In a report released Tuesday, the Veterans Affairs Office of Inspector General found that the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia missed the chance to prevent convicted murderer Reta Mays from killing patients at the facility.
“While responsibility for these heinous criminal acts lies with Reta Mays, an extensive healthcare inspection by our office found the facility had serious and pervasive clinical and administrative failures that contributed to them going undetected,” said VA Inspector General Michael J. Missal. “I hope that the victims’ families can find some measure of solace knowing that Mays was caught and punished, and that steps are being taken to help ensure other families do not suffer the same loss.
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Mays, 46, of Harrison County, West Virginia, was sentenced to seven consecutive life sentences, one for each murder, and an additional 240 months for her eighth victim on May 11.
She pleaded guilty in July 2020 to seven counts of second-degree murder in the deaths of veterans Robert Edge Sr., Robert Kozul, Archie Edgell, George Shaw, W.A.H., Felix McDermott, and Raymond Golden. She pleaded guilty to one count of assault with intent to commit murder involving the death of veteran Russell Posey.
During a press briefing, Missal said the IG report contains 15 recommendations and that officials at the medical center have concurred to those recommendations.
“One of these recommendations is for VA to take another look at the various patients that had quality-of-care issues outside of the hypoglycemic events,” Missal said.
Mays was employed as a nursing assistant at the medical center, where she worked the night shift during the same period of time that the veterans in her care died of hypoglycemia while being treated at the hospital. Nursing assistants at the medical center are not qualified or authorized to administer any medication to patients, including insulin. Mays would sit one-on-one with patients and admit to administering insulin to several patients with the intent to cause their deaths.
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The report found that Mays’ prior employment was not reviewed by VA and if it would have been, “allegations of excessive use of force” against her would have been spotted.
Among the report’s 15 recommendations are three to “the under secretary for health related to adjudicator follow-up of unreturned background investigation documentation, rescue medication security and management, and mortality data analyses.”
Two recommendations to the Veterans Integrated Service Network director to conduct “management reviews of the care of patients discussed in this report, as well as a broader external clinical evaluation of patients who may have been harmed in other ways by Ms. Mays’s actions during her tenure at the facility.”
The report also includes 10 recommendations to the facility director related to the “Pharmacy Service’s inventory accountability, endocrinology consults, clinical communication expectations and forums, clinical documentation reviews, clinical care-related reporting expectations, patient safety event training, interdisciplinary mortality workgroup activities, oversight and reporting, and a culture of safety.”
Mays was also ordered to pay a total of $172,624.96 to the victims’ families, the VA hospital, Medicare, and insurance companies.
Reach Julia LeDoux at Julia@connectingvets.com.
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