The nurse lay in a bathroom stall, a syringe in her hand and track marks on her arm. She died from an overdose of fentanyl, a potent painkiller meant for patients.

It was a rare accident two years ago at UT Southwestern Medical Center’s Clements hospital in Dallas.

Until it happened again.

Some 16 months later, a second nurse was found in a different bathroom at Clements, with a syringe in her arm. She had overdosed too, and died from the same drug.

UT Southwestern has released few details about the nurses' deaths and says it can't say for sure where the drugs came from. But experts say that when health care workers abuse drugs, they almost always steal the medicines from their workplace. The hospital's own reports and medical examiner records show that's a likely explanation, according to an investigation by The Dallas Morning News.

UT Southwestern's William P. Clements Jr. University Hospital (Nathan Hunsinger / Staff Photographer)

This kind of theft, known as drug diversion, is a serious matter for hospitals, especially amid the nation's opioid epidemic. In the last four years, for example, Texas hospitals have reported more than 200 thefts by employees. But the government doesn't track drug thefts that lead to overdoses or deaths.

Nurses and doctors who steal and abuse drugs put not only themselves at risk, but also patients. In recent years, the federal government has levied millions of dollars in penalties against hospitals for not tracking dangerous drugs.

It's unusual for one hospital to have two caregivers die of overdoses in such a short time, experts say.

"This is an extreme example," said Kimberly New, a nurse and lawyer in Tennessee who consults with hospitals nationwide on how to prevent diversions. "That type of alarming situation would be the reason to bring someone in and look at their controls."

UT Southwestern officials declined to specify what measures they took to prevent drug diversion after the deaths.

They told The News that there were no "reported patient care lapses" related to the incidents. Safety is a top concern, they said. Clements has a variety of procedures to prevent medicine from being stolen, and the hospital has used "multiple review systems" and increased staff education about drug abuse since the deaths.

"Because no system is infallible, we continuously examine potential improvements" to ensure that dangerous drugs aren't misused, university spokesman Russell Rian said in a statement to The News.

Experts say thefts can happen in spite of multiple safeguards.

“You can have really good systems in place and still be defeated by a diversion,” said Keith Berge, a doctor at the Mayo Clinic in Minnesota who studies the issue.

Problems at Clements

Williams P. Clements Jr. University Hospital, named for the two-time Texas governor and Dallas native, opened in late 2014 on Harry Hines Boulevard, replacing an older hospital with a modern, 460-bed facility. UT Southwestern Medical Center runs the hospital.

Like all major hospitals, Clements has an internal pharmacy that stores potentially addictive drugs, such as anesthetics, sedatives and painkillers so potent you can’t find them at your neighborhood drugstore.

Government regulations require hospitals like Clements to keep accurate records of how such drugs are used, to have a system in place to detect diversions quickly, and to report thefts.

In early 2015, UT Southwestern’s internal auditors found lapses in how Clements and other university facilities managed dangerous drugs.

Scores of employees had unauthorized access to the drugs. At Clements and Zale Lipshy University Hospital, staff members didn’t dispose of excess medicine correctly. Liquids were dumped down sinks, in violation of federal environmental rules. Employees didn’t dispose of pills or medicine patches in secure containers.

UT Southwestern said it followed through on all of the auditors’ recommendations for improvements.

Less than a year later, a nurse was caught stealing drugs.

A theft and an arrest

In January 2016, co-workers suspected a nurse was stealing drugs, according to records from the UT Southwestern police department.

Nurse Aaron Bradley Hudson pleaded guilty early this year to fraudulently obtaining a controlled substance. He died by suicide in June at age 39. (Facebook)

The nurse worked in a unit that treated patients recovering from surgery. Staff members aren’t supposed to remove drugs from a locked cabinet until the patient arrives from the operating room.

But Aaron Bradley Hudson, a nurse who worked for a temp agency, would sign out drugs and take them into a bathroom before his patients arrived, according to the police report. Co-workers spotted empty syringes in nearby staff bathrooms.

Reporting suspicious behavior is an important tool to prevent drug diversion, UT Southwestern said in a statement to The News.

That January, the same month that Hudson stole the drugs, UT Southwestern created a committee to address diversion of controlled substances “as part of ongoing commitments and efforts to continually improve patient and caregiver safety.”

Hudson lost his Texas nursing license in 2017 and pleaded guilty early this year to fraudulently obtaining a controlled substance. He died by suicide in June at age 39.

Hudson was smart and funny and enjoyed his job, said his mother, Cindy Huffine. But he also battled an opioid addiction.

“Once he was introduced to a drug of that magnitude,” Huffine said, “it was no match.”

The first overdose

Several months after Hudson stole the medicines, another nurse — Patricia Norman — began showing signs she might be using drugs.

Norman, known to family and friends as Tricia, had worked in the cardiac intensive-care unit at Clements since early 2015. Her mother said she had wanted to be a nurse since she was 15. Family described her as fearless and artistic, with a smile that showed off her dimples.

Her 12-hour shifts typically ended around 7 p.m., said her brother, Mark Norman. He recalled that sometimes his sister, after arriving home from work, would start walking into the walls of their apartment.

Norman denied using drugs, her brother said. When he asked her about syringes and empty medicine vials he found in their apartment, Norman would say she’d forgotten to throw them away at work.

But other events suggest Norman may have been battling an addiction.

Nurse Patricia Norman (Courtesy of Jeri Van)

In May 2016, Highland Park police and paramedics responded to a call around 7:30 p.m. on Mockingbird Lane near the Dallas North Tollway, about three miles from Clements. Norman had worked that day. She was found unconscious inside her gray Honda Accord, along with a used syringe, records show. A bystander broke the car’s window to get Norman out; rescue personnel started CPR and Norman regained a pulse.

When she awoke, she told paramedics she was using a prescription medicine for neck pain. She also said she had injected herself with an anti-nausea drug and taken some Xanax.

The ambulance took Norman to Parkland Memorial Hospital’s emergency room, just down the street from Clements.

Highland Park police did not investigate whether Norman had used illicit drugs, Lt. Lance Koppa said. As the officer at the scene saw it, no crime had occurred, Koppa said.

Less than two months later, Dallas police found Norman unconscious in her car, again after work and a few miles from Clements. A tourniquet was on her left arm and a needle was on her lap, records show.

Rescuers again broke a window to get into Norman’s Honda. Records show that to revive her, they had to use naloxone — a drug used to reverse opioid overdoses.

This time, rescuers took Norman to the emergency room at Clements. According to the police report, officers knew she worked there, and spoke to a supervisor about the incident. Dallas police took the needle and tourniquet to an evidence room and referred the case to their narcotics division.

Norman's mother, Jeri Van, gave The News a medical report that Norman had submitted to a supervisor. The report, printed just a few hours after Norman got to the hospital, lists "Drug Overdose" in a section called "Chief Complaint." According to the report, a urine test was negative for opioids, but experts say such tests are not always a perfect indicator.

Norman told her brother that her colleagues helped her keep her job, he said. She didn’t explain how.

“They knew she was a hard worker,” Mark Norman said, “and they covered for her.”

UT Southwestern said it would be inappropriate to comment on an allegation that didn’t include names or other details.

Dallas police never pursued the case. A department spokesman said the syringe was empty, so there was nothing to go on.

Norman died six months later after overdosing in a Clements restroom, at age 32. She was discovered late in the evening, still wearing scrubs from her day’s work. Norman’s mother and boyfriend told investigators from the medical examiner’s office that she had been seeing a doctor for blackouts but that she wasn’t using illicit drugs.

The medical examiner ruled her death an accident, due to an overdose of fentanyl.

UT Southwestern reported to state and federal regulators that on Dec. 15, the day Norman died, an employee stole fentanyl from the hospital.

University officials declined to identify the employee to The News.

According to state records, UT Southwestern told the Texas State Board of Pharmacy that the employee was a nurse. The university declined to comment on the pharmacy board’s findings.

After Norman died, university police obtained the syringe from her June episode, Dallas police records show. University officials said tests of the syringe came back negative for controlled substances.

Other details of UT Southwestern's police investigation are unclear. In response to a request by The News, the university withheld 22 pages of a 25-page police report, citing state law.

Another death

Fentanyl claimed Iyisha Keller about a year and a half later.

Keller, 36, had worked as a nurse at UT Southwestern since 2011. Family described her as a red-headed firecracker who loved her patients.

In April of this year, Keller took a break during her shift and stayed away longer than expected, according to UT Southwestern police and medical examiner records. Colleagues called her cellphone and heard it ring inside a staff bathroom. Maintenance workers had to unlock the door. They found Keller on the floor, a syringe labeled “Fentanyl,” in her arm. A nurse tried to revive her.

Nurse Iyisha Keller (Courtesy of the Keller family)

She was pronounced dead in the Clements emergency room.

One of the several syringes submitted as evidence contained fentanyl and a sedative called midazolam, medical examiner records show. University police also submitted an IV bag as evidence; the medical examiner found it contained midazolam.

The medical examiner ruled Keller’s death accidental, concluding she had died from toxic effects of “therapeutic medication including fentanyl” and alcohol. She also had midazolam in her system.

Her family wants to know more about what university police found.

“They said she never missed work,” said her mother, Denise Keller. “If she’s that good, why can’t you tell me what happened?”

More than 200 hospital thefts

The News asked the state pharmacy board for reports of thefts of controlled substances that occurred during the last four years.

We found that some 125 hospitals reported a combined total of about 220 thefts. Some were of a single pill, others thousands of doses. The state has more than 700 registered hospital pharmacies.

The drugs most commonly reported stolen were powerful and potentially lethal painkillers like morphine, fentanyl and hydrocodone. The list also includes sedatives, as well as anti-anxiety drugs such as Xanax and Valium.

The reports came from hospitals across the state, including in the Dallas area.

Three years ago, a nurse at Children’s Medical Center Dallas stole 123 syringes of morphine, vials containing more than a half-gallon of fentanyl, and a variety of other drugs.

Last year, two nurses at Medical City Plano pocketed more than a quart of fentanyl as well as sedatives and other painkillers.

And in July, a technician at Sundance psychiatric hospital in Garland pilfered 16 gallons of codeine cough syrup.

But The News found the state pharmacy board reports do not reflect every theft.

For instance, health care workers have been disciplined by their professional boards or arrested for stealing drugs from hospitals, but the pharmacy board had no records of the thefts.

In one case, the state nursing board revoked a nurse’s license after finding she had misappropriated morphine and other drugs from Promise Hospital in northwest Dallas in 2016. She later pleaded guilty to a drug-diversion charge. The hospital did not respond to repeated requests for comment about whether it reported the thefts to the state pharmacy board.

Another nurse took dozens of drugs, including methadone and hydrocodone, from Parkland Hospital last year, state nursing board records show.

Parkland did not report the theft to federal regulators or the state pharmacy board. A Parkland spokeswoman said that’s because initially it was unclear where the stolen drugs came from.

The nurse later pleaded guilty to taking the drugs from Parkland.

This week, in light of The News' questions, the hospital said it would review its reporting process.

It’s also hard to tell how often health care workers die from drugs they steal; when hospitals report thefts, the government doesn’t ask about deaths or injuries.

The News got a tip about the Clements deaths. Because Clements is operated by a public university, we were able to get records related to drug diversions there through the state's public information act.

To look for other cases, we contacted major hospitals in the area to ask if any staff members had died in the last five years after overdosing on drugs stolen from the workplace.

Three hospitals systems — Parkland Health, Children’s Health and Texas Health Resources — said none had. Three others — Baylor Scott & White, Medical City and Methodist Health System — declined to comment, citing employee privacy. We also checked Dallas County medical examiner records and did not find any other fatal overdoses inside hospitals.

Preventing thefts

When hospitals report drug thefts, they don’t have to offer a lot of detail. The U.S. Drug Enforcement Administration’s reporting form, which Texas hospitals typically also submit to the state pharmacy board, doesn’t ask how the theft occurred. It does ask what steps have been taken to prevent future thefts, but many hospitals don’t answer.

UT Southwestern officials told The News that Clements has many safeguards to prevent drug diversion: fingerprint access, education on signs of abuse, and having a witness watch the disposal of excess medicine.

Clements’ pharmacy director, Brian Cohen, said one of the most important tools the hospital uses is software to track unusual patterns of drug-handling by staff members.

“We need to be able to take care of those situations before it’s something that jeopardizes the patients' safety,” he said.

Since the hospital opened, Cohen said, Clements has hired more staff members to monitor medicines. The hospital also started using new containers that destroy leftover drugs.

But officials would not detail what changes they had put in place in response to the deaths of Norman and Keller.

The medical center said that drug diversion safeguards are “always an ongoing process.”

Federal regulators can impose steep penalties on hospitals with poor safeguards on controlled substances.

In Georgia and Massachusetts, hospitals recently paid millions of dollars after DEA investigators discovered thousands of pills had been stolen.

In August, the University of Michigan Health System agreed to pay a $4.3 million penalty to settle a case in which the DEA found multiple lapses in record-keeping. The investigation began after a doctor and a nurse overdosed on the same day at a university hospital.

Both were found in locked hospital bathrooms, each with a syringe, having overdosed on fentanyl and other drugs meant for patients, according to news reports. The doctor recovered; the nurse died.