CLARKSBURG, W.Va. – A former nursing assistant who confessed to using insulin to murder seven elderly patients at a VA hospital will spend the rest of her life in prison.
U.S. District Judge Thomas S. Kleeh called Reta Mays, 46, a monster of the “worst kind. You are the monster no one sees coming.” During a hearing Tuesday, he delivered a life sentence for each murder victim, plus 20 years for an eighth victim she tried to kill.
Mays, who said earlier in the hearing that she wouldn’t ask for forgiveness, sobbed as Kleeh sentenced her. When a U.S. Marshal approached her after the hearing, she sat down and buried her head in her hands, crying. She got up, and she was handcuffed and led out of the courtroom.
Mays is not eligible for probation for the seven life sentences, Kleeh said. She was ordered to pay restitution to the victims’ families.
The victims ranged in age from 81 to 96 and served in the Army, Navy and Air Force during World War II and wars in Korea and Vietnam. They died at the hands of the same person, at the same place, in the same way.
Mays pleaded guilty last year to murdering the seven veterans and to assaulting an eighth with intent to murder. The killings occurred at the Louis A. Johnson VA Medical Center between July 2017 and June 2018.
“Something always happens when I’m in the room, and I don’t know why,” Mays said while sitting in a hospital room as staff tried to save one of her victims, according to Assistant U.S Attorney Jarod J. Douglas as he argued for a stiff sentence.
After the hearing, the inspector general at the U.S. Department of Veterans Affairs released the results of an investigation concluding that “serious, pervasive, and deep-rooted clinical and administrative failures” at the hospital allowed the killings to go undetected for nearly a year.
“While responsibility for these criminal acts clearly lies with Ms. Mays, the OIG found inattention and missed opportunities at several junctures, which, if handled differently, might have allowed earlier detection of Ms. Mays’s actions or possibly averted them altogether,” the inspector general’s office concluded in a report released after the sentencing.
Nurses who kill: Medical murderers and the mystery of the Clarksburg VA hospital in West Virginia
Relatives of five of Mays’ victims spoke during the hearing, some appearing via video recordings and others addressing a crowded federal courtroom. They honored their loved ones, reflected on their lives and expressed grief and anger over their loss. None said they were ready to forgive Mays.
William Edge, a son of the first victim, Robert Edge, Sr., said the sentence finally delivered justice to victims’ families. “There will never be closure,” he said at the steps of the courthouse. “But I don’t feel cheated or anything. This is finally justice.”
‘Why should you ever be let out of prison to enjoy freedom?’
Robert Kozul “loved to dance to sing and to play his harmonica,” Becky Kozul, his daughter-in-law, said. “He loved life.”
She said he cried when he learned on Christmas in 2017 that he would be a great-grandfather. He never got to meet the child. “You took all that away from him,” Becky Kozul said.
Mays “confessed to killing seven men and ruining seven families by robbing us of our loved ones,” Becky Kozul said. “Why should you ever be let out of prison to enjoy freedom?”
In a video statement, Norma Shaw, the widow of George Shaw, said her husband was “trapped in his own body” when Mays gave the Air Force veteran, who wasn’t diabetic, a lethal dose of insulin.
“I don’t know why Reta did what she did. I don’t know if we’ll ever know. But she took my life away from me,” Norma Shaw said.
She met her eventual husband in 1959. Their first date was on Valentine’s Day at the Florida State Fair. “And like I told everybody, I spent his money that night and I would spend it the rest of his life,” she joked. The married months later in June.
Shaw said she and her husband were married almost 59 years. They had three children, nine grandchildren, 23 great-grandchildren and five great-great grandchildren by marriage.
Shaw said she struggled with whether she could forgive Mays. Maybe one day.
Robert Edge Jr., another son of Robert Edge Sr., said he couldn’t.
“Growing up, he was my hero,” Edge said. “He took care of me when I was little, and when it was time for me to take care of him, you took that away from me.”
In a short, tearful statement, Mays said she wouldn’t ask for forgiveness “because I don’t think I could forgive anyone who’d do what I did.”
“There are no words I can say,” Mays said. “I can only say that I’m sorry for the pain that I caused the families and my family.”
Judge: ‘You are not special’
Jay T. McCamic, Mays’ defense lawyer, argued for a 30-year prison sentence, the low end of sentencing guidelines. He said Mays had a history of mental health issues, including post-traumatic stress disorder and sexual trauma, tied to her military service and other events.
Kleeh said Mays’ mental health diagnoses and traumatic experiences weren’t that severe or uncommon, especially among veterans. “None of these other folks are killers, let alone serial killers,” he said. “You are not special.”
Kleeh said the timeline of the killings didn’t support Mays’ contention that stress pushed her to act out. McCamic described a mental health clinic visit in 2017 in which Mays said she was worried she would hurt someone. By then, Kleeh said, she had killed her first victim and would go on to kill others.
And while the VA’s institutional failings enabled Mays to act, Kleeh said she had the responsibility to blow the whistle and report these failings.
Mays lied to investigators three times about her role in the men’s deaths, Kleeh said. She watched a Netflix show called “Nurses Who Kill,” used her work computer to search “female serial killers” and compared her tally with others, Kleeh said.
That surprised William Edge, who had closely monitored the case and traveled frequently from his home near Cincinnati to attend court hearings in West Virginia. “That sealed it,” he said. “She’s watching shows about this and comparing herself to other serial killers.”
Prosecutor: ‘This was all about control’
Douglas argued for a life sentence for each murder victim because Mays showed “extraordinary callousness,” acted in a calculated manner, and put herself in a position to murder these men.
“This was all about control,” Douglas said. “These actions gave the defendant a sense of control.”
He dismissed any notion that the killings showed mercy to the ailing veterans, as he suggested that Mays had claimed. He also said her mental health conditions were not related to the violence she committed.
“Giving someone insulin that’s not prescribed to them is not merciful,” Douglas said before he detailed the painful effects the men felt as their blood sugar levels dropped. Edge was “thrashing around.” Shaw was “agitated,” “sweating” and had a “fast heart rate.” Felix McDermott experienced “latent breathing,” and a nurse found him “with most sheets, cold and clammy.”
Mays on multiple occasions reported the men’s conditions and participated in the life-saving efforts, Douglas, said.
Mays performed chest compressions on one of the victims for over half an hour, Douglas said. She then called her husband, who was incarcerated, and complained that her arms “felt like rubber” after doing compressions for so long. Mays also complained in Facebook messages about having to deliver medication that prolonged Shaw’s life, Douglas said.
Inspector general: Staff could have detected killing spree earlier
The inspector general’s investigation revealed oversights during Mays’ background check, shoddy medication tracking and a lack of follow-up when the patients suffered deadly drops in blood sugar. There were gaps in communication between staff caring for patients. And the hospital’s culture did not encourage staff to question patient care and report potential patient harm.
Mays was assigned to work overnight shifts on Ward 3A, the hospital’s medical surgical unit, in July 2017 when patients began suffering mysterious, acute drops in blood sugar.
A USA TODAY investigation in 2019 found that a string of oversights at the hospital may have cost veterans’ lives. Insulin wasn’t adequately tracked, and there were no surveillance cameras on Ward 3A. Staff didn’t conduct key tests to figure out why patients were experiencing severe episodes of low blood sugar. Nor did they file reports that could have triggered investigations.
The inspector general’s investigation echoed those findings and said those and other failures began with Mays’ hiring in June 2015 and didn’t stop until long after the string of deaths was discovered in June 2018.
Mays had been accused of using excessive force while working as a correctional officer at the West Virginia Department of Corrections from 2005 to 2012, but there’s no evidence that VA hospital staff reviewed those employment records.
The federal Office of Personnel Management conducted a background check and flagged potential items that could have disqualified her from being hired at the VA, but hospital staff did not document any follow-up, the inspector general’s office said.
“Had they done so, it is possible that based on her conduct at the jail, she would not have been hired for, or retained in, a position at the facility that involved patient care,” the inspector general’s office concluded.
A ‘spontaneous’ decision to kill with unsecured insulin
Insulin can be crucial in keeping diabetics’ blood sugar in check, but for non-diabetics and those who aren’t prescribed the medication, it can be deadly, driving blood sugar too low.
Mays told investigators she took insulin from the hospital ward, where it wasn’t adequately tracked, and put it into saline mixtures that were used to flush patients’ intravenous lines. In one case, she provided a nurse with a syringe of saline tainted with insulin, which the nurse unwittingly administered to a patient.
“Mays claimed that it was a spontaneous decision with each victim, that securing the insulin was not difficult, and that none of her supervisors or colleagues asked questions or otherwise appeared to be suspicious about her activities,” investigators from the inspector general’s office wrote.
Insulin was stored in an unlocked refrigerator in a medication room accessible to Mays and other staff, according to the inspector general’s office. It was also left on carts in hallways.
In June 2018, after hospital leaders started to figure out what she had done, investigators visiting the hospital still found medication wasn’t properly secured. That prompted additional warnings to staff about drug security.
Hospital staff didn’t investigate rash of unexplained low blood sugar
The deadly drops in blood sugar began with one patient on Ward 3A, Robert Edge Sr., in July 2017 when Mays worked the overnight shift. Then the pace quickened. Seven patients died after severe, unexplained low blood sugar in the first six months of 2018.
By comparison, investigators found that from January 2014 through December 2017, only one patient per year on average suffered acute hypoglycemia and died within a month of discharge.
In spring 2018, four of the hypoglycemic events occurred within three weeks. “That should have set off major alarm bells. Somebody should be asking the question and looking into it. They did not do so,” VA Inspector General Michael Missal said a news conference after the sentencing.
The rash of deaths did not prompt doctors to order key tests that could have detected the insulin, according to the inspector general’s office. In Shaw’s case, they ordered a test. But it was the wrong one and the sample was taken at the wrong time – after nurses had given him glucose to stabilize his blood sugar.
Some of the doctors appeared unaware of or misinformed about applicable lab tests, and endocrinologists, who specialize in diabetes and blood sugar, were not consulted.
“Timely endocrinology consultation would likely have led to a more tailored assessment of these patients that could have changed the course of events,” investigators concluded.
The absence of follow-up was exacerbated by a lack of coordination between caregivers. Doctors assigned to the ward alternated weeks on duty, and daily round meetings typically focused on discharge planning. Nurses often relied on informal communication that wasn’t always effective.
“Had staff members used meetings and forums to discuss patient outcomes, or had staff consistently taken the initiative to communicate concerns to leaders, it is possible that the emerging pattern of events would have been discovered sooner,” the investigators wrote.
No patient safety reports
Hospital staff did not file incident reports as required by policy that could have triggered a deeper review and revealed Mays’ killings. The inspector general’s office found doctors and nurses didn’t know what to report and when.
Even as the ward ran out of glucose as nurses frantically tried to raise patients’ blood sugar in a cluster of cases – including those without diabetes – staff didn’t flag any potential problems for review.
By the time doctors alerted supervisors in June 2018 to the string of suspicious deaths, eight patients had died. They notified an associate chief of staff who asked quality managers to do further testing and review what might have happened. The hospital director – since replaced – was on leave when he was notified and asked that the review continue until he could be briefed when he returned.
“Had facility leaders and managers escalated and pursued these adverse events sooner, additional lives might have been saved,” the report concluded.
At the end of June 2018, that director called officials at headquarters, who notified the inspector general that there was a potential “angel of death” at the Clarksburg VA.
VA pledges improvements
The Department of Veterans Affairs said in a statement last week that the agency has made a number of improvements in response to the investigation by the inspector general, an independent watchdog. They include steps to increase care coordination between medical providers, bolster endocrinology referrals and evaluations and better train nursing staff on diabetes.
“The Louis A. Johnson VA Medical Center grieves for the loss of each of these veterans and extends our deepest condolences to their families and loved ones,” the agency said. What happened “was unacceptable, and we want to ensure veterans and families know we are determined to restore their trust in the facility.”
The Clarksburg VA draws patients from across the region, serving about 70,000 veterans in north-central West Virginia and nearby Maryland, Ohio and Pennsylvania.
In December, the VA replaced the hospital director and chief nursing executive and retrained staff on critical incident reporting after an internal review identified problems with patient safety. The hospital conducted a “safety stand-down” in which noncritical patients weren’t admitted for several weeks.
“People are satisfied now,” said John Aloi, senior vice commander of VFW Post 573 in Clarksburg.
Wearing a black “United We Stand” mask after wrapping up a Monday night meeting at the post, Aloi said veterans want a measure of justice from the court hearing. Equally important, he said, are safety reforms at the VA hospital.
“But the real test is how things go in the future,” he said. “Once you lose trust, it’s hard to get it back.”
Contributing: Ken Alltucker