Fatal insulin injections spur latest VA inquiry Deaths investigated

The deaths in Clarksburg, W.Va. — three of which have been ruled homicides — are the latest criminal case to engulf the Department of Veterans Affairs, intensifying questions about whether it is doing enough to protect the veterans in its care.

Four months after Melanie Proctor’s father was buried with military honors for his combat service in Vietnam, she came home to her farm in August 2018 to find an unfamiliar tan SUV in the driveway. Two federal agents stepped out. Proctor, a tax preparer, wondered whether one of her clients was in trouble. “We’re here about your father,” one of the agents said. “We don’t believe he died of natural causes.” Flipping open a laptop, Proctor showed the agents her dad’s records from the three days he had been hospitalized at the local VA medical center. What the line graph showed was alarming.

In the early-morning hours that April, Felix McDermott’s blood sugar had dropped to dangerous levels. The retired Army sergeant his family knew as “Pap” died the next morning from severe hypoglycemia. Someone had given her father, who was not a diabetic, a deadly injection of insulin, the investigators said — and he was not the only one.

Multiple veterans had died under similar circumstances on the same ward, and the agents had come to Proctor’s farm in a hamlet 42 miles east of Clarksburg to ask the unthinkable: They wanted to dig up Pap’s body.

Her father was one of seven bodies exhumed in an investigation of 11 suspicious deaths at the Louis A. Johnson VA Medical Center, according to a person familiar with the case.

The 14-month inquiry is the latest criminal investigation to engulf the Department of Veterans Affairs, intensifying questions about whether the country’s largest health-care system is doing enough to protect the veterans in its care.

In August, a former VA pathologist in Arkansas was indicted on three charges of manslaughter after officials say he misdiagnosed thousands of patients while using drugs or alcohol. He has pleaded not guilty.

The cascade of inquiries threatens to undermine trust in the long-troubled agency.

Speculation

In Clarksburg, a small Appalachian community four hours west of Washington, hospital officials said they alerted VA leaders as soon as they learned that their medical staff suspected foul play.

The deaths from the second half of 2017 through July 2018, initially found to be of natural causes, are now being investigated as homicides. Federal authorities say they have identified a person of interest.

The probe has come to focus on a now-fired hospital employee, a woman who worked the overnight shift as a nursing assistant and left last year, according to people familiar with the case.

The woman’s name is being withheld because she has not been charged.

The deaths have set off feverish speculation among locals.

“When you have someone who is 80-something years old and they had health issues, you’re thinking, ‘This was their time,’” said Proctor, 53. “You don’t question it. None of us had a clue something was wrong.”

Similarities

Investigators have identified similarities in nearly a dozen deaths: Elderly patients in private rooms were injected in their abdomen and limbs with insulin the hospital had not ordered — some with multiple shots. The insulin, which was quickly absorbed, was given late at night when the hospital staff had emptied out. Within hours, the veterans’ blood-sugar levels plummeted.

The person of interest was assigned to monitor several of the veterans who died in what are known as one-on-one bedside vigils for patients who need extra attention.

Despite these common denominators, the medical staff and those with oversight of hospital procedures were slow to identify a pattern — a failure that could have cost lives, several people familiar with the investigation said.

The Clarksburg medical center reported 26 deaths from late 2017 through June 2018, according to an internal VA database that tracks mortality rates across the system. The suspicious deaths accounted for close to half of them, according to data.

Senate inquiry

The case has also brought new scrutiny to VA’s internal controls. The medical surgical ward in Clarksburg, known as 3A, did not have surveillance cameras, according to people familiar with the case. The woman is believed to have had improper access to the medical supply room. The medicine carts on the floor also were routinely left unlocked.

Wesley Walls, a hospital spokesman, said the facility has “many protocols in place to safeguard medication.”

But lawmakers are still demanding answers.

“All of us are up in arms,” said Sen. Joe Manchin III, D-W.Va., describing the reaction of his colleagues on the Senate committee that oversees veterans’ care. He said he is incredulous that hospital leaders in Clarksburg took so long to put the pieces together.

“You mean to tell me that for nine months you didn’t know what was going on in your hospital?” Manchin said. “Either you didn’t care, or there was a lack of competency.”

The senator said he is preparing to call for a “full-blown” Senate investigation into how VA handled the case.

Glenn Snider, the medical center director, has said he notified senior leaders in Washington, including the VA inspector general, as soon as his staff alerted him to their concerns.

“Immediately upon discovering these serious allegations, Louis A. Johnson VA Medical Center leadership brought them to the attention of VA’s independent inspector general while putting safeguards in place to ensure the safety of each and every one of our patients,” Walls said in a statement.

As the inquiry has unfolded, the hospital has required more rigorous tracking of its medications, including their dispensing and who has access to them.

Nursing aide suspect

VA Inspector General Michael Missal opened an investigation into the deaths in July 2018. The nursing assistant was moved to a dayside paperwork job and interviewed soon after, a person close to the case said. The hospital did not move to fire her for another seven months, the person said, eventually terminating her for lying on her résumé.

“Our hearts go out to the families affected by these tragic deaths,” VA Secretary Robert Wilkie said in a statement. He added that the allegations “do not involve any current” hospital employees, bringing “a small measure of accountability to the situation.”

Wilkie also called on Missal to bring to a close the investigation he is jointly leading with the U.S. attorney for the Northern District of West Virginia.

“More than a year later, the IG is still investigating and Clarksburg-area veterans are still waiting on the justice and answers they deserve,” Wilkie said.

Not mercy killings

Three deaths have been ruled homicides by insulin injection, according to people familiar with the investigation. In recent weeks, the Armed Forces deputy medical examiner changed the death certificates of the others from “natural causes” to “undetermined,” according to autopsy reports and two people familiar with the case.

A possible motive in the deaths is still unclear to investigators. But they say they do not believe they were mercy killings. Although the victims — all male — were hospitalized with underlying medical conditions, none was terminally ill.

The hospital had told McDermott’s family that his aspiration pneumonia was improving with antibiotics and intravenous fluids. They said he would probably be released in a few days once his strength improved, his daughter recalled.

“They were saying he was doing real good,” she said.

Then her cellphone rang at 1 a.m. April 9. Pap had taken a turn for the worse, the hospital said. His daughter arrived to find him hooked up to an IV bag of dextrose to raise his blood sugar, which was dangerously low.

Proctor’s father did not recognize her. He died a few minutes before 9 a.m.

Deaths piled up

West Virginia’s fourth-largest city is set among the hills of a rural region dotted with empty coal fields. VA is a major employer in Clarksburg, but the hospital has struggled to recruit and keep health-care workers to treat its aging veterans.

The 70-bed hospital serves 70,000 veterans with chronic disease, including diabetes.

The first patient afflicted with what would later be understood as sudden, unexplained hypoglycemia died in the second half of 2017.

The deaths piled up. One in January 2018. Another in March. Three more in April, three days apart, including McDermott. Two more in May. Another two in June. Another in early July, on the same day investigators arrived at the hospital.

The hospital staff recorded their apparent causes: Advanced dementia, sepsis, heart attack — unsurprising determinations for an elderly population with chronic conditions, including a small number with diabetes.

They also had extremely low blood-sugar levels.

It is “very, very rare” for blood sugar to crater so low that it leads to death, said Yogish Kudva, an endocrinologist with the Mayo Clinic in Rochester, Minnesota.

Deaths unreported

Two months before investigators arrived, on May 7, 2018, a team of inspectors from Missal’s office visited the medical center for an unannounced, weeklong spot inspection to conduct a routine review of clinical operations over the past three years.

Their report issued in October 2018 found general compliance with patient-safety measures, with one exception: The hospital had weak systems for identifying and reporting red flags that could lead to patient harm.

Clarksburg officials told the inspectors that during the past three years, there had been no “sentinel events,” or episodes of possible lapses in care that harmed patients. But the inspectors identified at least one case.

The watchdog’s office was unaware that three weeks earlier, three patients had died under suspicious circumstances — because no one had identified them, investigators said.

By mid-2018, a small number of doctors had begun to feel uneasy with the number of patients who had died of sudden hypoglycemia, according to people familiar with the case.

Still, they did not immediately report their concerns.

The tipping point

The tipping point came in mid-June, after the death of a Korean War veteran named John Hallman, 87, who served in the Navy. Hallman was admitted with liver issues and possible pneumonia. He died the next morning.

A team of doctors informally discussed the case. They noticed that the overnight staff had checked Hallman’s bloodsugar level. It had dropped to 26.

“We said, ‘Who checks the blood sugar on a non-diabetic in the middle of the night while they’re trying to sleep?’” the medical staffer recalled. “It was like, ‘Oh my gosh, this is not good.’”

It would be 10 more days before Snider, the medical center’s director, would escalate the case to the inspector general and other VA leaders in Washington — at least nine months after the first death.

‘Patterns of behavior’

The hospital had missed other clues. Clarksburg’s mortality statistics, viewed monthly by the quality staff, showed death rates twice as high as similar hospitals in the VA system for the first two quarters of 2018, data shows.

“You had 11 people die. There was a missed pattern,” said House Veterans’ Affairs Committee Chairman Mark Takano, D-Calif. “If you’re a manager, you have to understand the warning signs and patterns of behavior.”

When FBI agents arrived on the scene, they pored through patient medical records and began interviewing the staff and the person of interest.

They discovered that she walked the hospital ward late at night with a bedside glucose meter, pricking the edge of patients’ fingers to test their blood sugar. She pricked one patient 12 times in one night, the person on the staff recalled.

Her attention to blood-sugar levels did not raise alarms; with West Virginia’s high rate of diabetes, checks are not unusual.

The hospital — which had honored the person of interest with an award in 2017 — moved to fire her in February after discovering that she lied on her résumé when she was hired in 2014.

The seventh autopsy was completed last month. Although three of the deaths have been ruled homicides, the evidence of insulin was not strong enough in the other patients to make that determination.

All the veterans have been reinterred with military funerals.

PHOTOS BY JEFF SWENSEN / WASHINGTON POST Linda Shaw walks with her mother, Norma, on their farm. Linda’s father, George, died last year at the VA hospital in Clarksburg, W.Va., and an autopsy showed a severe blood-sugar drop hours before his death. It was similar to several other deaths.

Melanie Proctor holds a photo of her mother and father, Felix McDermott, who died in 2018. Because of his age, she said, “You don’t question it. None of us had a clue something was wrong.”