When Reta Mays worked as a corrections officer for the North Central Regional Jail in Greenwood, West Virginia, she was investigated on charges of using excessive force.
This was before she applied for a job as a nursing assistant at the Louis A. Johnson VA Medical Center in Clarksburg. Before she killed at least seven veterans by injecting them with deadly doses of insulin. Before she was sentenced to life in prison on all seven counts, plus 20 years for assault with intent to commit murder.
The Department of Veterans Affairs never reviewed those personnel records.
"You're the worst kind. You're the monster no one sees coming," said Judge Thomas Kleeh before delivering Mays' sentence Tuesday.
Mays, 46, pleaded guilty last year to charges of second-degree murder in the deaths of seven veterans, as well as assault with attempt to murder an eighth patient at the VA facility.
The sentencing marked the culmination of a three-year investigation into the mysterious deaths, which came to light after examiners began exhuming the bodies of several of the victims.
Mays worked the night shift at the medical center's medical surgical ward and was accused of injecting patients with fatal doses of insulin in 2017 and 2018.
Before she pleaded guilty last year, she said she administered insulin to the veterans because she wanted to ease what she perceived as suffering and "because she had a lot of stress and chaos in her personal and professional life and these actions gave her a sense of control," according to the VA Office of Inspector General.
Her attorneys said Mays, a former member of the West Virginia Army National Guard, suffered from post-traumatic stress disorder and other mental health issues related to a sexual assault she experienced in Iraq and pleaded for leniency in her sentencing.
But Kleeh showed little mercy, noting that Mays lied to investigators at least three times; watched a Netflix series, "Nurses Who Kill," after injecting her first victim; and Googled "female serial killers" from her work computer.
"You're not special," Kleeh said, pointing out that he sees many defendants with mental health issues who aren't killers.
All of Mays' victims were elderly but had been hospitalized for conditions from which they were expected to recover.
"We will forever miss him. I will never understand why you, Mrs. Mays, decided to play God," Amanda Edgell, daughter-in-law of Army veteran Archie Edgell, said in the sentencing hearing.
Following the announcement of the sentence Tuesday, the VA OIG released a damning report of failures at the facility that gave Mays access to medications and allowed her to kill veterans undetected for two years.
The VA OIG found that staff at the medical center failed to properly vet Mays before hiring her; didn't safeguard medication or conduct adequate medical investigations into the unexplained hypoglycemia, or low blood sugar caused by the unnecessary insulin injections; and failed to complete patient safety reports or recognize trends or spikes in mortality data.
"Our report found serious, pervasive and deep-rooted clinical and administrative deficiencies at the medical center," VA Inspector General Michael Missal said during a press conference. "It was a series of missed opportunities that contributed to the criminal action occurring, not being stopped and allowing it to go on as long as it did."
Specifically, according to the report, the VA failed to review Mays' personnel records from previous employers, nor did it contact them even as a federal background investigation found she had "potentially actionable issues ... which may be disqualifying under suitability/security considerations.'"
Also, Missal noted, when Mays received an award in 2017 for being an exemplary employee, another background check should have been initiated but wasn't -- another missed opportunity to root out a potentially dangerous employee.
In the ward where she worked, Mays had access to the medication room and medication carts, which, as a nursing assistant, she should not have been awarded. In fact, the entire staff on the ward had "full access to the medication room," and medication carts were often unlocked, the IG noted.
"Given the unexplained hypoglycemic events, open access to insulin stored in the medication room and medication carts is concerning," the VA OIG wrote.
Providers also failed to order diagnostic testing for seven of the eight patients; in the eighth case, they ordered the wrong test. Even when a series of hypoglycemic events occurred in a span of a few weeks, the providers didn't discuss the issues among themselves, nor were they reported as patient safety events.
The report made 15 recommendations to the VA, to include looking at the patients who had quality of care issues at the facility outside the hypoglycemic events.
"Nothing will bring back the veterans who are lost. Hopefully, the sentencing today and our health care inspections report will bring solace to the families and hopefully ensure that nothing as tragic as this ever happens again," Missal said.
Those who died at the hospital included:
- Robert Edge, a Navy veteran who served from 1952 to 1956
- Robert Kozul, an Army veteran who served from 1951 to 1953
- Archie Edgell, an Army veteran who served from 1953 to 1955
- George Shaw, an Air Force veteran who served from 1951 to 1982
- Felix McDermott, an Army veteran who served 1962 to 1968
- Raymond Golden, a dual Army and Air Force veteran who served from 1951 to 1953 and 1955 to 1973
- William Holloway, who served in the Army from 1942 to 1945
The family of another veteran, Russell Posey, filed a lawsuit last year over the suspicious circumstances of his death, which included a hypoglycemic event. In addition to the seven second-degree murder pleas, Mays pleaded guilty to one count of assault with intent to commit murder related to a patient identified as RRP, Posey's initials.
"At every opportunity today, we should honor them," acting U.S. Attorney for the Northern District of West Virginia Randy Bernard said during a press conference.
At her sentencing, Mays said she had no words that could "offer the families any comfort."
"I can only say I'm sorry for the pain I caused them and my family," she said.
Kleeh listed the letters he had received from the victims' family members, and let several speak prior to the hearing. Several said Mays had deprived them of their husbands, fathers, grandfathers and great-grandfathers.
"I do not forgive you. I would punish you with my own hands if it would do any good. I want you to experience what death feels like," said Robert Edge Jr.
-- Patricia Kime can be reached at Patricia.Kime@Monster.com. Follow her on Twitter @patriciakime.