something I have to live with every day.
“At the time of this offense I was struggling with addiction and I allowed it to affect my judgment and sense of moral clarity.
“As a nurse I understand the trust and responsibility that comes with that role, and I did not live up to those standards, and I betrayed the trust and safety of my patients.”
Christian earlier pleaded guilty to violating the federal anti-tampering act and obtaining controlled substances through misrepresentation.
He was told to report to prison by June 8.
A spokeswoman for Sutter Health Chief Medical Officer Dr William Isenberg did not respond to a request for comment – and so was unable to shed light on how 18 months elapsed before the crimes were uncovered, nor what steps have been taken to notify patients who were affected.
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