Veterans Disability Info Blog

Person of Interest Identified in VA Hospital Deaths

There is more information regarding the investigation into the deaths from insulin overdoses of at least 11 veterans at the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia, four hours from Washington, D.C. Authorities have identified a “person of interest” in the investigation, although she has not been identified by name.

The woman was apparently a nursing assistant, working the overnight shift on the notorious floor 3A where the deaths occurred, and she was fired last year. No charges have yet been filed.

One-on-One Bedside Vigils

The person of interest was assigned to monitor several veterans who later died from insulin injections, in what can be described as “one-on-one bedside vigils” for patients requiring extra care. All of the victims were elderly veterans. None had terminal illnesses at the time of their deaths. Some appeared to improve while in the hospital, until their sudden demise.

In some other cases where hospital staff was later found to have killed patients, many of the deaths might be deemed “mercy killings” of people experiencing great pain and suffering. That does not appear to have been the motive in this situation.

The circumstances under which the suspicious deaths occurred where the same. The patients, all in private rooms, had insulin –not ordered by the hospital – injected into their abdomen and limbs.

Autopsy results showed that some of the dead veterans received multiple injections. All of these injections were given late at night when very few staff were on duty.

On floor 3A, the nursing assistant was believed to have had access to the medical supply room, although she did not have the authority to access the medications stored there. Unlike other areas of the facility, there were no surveillance cameras on that floor. It was also customary to leave medical carts on the floor unlocked.

The FBI and others on the investigative team later learned the nursing assistant used to walk around floor 3A in the middle of the night with her bedside glucose meter, pricking the patients’ fingers to determine blood sugar levels. According to one person on the medical staff, she pricked the finger of one patient 12 times in a single night.

On another occasion, she told nurses on duty that she was bringing juice to a patient whose blood sugar levels had dropped. Because diabetes is so common among hospital patients, her behavior did not raise serious concerns. In fact, she was honored with an award by the hospital in 2017.

A Mortality Rate Twice That of Other Hospitals

It is not uncommon for aged veterans to die at the VA Hospital. However, it took far too long for anyone to recognize that a pattern was developing and that the mortality rate for the period in question was twice as high as other hospitals with similar patient populations.

From late 2017 until June 2018, the Clarksburg VA hospital reported 26 deaths. Roughly half of these deaths are now considered suspicious. Although some doctors were reportedly “uneasy” about the number of deaths related to hypoglycemia, or low blood sugar, no concerns were reported until the death of Navy vet John Hallman, 87, on June 2018.

Hallman, who was not diabetic, had his blood sugar checked in the middle of the night, which doctors found very odd. Although a supervisor was notified, this person did not follow the correct procedure of notifying the inspector general’s office. Instead, the information was sent to the hospital’s quality control team.

On the Job for Seven More Months

The nursing assistant did come under some scrutiny when an investigation into the deaths began in July 2018. The woman was taken off nursing assistant duties and placed in a job during the day doing paperwork.

She continued to work at the VA hospital for seven more months before she was fired for lying on her resume. Hired in 2014 as a certified nursing assistant, it later turned out she had no such certification.

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