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Person of Interest in VA Deaths Not a Nurse

PARKERSBURG — The person of interest in the suspicious deaths at the Louis A. Johnson VA Medical Center in Clarksburg was not a certified nursing assistant that the hospital thought it hired, according to a claim filed by the family of one of the deceased veterans.

“…a fact that is very easy to verify,” the family of John Hallman, 87, who died at the medical center on June 13, 2018, said in the basis of claim filed last week against the Department of Veterans Affairs. The action claiming negligence on the part of the medical center was filed by Hallman’s children, Mark Hallman and Debra Cutler, who are represented by attorney Tony O’Dell of the Charleston law firm of Tiano and O’Dell.

The independent Office of the Inspector General of the Department of Veterans Affairs is investigating the deaths of nine or 10 veterans who died around the same time period, were on the same floor and under similar circumstances, hypoglycemia, or low blood sugar, caused by unprescribed injections of insulin. A person of interest in the deaths no longer works at the medical center.

Hallman, who served in the Navy, was admitted to the hospital on June 12, 2018, on floor 3A for treatment of a suspected bowel obstruction. He died the following day at 11:35 a.m.

His blood sugar was tested around 9:30 p.m. June 12 and was normal, the claim said. A critically low level found around 6:45 a.m. June 13 was reported and the doctor prescribed medication, the claim said.

Subsequent readings were made around 7:45 and 8 a.m.

“No further glucose readings are taken to see if Mr. Hallman’s glucose level continues to decline, no testing, medication or intervention is provided for the unexplained severe hypoglycemic event,” the claim said.

A plasma reading taken at 10:40 a.m. showed a finding consistent with an insulin overdose, the claim said.

“A reasonable standard of care medical work up should have been ordered and implemented in the early morning hours of June 13 to discover the cause of, diagnose and treat the sudden severe hypoglycemia,” the claim said.

Hallman’s death and the other suspicious deaths were reported to the Inspector General and the investigation commenced, according to the claim.

Nine or 10 patient deaths “followed a pattern of being prompted by a sudden decline in medical condition while admitted on 3A: severe hypoglycemic events not explained by patient condition; timing of initial decline occurring during the early morning hours of the night shift; and all initial declines occurring while the person of interest was working,” the claim said.

The circumstances of the death were not disclosed to the family, so no autopsy was performed, the claim said. Hallman was cremated.

The medical center had a duty to provide competent medical care and protect and prevent patients from being administered insulin that was not medically necessary, the claim said.

“(Veterans affairs) also had a duty to determine whether employees were in fact qualified by reason of education and training to be placed in the job to which the employee was assigned,” the claim said. “Upon information and belief, the (medical center) hired the person of interest to work as a certified nursing assistant when in fact she was not a certified nursing assistant, a fact that is very easy to verify. Each of these affirmative duties of the (medical center) were antecedent and independent of the conduct of the person who wrongfully administered insulin to John Hallman and was a proximate cause of John Hallman’s death.”

No one has been charged. Five veterans have so far been publicly identified.

A notice of claim against the government filed by the daughter of Felix K. McDermott, 82, who was retired from the Army, in August was the first revelation that an investigation was underway and nine or 10 veterans died under similar circumstances. The claim also disclosed there was a person of interest.

Archie Dail Edgell, 84, died on March 26, 2018. William Alfred “Sport” Holloway, 96, died on April 8, 2018. McDermott died on April 9, 2018. George Nelson Shaw Sr., 81, died April 10, 2018.

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