A man, Dr. Abel Gideon, has fallen to the floor seemingly unconscious in a jail cell at the Baltimore State Hospital for the Criminally Insane. After deeming him unresponsive, they handcuff the man and bring him to the hospital's medical wing. He is awake, and moving soon after, however. And then he is suddenly standing behind the nurse attending to him. The nurse is assumed dead.
The next day, Crawford and Will come to investigate. Will is afraid they won't let him out. First they meet with the director, Dr. Chilton, who tells them that the reason the nurse was unattended was because Dr. Gideon cooperated for the past 2 years. The security surrounding him was therefore, slightly relaxed. Crawford wants Will to see the crime scene so he can put the pieces together. Gideon used a pick to get out of the handcuffs. Dr. Chilton also notes that Gideon removed the organs and marked the body much like the Chesapeake Ripper, but that killer hasn't committed a murder in two years, the same number of years Gideon has been incarcerated. They see the dead nurse, impaled over a dozen times on medical equipment and other objects. Dr. Chilton thinks he has the Chesapeake Ripper, that is, Gideon. Seeing this horrific sight sends Will into one of his visions, showing how Gideon attacked the nurse and gauges out her eyes. As she crawls, Will (as Gideon) strikes the nurse with the first medical stand. When Will snaps out of it, he can't believe what Gideon did.
Two years earlier: Crawford speaks to a young agent, Miriam Lass, and tries to get her on board the Ripper case. Miriam shows her skills in profiling the individual. Crawford says he picked her because of several degrees in various fields (psychology, forensics, criminology). Next, Alana talks to Dr. Chilton about Gideon. Apparently, Gideon murdered his wife in an impulsive way, and Will states that is very much unlike the Chesapeake Ripper, who is methodical. Alana has profiled Gideon before, based on two sessions two years ago. Alana and Will head down to interview Gideon. Gideon says he never liked being called the Chesapeake Ripper. But he never took credit for these murders until now. They try to question him about the process. The Chesapeake Ripper usually mutilates during the murder, the nurse was mutilated after her death. Something doesn't seem right.
Crawford goes to visit Dr. Lecter that evening. He's angry because Bella doesn't want to talk about her cancer. He's sad that she is going through this without him. Lecter says Crawford can't save her. Who else couldn't you save? Lecter asks. Two years ago: Crawford and Miriam overlook a body. She notes that the mutilation was done during the death and the organs were also harvested at the same time. He asks the same question to Will back in the present. The team also looks over the body, noting the similarities to the Chesapeake Ripper murders from two years ago. Will cries plagiarism.
Later that night, Crawford receives a phone call, apparently from the real Ripper, who plays the recorded voice of Miriam from two years previously when she suddenly disappeared. The team tries to trace the call the next day but they can't find anything. Well, Will says they know the Ripper is not Gideon, because it didn't come from the hospital. Crawford thinks that the Ripper knows that Gideon is copying him. Meanwhile, Will has another vision of the large antlered stag. Alana and Crawford want to try and get the Ripper to come out of hiding. They get Freddie Lounds to write a story about Gideon, hoping to provoke the real Ripper to make himself visible. Freddie is granted an interview with Gideon in return for writing a story saying that he is the Ripper. Lecter reads the article.
While Crawford talks to Gideon again, Gideon mentions that he killed Miriam, but by accident. Crawford asks why she never was put on display. Gideon says that he did. But Crawford receives another phone call at that very moment with the same recording. Therefore, Gideon can't be the real Chesapeake killer. He decides to bring the team to the house to investigate and they find a third person's DNA in the house, on the bed and elsewhere.
Two years ago: Crawford is dissatisfied with a report Miriam handed in. He tells her to head back to the lecture hall. The report breaks confidentiality laws and Miriam's suggestion to get a warrant for surgeon records won't be easy. Meanwhile, Alana is now interviewing Gideon again, trying to establish more trust. During a dinner with Alana and Dr. Chilton at Lecter's house, Dr. Chilton tells them he had suspected Gideon of being the Ripper. Alana tosses the idea that Chilton unintentionally planted the thought in Gideon's mind during a session, implying that, while Gideon is not the Ripper, he believes himself to be. Lecter and Chilton talk privately and he asks Chilton to tell him if he tried something with Gideon.
Crawford receives a third phone call of the recording, which the team traces to an old observatory. Will, Beverly, and Crawford find Miriam's cell phone clutched in the hand of a severed arm inside the observatory. A card next to it reads "What do you see?". Later, Crawford and Lecter talk about Bella again. Lecter suggests taking control. He apologizes for the troubles that he is having. Lecter then asks about Miriam again.
A final flashback reveals Miriam's fate: she visits Dr. Lecter to ask about an old patient, Jeremy Olmstead, whom he had come into contact with when working as an ER attendant, who has turned up as the latest Ripper victim. Jeremy had two scars on his thigh and Lecter was his ER attendant that night. While Lecter excuses himself to retrieve his medical journals from that time upstairs in his library, Miriam finds one of his sketches on the table. Underneath some normal sketches is one which precisely matches the manner in which Olmstead was murdered. Lecter sneaks up on her from behind and suffocates her, revealing himself as the real Chesapeake Ripper.
Back in the present, Crawford says she was a brave young woman.