CLARKSBURG, W.Va. — Four months after Melanie Proctor's father was buried with military honors for his combat service in Vietnam, she came home to her farm to find an unfamiliar tan SUV in the driveway.
Two federal agents stepped out into the hot sun in August 2018. Proctor, a tax preparer, wondered whether one of her clients was in trouble.
"We're here about your father," the FBI agent said. "We don't believe he died of natural causes."
Flipping open a laptop on her kitchen counter, the agents showed Proctor her dad's records from the three days he had been hospitalized at the local VA medical center.
What the line graph showed was alarming.
In the early-morning hours that April, Felix McDermott's blood sugar had bottomed to dangerous levels. The retired Army sergeant his family knew as "Pap" died the next morning from severe hypoglycemia.
Someone had given her father, who was not a diabetic, a deadly injection of insulin, the investigators told Proctor - and he was not the only one.
Multiple veterans had died under similar circumstances on the same ward, and the agents had come to Proctor's farm in a hamlet 42 miles east of Clarksburg to ask the unthinkable: They wanted to dig up Pap's body.
Proctor agreed, and her father was one of seven bodies exhumed in an investigation of 11 suspicious deaths at the Louis A. Johnson VA Medical Center, according to a person familiar with the case who, like others, spoke on the condition of anonymity because it is ongoing.
The 14-month inquiry is the latest criminal investigation to engulf the Department of Veterans Affairs, intensifying questions about whether the country's largest health-care system is doing enough to protect the veterans in its care.
In August, a former VA pathologist in Fayetteville, Arkansas, was indicted on three charges of manslaughter after officials say he misdiagnosed thousands of patients while using drugs or alcohol. He has pleaded not guilty. Meanwhile, in Beckley, West Virginia, a former VA doctor is under investigation for sexually assaulting as many as 20 of his male patients, according to two people familiar with the case.
The cascade of inquiries threatens to undermine trust in the long-troubled agency and undercut President Donald Trump's promises to reform the far-flung system, the foundation of his pitch to veterans as he runs for reelection.
In Clarksburg, a small Appalachian community four hours west of Washington, hospital officials said they alerted VA leaders as soon as they learned that their medical staff suspected foul play.
The deaths from the second half of 2017 through July 2018, initially found to be of natural causes, are now being investigated as homicides. Federal authorities say they have identified a person of interest in the case.
The probe has come to focus on a now-fired hospital employee, a woman who worked the overnight shift as a nursing assistant and left last year, according to people familiar with the case.
The Washington Post is not using the woman's name because she has not been charged. Through her son, she declined to speak to a reporter who visited her home outside Clarksburg.
The deaths have set off feverish speculation among local residents and dominated conversation during Tuesday night bingo at the local VFW hall.
"When you have someone who is 80-something years old and they had health issues, you're thinking, 'This was their time,' " said Proctor, 53. "You don't question it. None of us had a clue something was wrong."
Investigators have identified similarities in nearly a dozen deaths: Elderly patients in private rooms were injected in their abdomen and limbs with insulin the hospital had not ordered - some with multiple shots, according to people familiar with the case. The insulin, which was quickly absorbed, was given late at night when the hospital staff had emptied out. Within hours, the veterans' blood-sugar levels plummeted.
The person of interest was assigned to monitor several of the veterans who died in what are known as one-on-one bedside vigils for patients who need extra attention.
Despite these common denominators, the medical staff and those with oversight of hospital procedures were slow to identify a pattern - a failure that could have cost lives, several people familiar with the investigation said.
The Clarksburg medical center reported 26 deaths from late 2017 through June 2018, according to an internal VA database that tracks mortality rates across the system. The suspicious deaths accounted for close to half of them, according to the data reviewed by The Post.
The case has also brought new scrutiny to VA's internal controls. The medical surgical ward in Clarksburg, known as 3A, did not have surveillance cameras, according to people familiar with the case. The woman is believed to have had improper access to the medical supply room. The medicine carts on the floor also were routinely left unlocked.
Wesley Walls, a hospital spokesman, said the facility has "many protocols in place to safeguard medication."
But lawmakers are still demanding answers.
"All of us are up in arms," said Sen. Joe Manchin III, D-W.Va., describing the reaction of his colleagues on the Senate committee that oversees veterans' care. He said he is incredulous that hospital leaders in Clarksburg took so long to put the pieces together.
"You mean to tell me that for nine months you didn't know what was going on in your hospital?" Manchin said. "Either you didn't care, or there was a lack of competency."
"You can't be this removed" from hospital operations, Manchin said. "It's almost like you don't give a darn."
The senator said he is preparing to call for a "full-blown" Senate investigation into how VA handled the case.
Glenn Snider, the medical center director, has said he notified senior leaders in Washington, including the VA inspector general, as soon as his staff alerted him to their concerns.
"Immediately upon discovering these serious allegations, Louis A. Johnson VA Medical Center leadership brought them to the attention of VA's independent inspector general while putting safeguards in place to ensure the safety of each and every one of our patients," Walls said in a statement.
The spokesman declined to provide details but added: "It's important to note that regulations and protocols can only do so much to protect against criminal activity."
As the inquiry has unfolded, the hospital has required more rigorous tracking of its medications, including their dispensing and who has access to them, according to people familiar with the case.
VA Inspector General Michael Missal opened an investigation into the deaths in July 2018. The nursing assistant was moved to a dayside paperwork job and interviewed soon after, a person close to the case said. The hospital did not move to fire her for another seven months, the person said, eventually terminating her for lying on her résumé.
"Our hearts go out to the families affected by these tragic deaths," VA Secretary Robert Wilkie said in a statement to The Post. He added that the allegations "do not involve any current" hospital employees, bringing "a small measure of accountability to the situation."
Wilkie also called on Missal, who was appointed by President Barack Obama, to bring to a close the investigation he is jointly leading with the U.S. attorney for the Northern District of West Virginia, a Republican appointed by Trump.
"More than a year later, the IG is still investigating and Clarksburg-area veterans are still waiting on the justice and answers they deserve," Wilkie said.
Missal and U.S. Attorney William Powell have said their inquiry is continuing and remains a top priority. They declined to comment.
Three deaths have been ruled homicides by insulin injection, according to people familiar with the investigation. In recent weeks, the Armed Forces deputy medical examiner changed the death certificates of the others from "natural causes" to "undetermined," according to autopsy reports and two people familiar with the case.
A possible motive in the deaths is still unclear to investigators. But they say they do not believe they were mercy killings. Although the victims - all male - were hospitalized with underlying medical conditions, none was terminally ill.
"I was hoping against hope it was a mercy thing," Proctor said. "You can at least wrap your mind around that."
The hospital had told McDermott's family that his aspiration pneumonia was improving with antibiotics and intravenous fluids. They said he would probably be released in a few days once his strength improved, his daughter recalled.
"They were saying he was doing real good," she said.
Then her cellphone rang at 1 a.m. April 9. Pap had taken a turn for the worse, the hospital said. His daughter arrived to find him hooked up to an IV bag of dextrose to raise his blood sugar, which had careened to 12 milligrams per deciliter of blood. The normal range in a non-diabetic is 70 to 120, with the low end registering after several hours of not eating.
"This happens sometimes," Proctor recalled the staff telling her.
Her father did not recognize her. He died a few minutes before 9 a.m.
West Virginia's fourth-largest city is set among the hills of a rural region dotted with empty coal fields. VA is a major employer in Clarksburg, but the hospital has struggled to recruit and keep health-care workers to treat its aging veterans, data shows.
The 70-bed hospital sits high on a bluff at the edge of town, an imposing building of worn, salmon-colored bricks built in 1950, when the mountain hollows here emptied every morning into the coal fields and now-shuttered glass factories. Today many of the 70,000 veterans it serves struggle with chronic disease, including diabetes, local doctors say.
The first patient afflicted with what would later be understood as sudden, unexplained hypoglycemia died in the second half of 2017.
The deaths piled up. One in January 2018. Another in March. Three more in April, three days apart, including McDermott. Two more in May. Another two in June. Another in early July, on the same day investigators arrived at the hospital.
The hospital staff recorded their apparent causes: Advanced dementia, sepsis, heart attack - unsurprising determinations for an elderly population with chronic conditions, including a small number with diabetes.
They also had extremely low blood-sugar levels - some cratering as low as 12 milligrams per deciliter.
A high enough dose of insulin, especially the rapid-acting form, can be fatal for anyone, even with intervention to counteract it.
It is "very, very rare" for blood sugar to crater so low that it leads to death, said Yogish Kudva, an endocrinologist with the Mayo Clinic in Rochester, Minnesota.
Two months before investigators arrived, on May 7, 2018, a team of inspectors from Missal's office visited the medical center for an unannounced, week-long spot inspection to conduct a routine review of clinical operations over the past three years.
Their report issued in October 2018 found general compliance with patient-safety measures, with one exception: The hospital had weak systems for identifying and reporting red flags that could lead to patient harm.
Clarksburg officials told the inspectors that during the past three years, there had been no "sentinel events," or episodes of possible lapses in care that harmed patients. But the inspectors identified at least one such case.
The watchdog's office was unaware that three weeks earlier, three patients had died under suspicious circumstances - because no one had identified them, investigators said.
By mid-2018, a small number of doctors had begun to feel uneasy with the number of patients who had died of sudden hypoglycemia, according to people familiar with the case.
Still, they did not immediately report their concerns.
"If you're not looking for sinister things, it's going to take a while for something like this to come to light," said a member of the medical staff, describing internal thinking. "It's the context in which the hypoglycemia was presented. You're blind until finally there's a tipping point."
The tipping point came in mid-June, after the death of a Korean War veteran named John Hallman, 87, who served in the Navy. Hallman was admitted with liver issues and possible pneumonia. He died the next morning.
A team of doctors informally discussed the case. They noticed that the overnight staff had checked Hallman's blood-sugar level. It had dropped to 26.
"We said, 'Who checks the blood sugar on a non-diabetic in the middle of the night while they're trying to sleep?' " the medical staffer recalled. "It was like, 'Oh my gosh, this is not good.' "
The doctors emailed a high-ranking supervisor with their concerns. The supervisor forwarded the email to the local quality team for review instead of directly notifying the inspector general's office, as required by law, according to people familiar with the case.
It would be 10 more days before Snider, the medical center's director, would escalate the case to the inspector general and other VA leaders in Washington - at least nine months after the first death.
'Why is he dying?'
The hospital had missed other clues. Clarksburg's mortality statistics, viewed monthly by the quality staff, showed death rates twice as high as similar hospitals in the VA system for the first two quarters of 2018, data reviewed by The Post shows.
"You had 11 people die. There was a missed pattern," said House Veterans' Affairs Committee Chairman Mark Takano, D-Calif. "If you're a manager, you have to understand the warning signs and patterns of behavior."
Tony O'Dell, a Charleston, West Virginia, attorney representing several families in wrongful-death cases against VA, said one patient lived independently and was hospitalized after a fall but was about to be discharged.
"Most of these guys were getting better," O'Dell said. "Each one of these deaths was an opportunity to prevent the next one."
When FBI agents and Missal's staff arrived on the scene, they pored through patient medical records and began interviewing the staff and the person of interest.
They discovered that she walked the hospital ward late at night with a bedside glucose meter, pricking the edge of patients' fingers to test their blood sugar. She pricked one patient 12 times in one night, the person on the medical staff recalled.
Another night, she told the nurses' station that a patient's blood sugar had dropped and that she was finding juice to bring it back up. At the time, her attention to blood-sugar levels did not raise alarms; with West Virginia's high rate of diabetes, frequent checks are not unusual.
Investigators have not determined the source of the insulin they believe was used on patients. In some states, including West Virginia, insulin can be purchased without a prescription. At the hospital, the drug, though not a controlled substance, is secured in the medicine room by a coded keypad, according to people familiar with the protocol. However, people familiar with the case said the person of interest obtained access to the room and that medicine carts were often left unlocked.
Determining who may have accessed the insulin has presented a challenge. The hospital uses surveillance cameras in general areas such as waiting rooms, hallways and parking lots, a spokesman said. VA does not require their use in hospital wards and leaves the decision up to individual facilities.
Soon after they arrived, investigators began knocking on the doors of the victims' families.
They drove first to Norma Shaw's 116-acre farm past a closed coal mine west of town. In March 2018, her husband, George, 81, had shown signs of dehydration and was admitted to the VA hospital. His room was next to the nurses' station.
At one point, Shaw, a retired Air Force communications specialist, fell in his hospital room. Then a nurse told his family that George's blood sugar had dropped. "She said there was no explanation," his widow recalled. He died nine days later after being transferred to hospice care, where he alternated between agitation and lethargy.
The attending doctor urged them to get an autopsy, his family recalled. "We kept asking: Why is he in hospice?" his daughter, Linda Shaw, recalled. "Why is he dying?"
There was no satisfying answer, they said.
Without hesitation, Norma Shaw gave the FBI the go-ahead to exhume his body. "I said, 'Yes, take him,' " she recalled. "I just want to know the cause of it."
In January, Shaw's body was taken to Dover Air Force Base in Delaware for a forensic autopsy generally performed in cases of violent or suspicious deaths.
The federal medical examiner found four insulin injection sites in his arms and right thigh. The autopsy showed a blood-sugar drop to 17 in a span of a few hours, according to the family's attorney, David Glover.
Laid to rest, again
The insulin deaths have set off rumors and unease in a community where the VA medical center is a local institution.
Linda Shaw, an Air Force veteran who suffers from post-traumatic stress disorder, has canceled her therapy appointments at the hospital she says she is afraid to enter.
"Do I feel comfortable going there?" she said. "Hell no. I do not feel safe there."
The hospital - which had honored the person of interest with an award in 2017 - moved to fire her in February after discovering that she lied on her résumé when she was hired in 2014. At the time, she stated she was certified as a nursing assistant, when, in fact, she was not certified, a person close to the investigation said.
She remained at the hospital, working a day shift until April, when she lost an appeal of her firing.
The seventh autopsy was completed last month. Although Shaw's, McDermott's and one other death have been ruled homicides, the evidence of insulin was not strong enough in the other patients to make that determination, a person close to the investigation said.
All the veterans have been reinterred with military funerals.
In October 2018, Felix McDermott's gray casket was transported in a hearse back to his grave in Westmoreland County Memorial Park in Pennsylvania.
Melanie Proctor, her husband, Dale, and their daughter Candy paid their respects once again under a cloudy late-fall sky.
An honor guard sounded taps and fired a three-volley funeral salute. The soldiers, at Proctor's request, slipped six shell casings into the flap of an American flag before presenting it to the family: the first three from his first burial, another three from the second.
The Washington Post's Alice Crites contributed to this report.