George Nelson Shaw Sr. died at a VA hospital in West Virginia in 2018. His death was ruled a homicide by an Armed Forces medical examiner. It’s one of 10 deaths under investigation by authorities.
Jack Gruber, USA TODAY
CLARKSBURG, W.Va. – It was 1:55 a.m., and Felix “Kirk” McDermott was struggling to breathe.
He was cold and clammy. A doctor called to his bedside at the Veterans Affairs hospital in Clarksburg, West Virginia, noted white foam oozing from the 82-year-old’s mouth and a crackling sound coming from his lungs. McDermott’s heart was racing; his pupils were pinpoints.
Seemingly out of the blue, the Vietnam veteran’s blood sugar had plummeted dangerously – to one-sixth the level that triggers urgent treatment, medical records show.
That dramatic decline could have been a significant clue, since McDermott was not diabetic. But it was not recognized as such in the early morning hours of April 9, 2018.
It was just one in a string of oversights at the Louis A. Johnson VA Medical Center that risked, and may have cost, other veterans’ lives. Now, those missed opportunities limit the evidence available to prosecutors as they seek to build a criminal case.
Family members said investigators told them they are focusing on a person of interest who may have killed as many as 10 patients in 11 months by injecting them with insulin.
“When someone has intention to do harm in these settings, they will take advantage of any loopholes, any opportunities to exploit the system,” said Elizabeth Yardley, a criminology professor at Birmingham City University in England who has studied nurses convicted of murder. “It can be an investigative nightmare.”
Hospital spokesman Wesley Walls said officials notified authorities “immediately upon discovering these serious allegations” and put “safeguards in place to ensure the safety of each and every one of our patients.” The person has been removed from patient care.
Events before and after McDermott’s death suggest numerous lapses in medical diligence.
Nurses quickly began treating his symptoms, giving him glucose. But medical records do not indicate that anyone ordered a blood test that could have detected the unprescribed insulin investigators suspect coursed through his veins, killing him.
After he died, no one at the hospital ordered an autopsy despite the mysterious drop in blood sugar.
Insulin on the ward wasn’t adequately tracked, so there was no easy way to tell whether any was missing that night, employees said. In fact, they said, insulin was routinely left unsecured, violating the hospital’s own policies. Complicating matters further, Unit 3A had no video surveillance to document the movement of its insulin – or its employees.
McDermott was the second of three men to die under similar circumstances over three days. Yet no one tipped off authorities that something was amiss for two and a half months, even as the death toll continued to climb, on the same ward, in the same way.
High-risk insulin left out, violating policy
Insulin saves lives by keeping blood sugar in check, whether produced naturally in our bodies or administered, as with diabetics. But too much can be deadly.
Symptoms of overdose include cold sweats and a fast heartbeat, as well as confusion and loss of consciousness.
McDermott suffered from dementia, so confusion might have been hard to diagnose. But his heart was racing and, when his daughter arrived at his bedside before dawn, she found him drifting in and out of consciousness.
He was the only patient in a room near the end of a hallway, on the third-floor medical surgical unit known as 3A.
For four hours, McDermott’s blood sugar fluctuated, out of control. Nursing staff checked it every 15 minutes, his records show. When they gave him glucose, it shot up, then tanked again.
“You had like a couple minutes that he’d talk to you, then he’d be back like he was sleeping,” his daughter, Melanie Proctor, recalled. “Sometimes you could give his arm a shake, or, you know, ‘Hey dad, are you going to talk to us?’ and sometimes he would and other times, he wouldn’t.”
VA Inspector General Michael Missal has said his office is working with the FBI to investigate potential wrongdoing resulting in patient deaths at the hospital. His office declined to provide any details, as have the FBI and Department of Justice, saying they want to protect the integrity of the investigation.
Family members interviewed by investigators said they were told a person of interest may have been responsible for injecting the insulin that killed as many as 10 patients on Unit 3A, a scope confirmed by someone familiar with the investigation. The deaths under investigation span the last half of 2017 through July 2018.
“These guys were dying the exact same way, one after another,” said personal injury attorney Tony O’Dell. “It’s inconceivable that the hospital staff wouldn’t recognize this pattern and prevent the next one.”
But pinpointing where the insulin came from will be challenging.
The Joint Commission, which accredits a majority of hospitals across the country – including the more than 150 VAs that treat about 9 million veterans annually – flagged insulin nearly 20 years ago as a “high-alert” medication, one of five with the “highest risk of causing injury when misused.” The commission requires hospitals to manage the medications safely.
The VA has labeled insulin a “high-risk” medication since at least 2002 and requires its hospitals to take “all necessary actions to reduce the likelihood of intentional or unintentional untoward use.”
The agency lets each hospital create its own policies, so practices vary widely.
At the VA hospital in Clarksburg, policies dating to 2015 list insulin among high-risk medications that “must be stored in a locked area.” A memo signed by hospital director Glenn Snider on Feb. 10, 2018, directs that “all drugs stored in the ward and clinic areas will be kept locked in medication carts, cabinets or medication rooms.”
Yet on Unit 3A, insulin routinely was left unsecured on hallway medication carts, according to two hospital employees who spoke on condition of anonymity for fear of retaliation. One of them offered details: Insulin was left on top of the carts, the carts weren’t locked or the locks weren’t working.
Walls, the hospital spokesman, said it is not accurate that insulin was routinely left unsecured in violation of hospital policy. Insulin, he added, can be purchased at drug stores without a prescription.
“Also, it’s important to note that regulations and protocols can only do so much to protect against criminal activity,” Walls said.
Since the flurry of deaths last year, the Clarksburg VA has improved its insulin monitoring. A policy updated in September requires that two people be present when insulin is retrieved from locked medication cabinets, according to copies of internal directives obtained by USA TODAY.
Another, governing operation of medication carts, was issued April 2 and signed by Paul Carter, the hospital’s associate director for patient care services. It said nursing staff would be issued six-digit PIN codes for the carts.
“Once the medication(s) has been retrieved,” the policy warns, “you MUST ensure all drawers are closed and the medication cart is locked.”
Amid cluster of deaths, failure to detect a pattern
As McDermott’s body lay lifeless after the hours-long struggle to save him, staff placed a frame on his gurney and draped an American flag on top.
The hospital chaplain was summoned to say a prayer. A recording of taps played as workers slowly rolled the veteran away. Nursing staff and others stopped what they were doing. Some stood at attention, others offered their thoughts on the deceased.
“Anybody that had dealt with him that night … said something, you know, ‘I’m sorry for your loss,’ ” recalled Proctor, McDermott’s daughter. “I can remember one of them saying, ‘Your dad had one heck of a sense of humor.’ ”
The flag tradition is known as a “final salute.” It played out the same way the next day for George Nelson Shaw Sr., 81, an Air Force veteran and avid bowler, who also had suffered a bout of acute low blood sugar.
The VA follows many similar traditions. And it is bound by thousands of regulations, including strict protocols to avoid patterns of failure.
When a major incident causes a patient harm, hospital leaders are required to file a report in a national database. That information, kept confidential, is gathered to develop lessons for the nationwide health care system.
Such incidents are supposed to be designated “sentinel events.”
More than 1 million of these “root-cause” analyses and accompanying safety reports have been entered into the system since it was established, according to the VA.
At the Clarksburg hospital, the cluster of unexpected patient deaths after acute low-blood sugar episodes apparently triggered no such reporting or inquiry. In addition to Shaw and McDermott, William Alfred Holloway, 96, and Army veteran Archie Edgell, 84, all died within a 16-day period.
Weeks after the last of those deaths, inspectors visited the hospital for a routine care review. They noted the hospital had not designated a single event as sentinel in the prior 32 months.
The inspectors cited a half-dozen serious episodes over that time that they said should have been flagged as possible sentinel events. They said administrators failed to report other major medical problems and to disclose the information to patients and their families.
A month after that visit, in June 2018, a group of Clarksburg VA doctors brought concerns about the deaths to the hospital’s patient safety staff, according to a timeline released by Sen. Joe Manchin, D-W.Va. The safety staff notified the hospital director, who called VA headquarters in Washington.
The inspector general’s office again sent out inspectors, who arrived at the beginning of July – as the suspected death toll reached 10.
When asked about reporting delays, Walls, the hospital spokesman, said, “VA’s independent inspector general has been investigating this issue for longer than it took (hospital staff) to identify it.” He referred questions about “specific timelines” to investigators.
Missal, the VA inspector general, said federal authorities “have been working with urgency to complete the investigation. The families and the public deserve nothing less.”
Insulin tests came months late, after blood evidence was drained
Proving homicides by insulin injection can be difficult with even the best evidence. At the Clarksburg VA, tests for insulin came months later when bodies were exhumed – after potential blood evidence had been drained and bodies embalmed. One veteran had been cremated.
The doctor called to McDermott’s bedside early on the morning of April 9 had ordered a chest X-ray and a diuretic in case of fluid buildup in his lungs, medical records show. He was placed on a machine to help him breathe.
The doctor ordered blood tests that confirmed McDermott’s sugar and oxygen levels were low. But, according to a copy of the medical records provided to USA TODAY, those tests did not measure insulin or a key amino acid – C-peptide – that specialists said could have detected the unprescribed insulin.
“If people don’t have diabetes, they should do that (test),” said Adrian Vella, professor of medicine at the Mayo Clinic and author of a literature review on the topic. “You’re supposed to check glucose … and you’re supposed to get an insulin and C-peptide.”
Other specialists said providers may not routinely order such tests if other factors could help explain low blood sugar levels, such as liver problems, infection or other medications.
Washington University School of Medicine professor emeritus Philip Cryer said such factors wouldn’t explain McDermott’s “profound hypoglycemia all of a sudden.”
“You could not explain that absent measurements of insulin and C-peptide,” said Cryer, who co-wrote clinical guidelines for evaluating low-blood sugar disorders. “Ideally, those should have been measured.”
McDermott had been admitted to Unit 3A three days earlier with a fever and cough. He had heart problems along with his dementia. Medical staff diagnosed him with pneumonia from inhaled food.
He had been responding to antibiotics and, the day before his death, a doctor noted in his chart that he was “much more alert and talking with family.” His blood-sugar level was normal – until suddenly it wasn’t.
By 6 a.m., after staff had tried for four hours to stabilize McDermott without success, Proctor and other family members told them to stop medical intervention, to let him go.
When he died three hours later, his daughter said, the family didn’t request an autopsy because “we thought he had passed on his own, natural causes.”
Possible autopsy criteria itemized in McDermott’s medical record include “unexpected or unexplained” death “when clinical course seemed to be improving.” Staff did not indicate that he met that criteria.
Even if the family had asked for an autopsy, it’s unclear whether an examination at the hospital would have revealed anything untoward. When Shaw passed away the next day, a hospital autopsy requested by his family concluded he had died from heart failure.
Both deaths later were reclassified as homicides after federal investigators launched their probe.
McDermott’s remains were exhumed six months after his death, in October 2018, and sent to Dover Air Force Base for an autopsy. An armed forces medical examiner identified an injection site in his abdomen that tested positive for insulin.
On Shaw’s body, exhumed and re-autopsied in January, the examiner found four insulin injection sites – two on the left arm, one on the right and another on his right thigh.
Like McDermott, Shaw had no history of diabetes or prescribed insulin. The examiner concluded both men had been killed by insulin injection.
Walls, the hospital spokesman, declined to comment on blood tests and autopsies performed at the hospital, again referring questions to investigators.
Michelle Aurelius, a member of the Autopsy Committee with the College of American Pathologists, said the scope of hospital and medical examiner autopsies differ, even though the methods are similar.
A hospital autopsy typically looks for evidence of disease in a natural death to provide explanations for physicians and families. A forensic autopsy focuses on sudden, unexpected and possibly violent death, with a goal of determining the manner and cause while gathering evidence for law enforcement.
Since insulin needles are tiny, Aurelius said, it “may be very difficult or impossible to find an injection site.”
Howard Robin, a California pathologist, said initial autopsies may detect needle marks, but pathologists “must have a significant level of suspicion to make the diagnosis” of homicide by insulin injection.
Clarksburg spellbound by ‘Twilight Zone’ whodunit
Signs outside the Louis A. Johnson VA Medical Center clearly state its mission. One notes that the hospital “honors our heroes,” another that “the price of freedom is visible here.”
Inside, there is no indication of the pall cast by the recent headlines. A lobby shop stocks black and gold Steelers gear, women’s shoes and snacks. Medical workers in scrubs counsel a veteran in the emergency room lobby and wish visitors in hallways a good day.
Nearly everywhere else, news of the deaths has gripped the city of Clarksburg since it became public in August when the first legal action, a wrongful death claim seeking $6 million on behalf of McDermott, was filed by Tony O’Dell.
The VA hospital has a huge footprint here. It is among the economically depressed area’s biggest employers, with 1,000 workers, and draws patients from across the region, serving about 70,000 veterans in north central West Virginia and nearby Maryland, Ohio and Pennsylvania.
O’Dell, a partner in a firm in the state capital, also represents other victims’ families in the case. He blames the Clarksburg VA for failures both systemic and pervasive. O’Dell says the hospital breached its duty to warn patients and their families.
“There is simply no excuse whatsoever for these deaths to have gone on for so long,” he said. “That is an insult to these veterans’ families, and they should be ashamed.”
At a Panera Bread restaurant on the edge of Clarksburg, Norma Shaw fights back tears as she talks about her husband’s death. She is angry – at the possible assailant, at the hospital, at the VA in general.
“I trusted those people, I did,” she said.
McDermott’s daughter feels the same way.
“I’m still very angry – still very, very angry,” she said.
Veterans who gathered to hear a band on a recent Thursday at the American Legion Post `3 lamented that the case turned a national spotlight on the town, for all the wrong reasons.
“It just breaks our hearts,” said Michael Greaver, the post’s commander. “It’s so bad for morale in our community.”
Behind the bar, Susie Jimenez doled out Budweisers and pull-tab raffle tickets. She sees the outside attention a little differently, saying she hopes the pressure continues until “justice is served for these veterans.”
Jimenez criticized the hospital for not telling the public for 14 months after the investigation was launched, saying, “It shouldn’t have been swept under the rug.”
Walls said investigators instructed the hospital not to share information with anyone outside the inspector general’s office. The hospital told employees not to speak with the news media either. Many doctors, nurses and nursing assistants who worked on 3A at the time of the deaths declined to comment or failed to respond to messages left at their homes.
When a reporter visited a residence listed for the person of interest in public records, a man outside accepted a handwritten note seeking comment, but no one got back in touch.
Speculation about the person ripples through conversations in town these days. USA TODAY is not identifying them because authorities have not named or charged anyone. But locally, pictures of a former hospital employee have been posted and discussed online.
Back at the American Legion hall, Greaver – an Iraq War veteran with 17 years’ active duty in the Army and Navy – said he has received medical care at the hospital for years.
“I walk the halls of that hospital, and there’s family members, friends everywhere,” he said.
“It’s very unfortunate that an Alfred Hitchcock episode – “Twilight Zone” episode – happened here,” he said. “Now everybody’s asking questions, across America.”
Contributing: Ken Alltucker
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