Investigators contact more families of veterans who died at a West Virginia VA hospital
By KEN ALLTUCKER | USA Today | Published: September 10, 2019
A lawyer representing relatives of patients who died at a Veterans Affairs hospital in West Virginia said investigators contacted three more families, indicating a federal probe into about 10 suspicious deaths is expanding.
The VA's Office of Inspector General has been looking into the deaths at Louis A. Johnson VA Medical Center in Clarksburg, West Virginia. At least two of those deaths were reclassified as homicides after the bodies were exhumed.
The elderly patients received insulin injections they did not need, causing their blood sugar to plummet. They died one day apart in April 2018.
Last week, another family agreed to allow the body of their relative, who died in January 2018, to be exhumed to search for signs of foul play, said Tony O'Dell, a Charleston, West Virginia, attorney representing the families.
The VA's Office of Inspector General contacted two other families to say their relatives may have died under suspicious circumstances, O'Dell said. They died in March and April of 2018.
O'Dell declined to identify the families, saying they haven't decided to speak publicly.
There are two things in common, O'Dell said, among the five veterans whose families he represents: They were all patients in 3A, a unit on the hospital's third floor. And investigators told the families they suspect the patients were improperly injected with insulin.
The family of one of those veterans has come forward.
In June 2018, John Hallman, 87, a veteran of the Korean War, spent the night in unit 3A after being admitted with liver problems and signs of pneumonia. He didn't seem to be critically ill, and doctors did not place him in the intensive care unit, his children told USA Today.
He died the next morning.
"We really trusted them," said Debbie Cutler, Hallman's daughter, "That they would do whatever they could to make him well again. It was unbelievable. Heartbreaking."
Although doctors never told the family why he died, his death certificate listed the cause as cirrhosis of the liver, Cutler said.
The family didn't suspect anything. They honored Hallman's wish to be cremated.
In November, agents with the criminal investigation unit of the VA's Office of Inspector General arrived at Cutler's home. They explained they were looking into the deaths of about 10 patients who may have been injected with insulin – a lifesaver to people with severe diabetes but potentially fatal to others.
Agents showed Cutler and her husband, Gary, detailed graphs from Hallman's medical records, displaying how the level of insulin in Hallman's blood had spiked before he died.
"There were big spikes," Cutler said. "It was definitely suspicious."
Hallman did have diabetes, but he didn't take insulin, Cutler said. He kept his blood sugar levels under control with pills.
The family's account is similar to that of two other families who talked to USA Today.
In the past year, the bodies of 82-year-old Army veteran Felix Kirk McDermott and 81-year-old Air Force Veteran George Nelson Shaw Sr. were exhumed and autopsied.
A federal medical examiner concluded McDermott's death was caused by an insulin injection into his abdomen. Shaw's autopsy revealed four injection sites that tested positive for insulin.
Neither man had diabetes. The insulin injections caused sudden, fatal drops in their blood sugar levels.
Cutler and her five siblings communicated with agents about Hallman's death over the following weeks, including the inspector general's office, the Federal Bureau of Investigation and the U.S. Attorney's Office in the Northern District of West Virginia.
Agents recorded interviews with them and requested DNA samples. Victim specialists gathered details about Hallman.
During the Korean War, he managed stockrooms on a depot ship in Panama that supplied submarines. After a long day, he'd retreat to the ship's deck to eat crackers and sardines, Cutler said.
Later in life, he often wore a hat commemorating his service and was quick to pick up the restaurant tab of fellow vets.
Cutler said an inspector general agent told her in January that a person of interest was no longer caring for patients.
"They said they had to have a rock-solid investigation done," Cutler said, "so they could prove it."
The VA said the investigation doesn't involve a current employee.
"Reports that say a 'person of interest' is being investigated refer to someone who was removed from their position in Clarksburg," Dr. Glenn Snider, director of the VA hospital, wrote in a column in The Exponent Telegram, the Clarksburg newspaper.
O'Dell said all five families he represents have been contacted by the VA's Office of Inspector General. An investigator told him the string of suspicious deaths dates back to the summer of 2017.
Hallman, an active man who once ran an auto body repair shop, checked into the hospital nearly a year later. He had purchased a small bass boat and planned to move to a riverfront property.
"It could have been avoided if they took action at the hospital sooner," Mark Hallman, his son, said. "He wouldn't have died."
Representatives of the VA hospital said the hospital acted swiftly.
"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," hospital spokesman Wesley Walls wrote in an email.
Five days after Hallman died, VA doctors informed the hospital's quality management team that eight patients had experienced unexplained, dangerously low blood sugar, according to a timeline released by the office of U.S. Sen. Joe Manchin, D-W.Va.
Eight days later, on June 26, Snider informed a senior official at the VA about the suspicious deaths. Agents with the Office of Inspector General visited the hospital July 2.
Manchin was informed July 5. By then, the number of cases had ticked up to nine.
Walls said the hospital instituted safeguards after learning of the deaths. He declined to specify what was done, saying that could compromise the measures.
The Office of Inspector General acknowledged an investigation of "potential wrongdoing resulting in patient deaths" but has not released details. The office did not respond to a request for comment Monday.
William J. Powell, U.S. attorney for the Northern District of West Virginia, declined to provide updates on the case, a spokeswoman said Monday.
A hospital's pharmacy should be able to track all insulin supplies, said Patrick Horine, CEO of DNV GL Healthcare, which accredits hospitals and other health facilities.
If a doctor prescribes insulin for a patient, the hospital pharmacy will fill it. Many hospitals have automated dispensing systems that allow nurses and other authorized personnel to access insulin at any time, Horine said.
Under such automated systems, a pharmacist reviews a doctor's order and authorizes the drug to be automatically dispensed. If a pharmacist has not reviewed the order, these systems allow some hospital employees to access the medication anyway, and the pharmacy would be able to review those overrides.
That means a hospital's pharmacy should know when insulin or any other drug is not used according to a physician's order. Hospitals closely track narcotics and other controlled substances that can be abused. Insulin, however, is not a controlled substance.
If the insulin in question came from the hospital, "chances are, they tricked the system in some way to do it," Horine said. "The pharmacy would know one way or another, even if it was after the fact."
Walls has not answered questions about how the Clarksburg hospital stores and tracks insulin supplies.
"It's important to note that regulations and protocols can only do so much to protect against criminal activity," he said in an email.
A pharmacists' group representative said insulin could be misused at any hospital.
Insulin comes in multi-dose vials, so it would be difficult to monitor whether a partial dose is missing, said Michael Ganio, a director at the American Society of Health-System Pharmacists, which has about 50,000 members.
Hospitals might keep emergency vials that are not assigned to a particular patient. Refrigerated automated dispensing systems aren’t common because they’re expensive, he said.
Doses of insulin change based on a patient's blood sugar level, so a pharmacy can't know how much would be needed for a single dose, he said. Those calculations are done by medical staff treating the patient.
In short, Ganio said, the system is not really meant to prevent a killing, which is rare in a hospital environment.
"When it comes to a product like insulin," he said, "it's a tricky situation."
Contributing: David Heath and Donovan Slack
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