BASIS OF CLAIM

On April 9, 2018, Felix Kirk McDertnott, a patient at the Louis A. Johnson VA
Medical Center in Clerksburg, WV (hereinafter sometimes referred to as died as a result
of the VAMC breaching its af?n'native duty to keep him safe when he was foreseeably injected
with a fatal dose of issu?lin, either negligently or willfully, by an unidenti?ed person while he was
an admitted patient of the VAMC. Regardless of the relationship of this unidenti?ed person to
VAMC, if any, the VAMC still had an independent duty to protect its patients, including Ret.
Anny Sgt. McDermott, from foreseeable hens. once it knew or should have known that its patients
were being mongfully ?injected with insulin. Under the facts of. this case, the VAMC breached its
independent and affmnetive duty or protect Ret. Army Sgt. McDemott from foreseeable harm,
and as a direct and proximate result. of that breach, Ret. Army Sgt. McDemott died. Moreover, if
the unidenti?ed person who injected Ret. Army Sgt. McDermott with insulin was an employee,
and if this person injected Rot. Anny Sgt. MeDennott wii-l??nlly with insulin with an intent to harm
him, this act was not coinmitted within the scope of her/Ins employment with the 
Government. If the insulin was injected into Ret. Army Sgt. MeDertnott negligently, then the

VAMC is also responsible because the negligence of its employee is imparted onto the VAMC.

Upon infonnation and belief, before April 9, 2018., nine or ten patients of the Louis
A. Johnson VA Medical Center in Clarksburg, WV, had died expectedly as a reSult of unexplained
severe hypoglycemia, elk/a low blood sugar. The employees of the VAMC were aware of each of
the unexpected and suspicions deaths. Eachof these nine or ten patients had received a large and
wrongful injection of insulin in the abdomen that was neither ordered by a doctor or medically

necessary. The employees of the VAMC either knew, or should have known, of the wrongful

insulin injections to each of nine or ten patients who died as a result of wrong?ll insulin injections.
Therefore, as of April 6, 2018, when Rot. Army Sgt. McDonnott was admitted to the VAMC, there
was a reasonably foreseeable risk of harm that more VAMC patients would become victims of the
Mongful insulin injections unless the VAMC took af?nnative action to protect the 
patients from such foreseeable and wrong?tl conduct. As a US. Veteran hospital, the VAMC had
a special relationship with its veteran patients that created an al?nnative duty to protect those
patients from reasonably fbreseeable harm. The VAMC had an a?innativc duty to ensure that Rot.
Anny Sgt. MoDennott received high-quality and timely healthcarc services in compliance with
the standard of care. In this case, the took custody of Rat. Army Sgt. McDonnott, who
suffered from dementia and physical disability due to a previous stroke and the VAMC had. an
af?nnative duty to keep him safe. Therefore, there is undoubtedly a special relationship beMeen
the VAMC and Rot. Anny Sgt. under the facts of this case. Under West Virginia law,
fareseeability is the ?primary factor? in detenuining whether a duty exists. Robertson v. LeMaster,
171 W. Va. 607, 301 563 (1983). The ?ultimate test of the existence of a duty to use care
is found in the foreseeab??y that harm may result if it is not exercised.? Syl. Pt. 8, Aikens v. Debow,
208 4'86, 541 576, 579 (2000) (citing Syl. Pt. 3, Sewell v. Gregory, 179 W. Va. 585,
371 812. (1988)). West Virginia law also requires caregivers, like the VAMC, who accept

responsibility for the care of incapacitated elderly people, to protect them from harm.

At the time of Rat. Army Sgt. McDeunott?s death, nobody at the medical center
told his family about the sudden and unexplained hypoglycemia that caused his death. Nor were
the family members told that prior to Rot. Army Sgt. McDonnott?s death, nine or ten other patients
at the facility had suffered similar unexplained deaths due to sudden onset of unexplained medidal

conditions. It was not until months later that government investigators contacted Rot. Army Sgt.

McDonnot-t?s daughter Melanie Proctor and advised her of the earlier deaths and their belief that

her father?s death was not a result of natural causes.
McDermott?s Admission and Initial Treatment at the Lou-is A. Johnson VA Medical Center

Felix Kirk McDermott Was a Vietnam Veteran, a retired sergeant after 20 year's of active
US. Army service and subsequently a member of the National Guard, who was
admitted to the Louis A. Johnson VA Medical Center in 'Clark?sbmg, WV, on April 6, 2018. Rat.
Army Sgt. McDermott came to the facility because he had aspirated on some food and developed
aspiration pneumonia. During his initial stay at the facility, Rot. Army Sgt. McDerrnott?s health

condition irnproVed.

Ret. Army Sgt. McDe'rrno'tt did not sn?i'er from diabetes. Ret. Army Sgt. McDerrnott had
never been diagrased with diabetes. Ret. Army Sgt. McDermott did not have a history of ever
taking oral medication or. insulin injections for diabetes. During his treatment at the VAMC, Ret.
Army Sgt. McDermott had his blood glucose levels monitored dally via a ?ngerstick blood test.
Ret. Army Sgt. McDermott?s daily ?ngerstick blood glucose levels Were within the normal range
of 100-181 mg/dL. There was no medical need for Ret. Army Sgt. McDonnott- to receive or take
insulin and there were no physician orders for insulin during, Rot. Army Sgt. McDermott?s April

2019 hospitalization.
McDermott?s Unexplained Sudden Health Decline and Death-

I-n the early morning hours of April 9, 2918, while still a patient at the Louis A. Johnson
VA Medical Center, Ret. Army Sgt. McDermott unexpectedly developed shortness of breath. A
?ngerstick blood glucose test revealed that Ret. Army Sgt. McDonnott had a critically and

profoundly low blood sugar level of just 12 mg/dL. Low blood sugar is also called hypoglycemia.

Rot. Army Sgt. McDonnott?s severely low blood sugar level was so low, that medical efforts to
raise his blood sugar level back to nonnal were unsuccess?tl. His condition continued to worsen,
and he died severe hypoglycemia at roughly 9:00 am. onthe morning of April 9, 2018.
Employees of the VAMC never explained to Ret. Army Sgt. MoDennott?s- family the unexolaine?d
diagnosis of hypoglycemia. Ret. Army Sgt. McDennott?s family was only advised of his death.
Ret. Army Sgt. McDermott?s family had his body sent to a funeral home and prepared for burial.

Felix Kirk McDonno-tt was buried on April 13, 2018.
Subsequent Investigation

Under the jurisdiction of the VA. Of?ce of the In?SpectOr General, Ret. Army Sgt.
McDennott?s remains were disinterred on October 23, 2018- and sent to Dover Air Force Base for
autopsy heaanse of the suspicious manner of Mr. Bennett?s death. During its investigation, VA
imiestigators advised Melanie Proctor, Rel. Anny Sgt. McDonnott?s daughter and the
administratrix of his estate, that there was evidence that nine or ten other patients of the Louis A.
Johnson VA Medical Center had been wrongfl?ly injected. with insulin in their abdomen, thereby
causing their deaths. M's. Proctor was ?nther adv-Rd that her father was one of the last known

victims.
Exhumation and 

The exhumation and autopsy con?rmed investigators? suspicions that Ret. Army Sgt.
McDermott had received an exogenous insulin shot in the left side of his abdomen. That ?nding
was consistent with the clinical history of a profound hypoglycemic event that occurred the
morning of April 9, 2018. The autopsy report con?rmed that Ret. Army Sgt. MeDermott was not

a diabetic and had no history of oral hypoglycemic use or previous insulin administration. The

autopsy report also con?rmed there were no hospital orders for the. administration of insulin. The
autopsy report noted that despite Ret. Army Sgt. McDerrnott?s preexisting health issues, he was
showing clear improvement in his medical condition when he was negligently, wrong?tlly, or

intentionally injected with insulin.
Autopsy Findings and VA Investigation

As a result of the investigation, the Anned Forces Medical Examiner ruled that the manner
of Felix Kirk McDermott?s death is homicide. If the medical examiner?s conclusion is correct,
Felix Kirk McDemott was murdered while he was in the care and custody of the Louis A. Johnson
VA Medical Center despite the VAMC being on notice of the previous wrong?ll injections. Ret.
Army Sgt. McDonnott?s family has been advised that? the. VA investigators have a person of
interest in the deaths. of the multiple VAMC patients. As of the submission of this claim form, that

person?s identity has not been shared with Ret. Army Sgt. McDennott?s family.
The Duty and Breach of Duty

Nine or ten other VAMC patients inexplicably died before Ret. Army McDermott
became a similar fatality victim. These nine or ten prior deaths created an antecedent, independent
and 'a?innative duty to act. to protect Ret. Army Sgt. McDerrn-ott and other VAMC patients from
foreseeable harm before Ret. Army Sgt. MeDermott was also wrong?tlly injected with insulin and.
killed. The VAMC breached this af?rmative duty and was negligent in multiple ways: by failing
to thoroughly investigate each of these suspicious deaths and discover the cause of these deaths
which resulted from the unwarranted injection of insulin by the unidenti?ed person; by failing to
alert Rat Army Sgt. MeDermott or his family that multiple other VAMC patients at the Louis A.
Johnson VA Medical Center had died suspiciously; by failing to adequately staff its medical

center; by failing to designate each of the other nine or ten deaths as sentinel events despite each

of those deaths meeting the criteria to be designated as a sentinel event, and by failing to identify,
report and investigate each sentinel event as required by the standard of care; by failing to initiate
a root cause analysis after each of the nine or ten other deaths in order to prevent additional deaths
and reduce the potential for patient harm; by failing to have proper reconciliation of medications,
including insulin; by failing to have proper oversight by senior VAMC management staff; by
failing to properly train VAMC staff; and by failing to warn Reit. Army Sgt. McDermott and his
family of other nine or ten deaths. If Ret. Army Sgt. McD?ermott or his family had been so apprised
and properly warned, they could have made an infonued choice about whether to. seek care at that
facility. Due to the negligent concealment of those other suspicious deaths and infomation, neither
Ret. Army Sgt. McDermott nor his family had an opportunity to choose. Moreover, had the 
not acted negligently as described? above, Ret. Army gt. untimely death would have

been prevented.

The VAMC had a duty to provide reasonable and competent medical care to its patients,
including Felix Kirk MeDeu'uott. Ret. Army Sgt. McDonnott had an absolute right to be free from
abuse by the staff at the facility. The VAMC had a duty to protect and prevent its patients, including
Ret. Anny Sgt. McDermott, from being administered drugs and injections that were not medically
necessary. The VAMC had a duty to properly screen and hire its employees. The had a
duty to thoroughly investigate the cause of suspicious and unexpected deaths in order to prevent
additional patients, including Ret. Army Sgt. McDonnott, from being exposed to the unreasonable
risk of being injected with medications meant to harm them. The VAMC had a duty to warn
patients of the multiple, suspicious and unexpected deaths so that new patients, including Ret.
Army Sgt. McDerruott, could make an informed decision about whether to seek care there. The

VAMC had a duty not to conceal from patients the multiple, suspicious and unexpected deaths so

that new patients, such as Ret. Army Sgt. McDermott, could make an informed decision about
whether to seek care there. The VAMC had a duty to keep good control of its drugs and inventory,
including injectable insulin, so thatemployees of the Louis A. Johnson VA Medical Center did
not have unaccounted for access to drugs and injections that could be misused or abased. The
VAMC had a duty to properly supervise its employees and not to retain employees that were a
danger to patients. Each of these af?nnative duties of the VAMC Were antecedent and independent

of the conduct of person who wrongfully injected Rot. Army Sgt. McDennott.

The VAMC breached each of?the above listed duties, which breaches were deviations from
the appropriate standard of medical care and were a proximate cause of Ret. Army Sgt.
McDern-iott?s injuries and death. As a result of those deviations from. the appropriate standard of
care, Rot. Anny Sgt. McDeImott Was exposed to urmecessary, foreseeable and preventable
dangers, and it was these deviatiotts by the VAMC that were a proximate cause of his death. In
addition, if the employee of the Louis A. Johnson VA Medical Center who wrongfully injected
Re't. Army Sgt. McDonnott in the abdomen with insulin did so negligently, then such negligence
is also deviation ?oor the appropriate standard, and the VAMC is responsible for the negligence

of its employees under respondent superior.
Monetary Bamages and Claim for Relief

As a direct and proximate result of deviations from the appropriate standards of medical
care described herein which caused Ret. Army Sgt. McDermott?s injuries and wrongful death, his
statutory bene?ciaries are entitled to all non-economic and economic damages allowed under West
Virginia law, including sorrow, mental anguish, and solace which may include society,

companionship, comfort, guidance, kindly of?ces and advice of the decedent, pain and suffering,

mental anguish, funeral costs of $7,500 and less of income to Rel. Anny Sgt. MeDermott?s Estate

of approximately $2,200 per month throughout the remainder of his natural life.
Attachments

1. Letter of Administration from the Tyler County, WV, Cemiesion appointing Melanie
Preetor as the Administrat?x of the Estate of Felix Kirk MeDermett dated July 27, 2018.

2. Autopsy Repert of Felix Kirk McDermett dated February 13, 2.019 frem the US.
Depamttent ef Defense?s Anned Forces Medical Examiner System

Funeral Bill for the ?meral of Felix Kirk MeDenno?tt
4. Death Certi?cate. of Felix'Kirk MeDermett ?le timber 007446.