By Brad McElhinny/MetroNews

A veteran’s hospital physician identified only as “Hospitalist B” was the first person to put words to a horrifying truth.

After eight veterans had died under similar, unexplained circumstances, the physician took concerns to the hospital’s associate chief of staff.

But the boss’s reaction, federal investigators wrote later, “exemplified the response of most employees — that the events were likely medically-based and that there was no need to report.”

Hospitalist B insisted.

“Something is going on” and it might be criminal.

The alarm sounded by the doctor set in motion an investigation that eventually led to the identification, arrest and sentencing of nursing assistant Reta Mays.

Prior to that her quiet death march — including three deaths in three days of April, 2018 — prompted just ripples of suspicion.

Investigators who pieced together a 100-page report on the lapses concluded that if staff and managers had reacted to suspicious events sooner then lives could have been saved.

The investigation placed the heaviest responsibility for the deaths on Reta Mays, the overnight nurse’s aid who administered lethal doses of insulin. And the hospital’s top leaders deserved blame for a systemic failure allowing the tragedies.

Broadly, though, there was also blame to go around over not questioning or communicating the odd circumstances surrounding the veterans’ deaths.

“During our interviews, there was chatter described by physicians and nurses that focused on these unexplainable hypoglycemic events. It seemed to have stopped there. Maybe a hallway conversation. Maybe a phone call to someone who was on a previous shift. But it stopped there,” Julie Kroviak, deputy assistant inspector general for healthcare inspections, told reporters last week.

“It really took several events to get to where people took the issue to leadership.”

A full alarm fire

Mays was sentenced last week to consecutive life terms for the deaths of eight veterans. Mays admitted causing their deaths by administering unnecessary and lethal doses of insulin while she worked the overnight shift. She had obtained the insulin from supplies at the hospital, although she was not supposed to possess it or administer it.

The former nursing assistant pleaded guilty to killing veterans Robert Kozul, Robert Edge Sr., Archie Edgell, George Shaw, a patient identified only as W.A.H., Felix McDermott and Raymond Golden. She is also accused of administering insulin to “R.R.P.,” another patient who was not diabetic, with intent to kill him.

The deaths spanned from June, 2017, until June 15, 2018. Three of the veterans died April 8, 9 and 10, 2018.

Michael Missal “That should have really raised a lot of alarms. It should have been a full alarm there,” said Michael Missal, the inspector general for Veterans Affairs.

“They didn’t have a culture that was patient-centric. Instead of saying ‘This looks a little odd,’ you need to push it further, particularly when it’s coming up multiple times.”

The inspector general’s report found that some clinical leaders, managers and staff “failed to report and follow up on the surprising number of profound hypoglycemic events that occurred in 2018.”

Even though hypoglycemia is rare in patients who are not receiving medication for diabetes, the report noted, hospital staff did not conduct robust evaluation of the eight victims’ clinical scenarios and did not pursue diagnostic testing in seven of the eight.

In particular, the series of hypoglycemic emergencies in the spring of 2018 should have drawn serious scrutiny, the inspector general concluded. The report characterizes all but the very first as missed opportunities to report something nefarious.

“I don’t think these tools have to be designed to pick up serial killers. But we do believe they had opportunities to use their data to avoid further tragedies,” Kroviak said.

Numerous breakdowns

The second death of spring 2018 did prompt a review of nursing schedules and patient assignments to determine whether it was possible that a nurse inadvertently administered insulin to the wrong patient. But nurses did not identify any common denominators between the recent deaths.

Moreover, nobody appeared to report the deaths up the chain of command.

When federal investigators asked, the employees “either could not or did not explain why they did not report or follow up on the hypoglycemic events.

“Some interviewees referred to the discussions with their colleagues as informal and focused on the curiosity of the events rather than concern of wrongdoing,” the investigators wrote. “Some employees assumed or implied that other staff members should have reported specific events.”

As the blood sugar of a third patient that spring plunged to fatal levels, “a nocturnist expressed concern about surreptitious insulin administration but did not suspect it was a staff person.”

The employee did not pursue a hypoglycemia workup or notify leaders of concerns. But the nocturnist did enter a recommendation into an electronic health record for an endocrinology consultation to help determine the cause. It was not pursued.

By then, the medical director of inpatient services was aware of two instances of unexplained hypoglycemic events in about 10 days. But that did not prompt additional reviews, and the concerns were not passed to the chief of staff or the associate director for patient care services.

Shortly after that, blood sugar crashed for another veteran even though the patient had no history of diabetes or insulin therapy.

Despite being yet another in a series of similar instances in short order, “no additional reviews, notifications or actions were initiated.”

The inspector general’s report broadly concluded that the hospital lacked a culture of patient safety. That resulted in weak oversight and breakdowns in reporting.

“The OIG found that the facility had serious, pervasive and deep-rooted clinical and administrative failures that contributed to Ms. Mays’s criminal actions not being identified and stopped earlier,” investigators wrote.

The dropped clues cost lives.

“They didn’t communicate well with one another. They should have realized that unexplained hypoglycemia is a very, very rare event. Had they done so, questions could have been asked at a much earlier stage. Lives could have been saved there as well” Missal said.

“There were opportunities to stop this at an earlier stage, and they were not done. There were isolated incidents where people did ask, whether it was a doctor or a nurse, ‘Gee this is strange. This is odd.’ But they didn’t have a culture where they followed through with that. They just left the questions unanswered.”