On June 27, 2018, the director of the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia, reached the after-hours duty agent at the Department of Veterans Affairs Office of Inspector General. The hospital, the director said, believed that at least one crime, and possibly more, had been committed on its wards. Elderly patients on Ward 3A, the general medical ward, had been suffering sudden and profound drops in blood sugar that nobody could explain, and several of them had died. The next day the head of the Veterans Health Administration, Dr. Carolyn Clancy, passed the warning to Inspector General Michael J. Missal in blunt terms: there might be an "Angel of Death" in Clarksburg, where a number of patients in their eighties and nineties had died of low blood sugar. A criminal investigation opened that same day.
It took two years to finish. It ended in July 2020 with a former nursing assistant, Reta Mays, admitting in federal court that she had killed seven of the men in her care by giving them insulin they did not need, and that she had tried to kill an eighth. The case also exposed a hospital where nobody had checked her past, where the medicine room stood open to the whole ward staff, and where a run of medical emergencies that should have raised alarms passed almost without comment.
Mays lived in Harrison County, West Virginia; CBS News gave her hometown as Reynoldsville. She had served in the West Virginia Army National Guard. WV MetroNews reported that she deployed to Iraq in 2003 as a chemical equipment repairer with the Guard's 1092nd Engineer Battalion; CBS News described her service as a noncombat role in Iraq and Afghanistan. Her lawyers later said she suffered from post-traumatic stress disorder connected to a sexual assault during her service in Iraq.
From 2005 to 2012 she worked for the West Virginia Department of Corrections as a corrections officer at the North Central Regional Jail in Greenwood, where, according to the inspector general, she was the subject of allegations of excessive force. Her last job before the hospital was at a residential facility outside the VA.
She started at the Clarksburg hospital in June 2015. The facility served about 70,000 veterans in north central West Virginia and neighboring parts of Maryland, Ohio and Pennsylvania. Her shift ran from 7:30 p.m. to 8 a.m. Her duties were to take vital signs, check blood sugar with fingerstick tests, and sit one-on-one with patients who needed to be watched through the night. The job required no license or certification. Nursing assistants at the hospital were not authorized to give any medication, insulin included.
On paper she was a model employee. Her performance ratings rose from fully successful in October 2015 to excellent in 2016 and outstanding in 2017. She sat on the ward's morale and scheduling workgroups, drew up the schedule for the nursing assistants and helped train new staff. In December 2016 her nurse manager nominated her for the VA Secretary's Award for Excellence in Nursing, describing a hard worker with an excellent rapport with the ward team who showed "a true compassion" for veterans. On September 12, 2017, she received the hospital-level award as Nursing Assistant of the Year, with a $500 bonus. She received cash awards in February 2017 and February 2018 as well.
Her supervisors later told inspectors a less tidy story. She had been verbally counseled twice, once for improperly drawing blood from a sample tube and once for leaving a patient in soiled bedding at the end of her shift, though no record of either counseling could be produced. Hospital documents described incidents in which she was said to have disconnected intravenous lines and turned off or cleared the data on IV pumps. Some colleagues remembered odd or aggressive behavior toward patients, which they put down to stress in her personal life. None of them, inspectors found, suspected her of anything worse.
Ward 3A took fragile patients: men who were too sick to go home but did not need intensive care. The men Mays killed were in their eighties and nineties, veterans of World War II, Korea and Vietnam. Each had been admitted for a condition, such as pneumonia, an infection or the effects of dementia, from which doctors expected him to recover.
Low blood sugar, or hypoglycemia, is a familiar danger for diabetics who take insulin or other drugs that lower glucose. In a patient who is not receiving such drugs, a severe episode is rare, and the most common cause is still insulin or diabetes medication that someone has given. Some of the men on Ward 3A had no history of diabetes at all. Others had diabetes but were not on insulin in the hospital. Either way, nobody had ordered the insulin that sent their blood sugar crashing.
Mays later told investigators that she had drawn insulin from the ward's own supply, kept in the medication room and on the medication carts, and added it to the saline mixtures used to flush patients' intravenous ports. She said that on one occasion she handed a tainted flush syringe to a nurse who, knowing nothing, gave it to the patient. She described each decision as spontaneous.
The prosecution said she sometimes took part in the frantic efforts to revive patients after she had caused the emergencies. "The defendant knew exactly what symptoms were coming, having observed them herself," Assistant U.S. Attorney Jarod Douglas said at her sentencing.
The seven murder counts named these veterans. The inspector general's report, which protected patients' identities, describes the charged deaths as running from the summer of 2017 to the late spring of 2018; NPR, reporting on the plea, put them between July 2017 and June 2018.
Robert Edge Sr., 82, served in the Navy from 1952 to 1956. His son, Robert Edge Jr., called him "my hero" and said that when the time came for him to look after his father, Mays took that away.
Robert Lee Kozul Sr., 89, served in the Army from 1951 to 1953. His family filed a wrongful death lawsuit against the Department of Veterans Affairs on July 22, 2020, eight days after the plea, arguing that his death had been preventable.
Archie D. Edgell, 84, was drafted into the Army in 1953 and served two years, stationed in Germany. He grew up in Doddridge County and worked for 20 years for the street and water commission in Salem, in Harrison County. He was married to his wife, Francis, for more than 60 years; she died within a year of him, and his son Steve said it was of a broken heart. In his last years he lived with Steve and his daughter-in-law, Amanda. He had dementia and diabetes, and his family gave him insulin at home, but the hospital had not ordered any for him. In March 2018 he was admitted to the medical center to begin a move to the VA nursing home nearby. Prosecutors said that after Mays injected him his blood sugar fell to 24; staff brought it back up and stabilized him, and she injected him again. This time he could not be saved. He died on March 26, 2018, four days after he was admitted. Ages for him differ slightly in news reports, which give 84 or 85.
George Nelson Shaw Sr., 81, spent 28 years in the Air Force as a communications specialist, serving from 1951 to 1982 by the dates published at his killer's sentencing. After he retired he worked in the mail room of the same VA hospital in Clarksburg. He had been married to his wife, Norma, for almost 59 years. According to USA Today, he died on April 10, 2018, about two weeks after an unexplained drop in his blood sugar. When his body was exhumed and examined at Dover Air Force Base, four injection sites, on both arms and his right thigh, tested positive for insulin. He had never had diabetes or a prescription for insulin. "This cannot happen to another family, ever," his daughter, Linda Kay Shaw, told USA Today.
Felix Kirk McDermott, 82, served in the Army from 1962 to 1968 by the dates given at sentencing; USA Today described him as a retired sergeant major with 20 years of active duty, including a tour in Vietnam. He was admitted with aspiration pneumonia after food went into his lungs, and he died three days later, in April 2018. He was not diabetic and did not take insulin. His family believed he had died of natural causes until late August 2018, when FBI agents came to the home of his youngest daughter, Melanie Proctor. "I thought my dad was safe there," she said. He was exhumed in October 2018, and the Armed Forces medical examiner ruled his death a homicide by insulin injection. He is buried in Westmoreland County, Pennsylvania.
Raymond Golden, 88, served in the Army from 1951 to 1953 and in the Air Force from 1955 to 1973. At the plea hearing the prosecutor said his blood sugar had fallen to 7 milligrams per deciliter. A reading below 70 is considered low; all seven charged victims had readings in the mid-30s or lower.
William Holloway, 96, known as "Sport," served in the Army from 1942 to 1945. Court papers identified him only by his initials, W.A.H. He died on April 8, 2018, a few hours after his family was told he was doing better. For months they believed he had died of sepsis. In the fall of 2018 federal officials asked to exhume him. The examiner found severe hypoglycemia over about 30 hours with no natural cause to explain it. "His life was taken," his daughter, Karen Holloway, said. USA Today reported that he was an insulin-dependent diabetic, which conflicts with other accounts that none of the victims had diabetes.
The eighth count, assault with intent to commit murder, concerned Russell R. Posey Sr., 92, a Navy veteran who was not diabetic. Mays injected him in June 2018. Hospital staff stabilized him, and he died about two weeks later in a nursing home. A medical investigator could not say whether the insulin had contributed to his death, so the charge was not murder. Prosecutors said she had meant to kill him.
The inspector general's later inspection traced, week by week, how the signs piled up in the spring of 2018 without anyone pulling them together.
In what the report calls Week 1, a patient in the mid-80s with many medical problems, diabetes among them, suffered repeated, profound drops in blood sugar while receiving no insulin. Doctors put it down to the patient's frailty and malnutrition. The same week a second patient, who was not diabetic, had a severe episode. Two hospitalists and the ward's nurse manager discussed the case and told the medical director of inpatient services. Two nurses checked schedules to see whether someone might have given insulin to the wrong patient by mistake. They found no common thread, and the inquiry went no further. Nobody reported the cases up the chain.
Nine days later a third patient, a diabetic who was not on any glucose-lowering drug, crashed repeatedly and needed one dose after another of D50, a concentrated sugar solution injected to revive hypoglycemic patients. In all the patient received 16 ampules. A night doctor suspected that someone had secretly given him insulin, but assumed it was not a member of staff, and recommended an endocrinology consultation that never took place. The ward used so much D50 that the hospital's supply ran down, and still nobody alerted the pharmacy. Five days after that, a fourth patient, in the eighties, with dementia and an irregular heartbeat and no history of diabetes, turned cold, clammy and unresponsive in the early morning, with a blood sugar of 12. The family had found the patient back to normal the evening before. Staff gave five ampules of D50, a continuous dextrose drip and glucagon without lifting the sugar level, and the patient died later that morning after the family chose hospice care. A nurse told inspectors that Mays had been on the ward's night shift.
That made four unexplained crises in under three weeks, all treated with repeated doses of D50, and they generally happened during or just after one of Mays's shifts. Two more followed about eight and ten weeks later. Only then did a hospitalist go to the associate chief of staff and insist that "something was going on," possibly something criminal. Quality staff began a review, the director was told, and on June 27 the inspector general was called.
Inspector general agents were at the hospital within 24 hours. Investigators from the inspector general's office and the FBI led the case, with the U.S. Attorney's Office, the West Virginia State Police and the Greater Harrison Drug and Violent Crimes Task Force. The inspector general's medical staff reviewed the records of the nine patients the hospital had flagged and of all 112 patients who had died on Ward 3A since mid-2015, when Mays was hired. They found a possible tenth case, from the summer of 2017. Two of the ten patients' episodes turned out to have reasonable medical explanations. The other eight became the eight counts of the plea.
On July 5, 2018, after investigators identified Mays as a person of interest, the inspector general recommended that she be taken off patient care, and the hospital moved her to a job with no patients that same day. Missal later said that this step alone had probably saved lives. Inspectors told the director of urgent problems, among them the unsecured insulin, on July 11 and 13, and those were fixed quickly.
The criminal team conducted more than 300 interviews and worked through thousands of pages of medical records together with Mays's phone, social media and computer records. They consulted forensic experts and endocrinologists and reviewed staff and visitor logs. When investigators questioned Mays, she denied involvement three times. In October 2018 the hospital began reviewing what investigators called her dishonest answers, and her federal employment ended on March 6, 2019.
Because the men had been buried, the evidence had to come from the ground. Families were approached one by one. Agents arrived at Proctor's home in late August 2018. McDermott was exhumed in October 2018. Edgell's son Steve opened his door to inspector general agents and asked, "They killed him, didn't they?" With the family's permission his father was exhumed on December 11, 2018, and taken to Dover Air Force Base, where the autopsy found four injection sites on his thigh and arm and called the findings "strongly suspicious for unprescribed insulin administered during hospitalization." Holloway and Shaw were exhumed as well. The autopsies pointed to injections of insulin that nobody had prescribed.
The investigation stayed out of public view for a year. In August 2019 the families' lawyers began to talk. WV MetroNews reported McDermott's autopsy on August 26, 2019, and the names of Shaw, Edgell, Holloway and a Korean War Navy veteran, John Hallman, followed through September and October. By an unofficial count reported in October 2019, 16 families had hired lawyers or contacted investigators about deaths at the hospital. "How many people have to die before someone says, 'Hey, what's going on here?'" asked Dino Colombo, the Edgell family's lawyer. Senator Joe Manchin, a member of the Senate Veterans' Affairs Committee, said he was doing everything in his power. Hospital officials said only that a person of interest had been removed and was no longer a current employee.
Families began filing wrongful death suits against the federal government in the second half of 2019. The Shaw family's suit accused the VA of failing to screen employees, control medications, keep patients safe and warn families of its concerns.
Federal prosecutors filed charges on Monday, July 13, 2020. The next day Mays, then 46, pleaded guilty before U.S. District Judge Thomas S. Kleeh in Clarksburg to seven counts of second-degree murder and one count of assault with intent to commit murder. She admitted giving insulin to several patients intending to cause their deaths. She spoke little, wept as she admitted her guilt and said she was taking medication for post-traumatic stress disorder. She gave no reason. At least 26 relatives attended, with others watching online because of the pandemic. After the hearing she was sent to a West Virginia regional jail to await sentencing.
Each murder count carried up to life in prison, and the assault count up to 20 years. U.S. Attorney Bill Powell said the government would seek the maximum and that the charges reflected the strongest provable cases; the number of victims, he said, could be higher. Under her plea agreement Mays sat for a further interview with investigators in October 2020. That was when she described the saline flushes and the insulin taken from ward stock, and gave her two explanations: that she had wanted suffering patients to pass "gently," and that her acts gave her a sense of control at a time of stress and chaos in her personal and professional life.
The civil cases moved faster than the criminal one. In October 2020 six families reached tentative settlements with the federal government: $700,000 for the family of Archie Edgell, $700,000 for Russell Posey's, $975,000 for George Shaw's, $950,000 for John Hallman's and $775,000 each for the families of Robert Kozul and Felix McDermott. Their lawyer, Tony O'Dell, said the sums were the most West Virginia law allowed, but that the families still wanted the people responsible at the hospital held accountable. In March 2021 he said the settlements for seven families were nearly complete and provided "some closure." By the time of the sentencing, Kleeh said, settled suits had cost the government more than $5 million, and at least five more families had cases pending. O'Dell, who represented 11 families, said that 12 other deaths remained unexplained.
Mays was sentenced on May 11, 2021, in a hearing that began at 9 a.m. and was attended in person by more than 30 relatives of the men. She sat at the defense table in an orange jumpsuit while some of them spoke.
Robert Edge Jr., in a recorded statement, said she had "murdered my father without cause or reason." He told her he did not forgive her. Melanie Proctor said Mays had taken some of the finest men, "our loved ones," and preyed on them "at their weakest," and she called her a coward. "May God forgive you, as I never will," she said. Norma Shaw said she did not know why Mays had done it and did not know if anyone ever would. "But she took my life away from me," she said. Amanda Edgell, speaking with her husband, Steve, said that none of the men deserved what had been done to them. "I will never understand why you, Mrs. Mays, decided to play God," she said.
Douglas called the killings "predatory and planned, not reactionary," and said the men "were not in need of mercy." Mays, he argued, seemed to find some excitement or self-worth in creating the emergencies, and the acts gave her a sense of control. Her lawyer, Jay McCamic, described a long history of depression, anxiety and other medical problems and asked for a term at the low end of the range. He said the question of why could not be answered. "Reta Mays doesn't know why," he said.
Mays wept and apologized. "There are no words I can say that would offer the families any comfort," she said. "I can only say that I'm sorry for the pain I caused the families and my family." She did not ask for forgiveness, she said, because she did not think she could forgive anyone who had done what she did. She could not finish her statement.
Kleeh rejected the defense's portrait. He noted that many people with mental health problems never harm anyone. He said the evidence showed that while the deaths were occurring, Mays had searched for female serial killers on her work computer and, after the first injection, watched the Netflix series "Nurses Who Kill." She had lied to investigators at least three times. "You knew what you were doing," he told her. Of the men, he said that "to a man, they were good and decent people who served their country honorably." He sentenced her to seven consecutive life terms, one for each murder, plus 20 years for the assault on Posey, and ordered her to pay $172,624.96 to the families, the hospital, Medicare and insurers. There is no parole in the federal system. At noon the hearing ended and she was handed over to the U.S. Marshals.
Kleeh also said that while the intent behind the crimes belonged to Mays alone, the VA was responsible for its own failures and "will continue to pay for their problems." He mentioned a nurse who had described insulin left sitting on top of medication carts.
The same day, the inspector general published its inspection of the hospital, a report of about 100 pages. Missal said it had found "serious, pervasive, and deep-rooted" clinical and administrative failures that let the deaths go undetected.
The report found that the hospital had never properly vetted Mays. Nobody contacted the jail or her most recent employer. The federal investigator who completed her background check in 2015 had marked it with a code meaning there were "potentially actionable issue(s)" that could be disqualifying, but the hospital employee responsible for reviewing it never did. Mays worked there for almost four years without that basic safeguard. When she was nominated for the Secretary's award, the same employee wrongly certified that her background check had been favorably cleared.
On her ward, every staff member had full access to the medication room, in breach of policy, and some medication carts were left unlocked and unattended. The pharmacy was not using the system the VA required to track ward stock, including insulin and D50. Doctors ordered no diagnostic tests for seven of the eight patients and ordered the wrong test for the eighth, and too late, after D50 had already been given. No patient safety report was filed for any of the events, partly because staff had not been trained in what to report. The report counted nine spikes in the hospital's mortality rate during the three years Mays cared for patients, against two in the two and a half years before she arrived and none in the year after she was removed. Nobody had looked. A national review the VA ran in 2019 had concluded that there were no unusual patterns, a finding the inspectors could not reconcile with the records.
The report made 15 recommendations, to the hospital, its regional network and the national health administration. The VA said it would put them into effect by mid-2022. Several staff members were fired or reassigned, among them the former medical center director, Glenn Snider Jr. The department also began reviewing how high-risk drugs are stored across its hospitals, and how to flag heavy use of rescue drugs like D50 and spikes in mortality automatically.
In October 2021 the Council of the Inspectors General on Integrity and Efficiency gave the investigative and prosecution team an award for excellence.
When the inspector general returned to Clarksburg for a routine comprehensive inspection in 2023, published in April 2024, the hospital's new leaders said they had had to rebuild trust with staff after the murders and the 2021 sentencing. The director said the case had taken an emotional toll and contributed to heavy nursing turnover. A shortage of nurses forced the hospital for a time to close its medical and surgical inpatient unit and merge it with intensive care. Leaders described new measures: hospital-based doctors to coordinate inpatient care, round-the-clock cardiac monitoring and regular leadership rounds on every shift, including nights and weekends.
Former U.S. Attorney Bill Powell said that about 20 deaths during Mays's time at the hospital were suspicious, but that charges were brought only where prosecutors believed the evidence was strong enough. John Hallman, the Navy veteran whose family received one of the settlements, was 87 when he was admitted on June 13, 2018, with liver trouble and signs of pneumonia; he died the next morning. Investigators showed his daughter, Debbie Cutler, graphs showing his blood insulin had spiked before his death, but he had been cremated, so no autopsy was possible, and no charge was brought. No court has attributed any death to Mays beyond the eight counts, and the hospital deaths that families still question remain unproven.
Her motive remains in dispute. She told inspectors she meant to spare suffering men; prosecutors rejected the idea of mercy, and the inspector general pointed out that every one of the men had been expected to survive the illness that brought him to the hospital. Her own lawyer said she did not know why. Mays has not appealed, and no change to her sentence has been reported. She is serving her life terms in federal custody.
2005 to 2012: Mays works as a corrections officer at North Central Regional Jail.
June 2015: She is hired as a nursing assistant at the Louis A. Johnson VA Medical Center.
September 12, 2017: She receives the hospital's Nursing Assistant of the Year award.
Summer 2017 to late spring 2018: She gives insulin to patients on Ward 3A.
March 26, 2018: Archie Edgell dies.
April 2018: William Holloway (April 8), Felix McDermott and George Shaw (April 10) die.
June 2018: Russell Posey is injected; he dies about two weeks later.
June 27, 2018: The hospital director contacts the VA inspector general; the investigation opens June 28.
July 5, 2018: Mays is removed from patient care.
October to December 2018: Exhumations, including McDermott in October and Edgell on December 11.
March 6, 2019: Her federal employment ends.
August to October 2019: Victims' names become public; families file wrongful death suits.
July 14, 2020: Mays pleads guilty.
October 2020: Six families reach tentative settlements; Mays gives her post-plea interview.
May 11, 2021: Mays is sentenced to seven consecutive life terms plus 20 years; the inspector general publishes its report.
October 2021: The investigative team receives an award for excellence.
April 23, 2024: The inspector general publishes its 2023 comprehensive inspection of the hospital, describing staff turnover and the work of rebuilding trust.