What Happened
Christopher Robert Pattinson, a paramedic field lieutenant supervisor at a Denver-area hospital, stole approximately 1,900 vials of fentanyl from the paramedic department over four years, falsifying records the entire time to cover his tracks.
According to his plea agreement, Pattinson stole the fentanyl over a four-year period, altering the hospital's narcotics logs and making false entries in its records to conceal the theft. In the final months of his employment, he began tampering with fentanyl vials intended for patient use: removing vials from a locked narcotics supply cabinet, replacing the drug with a clear liquid believed to be saline, and placing the tampered vials into narcotics kits used on ambulances responding to emergencies.
He was sentenced on April 19, 2023 to three years in federal prison, followed by three years of supervised release, and was ordered to pay restitution to the hospital.
What Went Wrong
- A supervisor's position gave him control over the very logs meant to catch him. As a field lieutenant supervisor, Pattinson had the access and authority to alter narcotics logs, removing a key independent check on his own activity.
- Four years of theft went undetected. Stealing roughly 1,900 vials over that period, without discovery, indicates no reconciliation process was independently verifying the logs Pattinson controlled.
- Tampered vials reached ambulances responding to real emergencies. Diluted or substituted fentanyl in an ambulance kit puts patients at risk in exactly the high-acuity moments when effective pain control matters most.
How It Could Have Been Prevented
- Separate narcotics log custodianship from supervisory authority so no single person can both control access and self-report on it.
- Reconcile ambulance and field narcotics kits against a central pharmacy or hospital inventory on a fixed, independent schedule.
- Physically inspect vials in ambulance kits for tamper evidence at each restock and shift changeover.
- Rotate audit responsibility for EMS narcotics supplies among independent reviewers rather than leaving it with unit leadership alone.
Related Guidance
- Investigation Playbook — Auditing narcotics logs when a supervisor controls recordkeeping.
- 15 Red Flags of Drug Diversion — Indicators of diversion by staff with supervisory or custodial access.
- Policy Templates — Separation-of-duties policy templates for EMS and field narcotics custody.
- Regulatory Guide — Controlled substance recordkeeping requirements for EMS operations.