. BASIS OF CLAIM 1. 'On April 10, 2018, George Nelson Shaw, Sr., a patient at the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia (hereinafter referred to as Medical Center?) died as a result of the VA Medical Center breaching its af?rmative duty to keep him safe when he was foreseeably injected with a fatal dose of insulin, either negligently or willfully, by an unidentified person while he was an admitted patient of, the VA Medical Center. 2. Mr. Shaw was a decorated Retired Senior Master Sergeant with the United States Air Force. He had a distinguished 28 year military career in the United States Air Force. After his retirement, he was employed at the Louis A. Johnson VA Medical Center for 8 years. He was married to his loving wife of 59 years, Norma Shaw. The two had three children: son George Shaw, Jr. .(who served 20+ years in the Air Force), and daughters Linda Kay Shaw (who served 22 years in the Air Force) and Mary Shaw Wood. Ret. SMS gt. Shaw has 2 grandchildren with service in the Air Force and Army. In addition, Ret. Shaw had 3 brothers who served I 3. Ret. Shaw was admitted to the Louis A. Johnson VA Medical Center in Clarksburg on March 22, 2018. Ret. Shaw came to the facility that day because he was not feeling well and wanted to be checked out. He was examined and subsequently admitted. Ret. Shaw?s health was improving over the next couple days. 4. Then, on March 26, 2018, Ret. Shaw experienced an episode of hypoglycemia (very low level of blood sugar) in which his glucose levels ranged from 17-40 between 7:22 am. and 9:53 am. Low blood sugar is also called hypoglycemia. Ret. SMS gt. Shaw?s severely low blood sugar level was so low, that medical efforts to raise his blood sugar level back to normal were unsuccessful. His condition significantly deteriorated and his family repeatedly asked why his health condition was declining so rapidly. On March. 28, 2018, Ret. SMS gt. Shaw was summarily discharged from the VA Medical Center and sent to River Oaks nursing home. On April 4, 2018, River Oak?s. sent him back to the VA Medical Center and. he was readmitted that day. On April 5, 2018,. Ret. Shaw was placed on comfort care measures at the'VA Medical Center. Shaw died a very painful death from severe hypoglycemia at roughly 8:23 am. on the morning of April 10, 2018. Employees of the VA Medical Center never explained to Ret. Shaw?s family the unexplained diagnosis of hypoglycemia. Ret. Shaw?s family requested an autopsy, Iwhich was done on April 11, 2018, at the VA Medical Center. The cause of death from this autopsy was determined toibe congestive heart failure. Ret. SMS gt. Shaw?s family had his body sent. to a Dorsey Funeral Heme and prepared for burial. Ret. was buried on April 16, 2018, at Floral Hills Memorial Gardens in Mount Clare, WV. I 5. Ret. Shaw did not Suffer from diabetes and had never been diagnosed with diabetes.- Ret. SMS gt. Shaw did not have a history of ever taking oral medication or insulin injections for diabetes. There was not medical need for Ret. Shaw to receive or take insulin and the-re were no physician?orders fOr insulin during Ret. Shaw?s hospitalization at the VA Medical Center. 6. At the time of Ret. SMS gt. Shaw?s death, nobody at the VA Medical Center told his family about the sudden and unexplained hypoglycemia that caused his death. Moreover, the family members were not told that, prior to Ret. Shaw?s death, '9 or 10 other patients at, the VA Medical Center had sufferedsimilar unexplained deaths due to sudden onset of unexplained medical conditions. It was not until months later. that VA investigators and the FBI contacted Ret. Shaw?s wife, Norma Shaw, and advised her of the earlier deaths and their belief that her husband?s death was not a result of natural causes. During its investigation, VA investigators. and the FBI advised Norma Shaw that there was evidence that 9 or 10 other patients of the VA Medical Center had been wrongfully injected with insulin, thereby causing their deaths. Mrs. Shaw was further advised that her husband was one of the last known victims. 7. Under the jurisdiction of the VA Office of the Inspector General, Ret. Shaw?s remains were disinterred and. sent to Dover Air Force Base for a second autopsy because of the suspicious, manner of Ret. VSMS gt. Shaw?s death. 8. The autopsy con?rmed investigators? suspicions that Ret. SMS gt. Shaw had receiVed unprescribed exogenous insulin injections in four areas of his body; That finding was consistent with the clinical history of a profound hypoglycemic event that occurred the morning of March 26, 2018. The autopsy report confirmed that Ret. Shaw was not a diabetic and had no history of oral hypoglycemic use or previous insulin administration. The autopsy report also confirmed there Were no hospital orders for the administration of insulin. The autopsy report noted that Ret. Shaw never returned to his clinical baseline after he was negligently, wrongfully, or intentionally injected with insulin. The autopsy report further noted that the hypoglycemic event was the precipitating event for his terminal clinical decline. 9. As a result of the investigation, the Armed Forces Medical Examiner ruled that the manner of Ret. Shaw?s death is homicide. If the medical examiner?s conclusion is a correct, Ret. Shaw was murdered while he was in the care and custody of the Louis A. Johnson Veteran?s Administration Medical Center despite the VA Medical Center being on notice of the previous wrongful inj ections. Ret. SMS gt. Shaw?s family has been advised that the VA investigators and the FBI have a person of interest in the death of Ret. Shaw and the deaths of the multiple VA Medical Center patients. As of the submission of this claim form, that person?s identity has not been shared with Ret. SMS gt. Shaw?s family. 1-0. Regardless of the relationship of the unidentified person to the VA Medical Center, if any, the VA Medical Center still had an independent duty to protect its patients, including Ret. Shaw, from foreseeable harm once it knew or should have known that its patients were being wrongfully injected with insulin. The VA Medical Center breached its independent and affirmative duty to protect Ret. Shaw from foreseeable harm, and-as a direct and proximate result of that breach, Ret. Shaw died. Additionally, if the - unidentified person who injected Ret. Shaw with insulin was an employee, and if this person injected Ret. Shaw willfully with insulin with an intent to harm him, this act was not committed within the scope of her/his employment with the VA Medical Center. If the insulin was injected into Ret. SMS gt. Shaw negligently, then the VA Medical Centeris also responsible because the negligence of its employee is imparted onto the VA Medical Center. 11. Upon information and belief, before April 10, 2018, approximately 10 patients of the VA Medical Center in Clarksburg' died as a result of unexplained severe hypoglycemia. The employees of the VA Medical Center were aware of each of the unexpected and suspicious deaths. Each of these approximately 10 patients had received a large and wrongful injection of insulin that was neither ordered by a doctor nor medically necessary. The employees of the VA Medical Center either knew, or should have known, of the wrongful insulin injections to each of the approximately 10 patients who died as a result of wrongful insulin injections. Accordingly, when Ret. Shaw was admitted to the VA Medical Center, there was a reasonable foreseeable risk of harm that more VA Medical Center patients would become Victims. of the I wrongful injections unless the VA Medical Center took affirmative action to protect the VA Medical Center?s patients from such. foreseeable and wrongful conduct. 12. The VA Medical Center had a special relationship with its veteran patients that created an affirmative duty to protect those patients from reasonably foreseeable harm. The VA Medical Center had an affirmative duty to- ensure that Ret. Shaw'received high-quality and timely healthcare services in compliance with the standard of care. In this case, the VA Medical Center took Custody of Ret. Shaw, who suffered from dementia, and the VA Medical Center had an affirmative duty to keep him safe. Therefore, there is undoubtedly a special relationship betWeen the VA Medical Center and Ret. SMS gt. Shaw under the facts of this case. Under West Virginia Law, foreseeability is the ?primary factor? in determining whether a duty exist-s. Robertson v. LeMaster, 301 563 (1983). The ?ultimate test of the existence. of a duty to use care is found in the foreseeability that harm may result if it is. not exercised?? Syl. Pt. '8,Aikens v. Debow, 54:1 579 Syl. Pt.3, Sewell v. Gregory, 371 82 (1988)). West Virginia law also requires caregivers, like the VA. Medical Center, who accept responsibility for the care of incapacitated elderly people, to protect them from harm. 13. Several other (possibly up to ten) VA Medical Center patients inexplicably died before Ret. Shaw became a similar fatality victim. These prior deaths created an antecedent, independent and affirmative duty to act to protect Ret. Shaw and other VA Medical Center patients from foreseeable harm before Ret. Shaw was also wrongfully injected with insulin and killed. The VA Medical Center breached this affirmative duty and was negligent in multiple ways: a. by failing to thoroughly investigate each of these suspicious deaths and discover the cause of those deaths which resulted from the unwarranted injection of insulin by the unidentified person; b. by failing to alert Ret. Shaw or his family that multiple other VA Medical Center patients at the Louis A. Johnson Veteran?s Administration Medical Center had died suSpiciously; c. by failing to adequately staff its medical center; by failing to designate each of the Other 10 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 10 deaths in order to e. prevent additional deaths and reduce the potential for patient harm; f. by failing to have proper reconciliation. of medications, including insulin; g. by failing to have proper oversight by senior VA Medical Center management staff; h. by failing to properly train VA Medical Center staff; and E- And by failing to warn Ret. Shaw and his family of other deaths. 14. If the VA Medical Center had properly warned Ret. Shaw or his family, they could have made an informed choice about Whether to seek care at that facility. Due to the- negligent concealment of those other suspicious deaths and information, neither Ret, Shaw nor his family had an opportunity to choose. Moreover, had the VA Medical Center not acted negligently as described above, Ret. Shaw?s untimely death would have been prevented. 15. The VA Medical Center had a duty to provide reasonabIe and competent medical care to its patients, including Ret. Shaw. He had an absolute right to be free from abuse by the staff at the VA'Medical Center. The VA Medical Center had a duty to protect and prevent its. patients, including Ret. Shaw, from being administered ?drugs and injections that Were not medically necessary. The VA Medical Center had a duty to properly screen and hire its employees. The VA Medical Center had a duty to thoroughly investigate the cause of suspicious and unexpected deaths in order to prevent additional patients, including Ret. SMS gt. Shaw, from being exposed to the unreasonable risk of being injected with medications meant to harm them. The VA Medical Center had a duty to warn patients of the multiple, suspicious and unexpected deaths so that new patients, including Ret. Shaw, could make an informed decision about whether to seek care at that facility. The VA Medical Center had a duty not to conceal from patients the multiple, suspicious and unexpected deaths so that new patients, such as Ret. Shaw, could make .an informed decision about whether to seek care at that facility. The VA Medical Center had a duty to keep good control of its medications and inventory, including injectable insulin, so that employees of the VA Medical Center did not have unaccounted for access to medications and injections that could be misused or abused. The VA Medical. Center had a duty to properly supervise its employees and not to retain employees that were a danger to patients. Each of these affirmative duties of the VA Medical Center were antecedent and independent of the conduct of the person who wrongfully injected Ret. Shaw. 16. The VA Medical Center 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. Shaw?s injuries and death. As a result of those deviations from the appropriate standard of care, Ret. Shaw was exposed to unnecessary, foreseeable and preventable dangers, and it was those deviations by the VA Medical Center that were a proximate cause of his injuries and death, In addition, if the employee of the Louis A. Johnson VA Medical Center who wrongfully injected Ret. Shaw with insulin did so negligently, then such negligence is also deviation from the appropriate standard, and the VA Medical Center is responsible for the negligence of its employees under respondeat superior. 17. As a direct and proximate result of deviations from the appropriate standards of medical care described herein which caused Ret. Shaw?s injuries and wrongful death, his statutory beneficiaries 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 officesand advice of the decedent, pain and. Suffering, mental anguish, funeral costs of $6,561.47 and loss of income of to Ret. Shaw?s Estate of $3,904.29 per month throughout the remainder of his natural life. In support of this Claim, please see the attached documentation:? 3' b. Death Certificate of George Nelson Shaw. Autopsy Report of George Nelson Shaw dated from the United States. Department of Defense?s Armed Forces Medical Examiner System. Funeral bill for the funeral of George elson Shaw. DEFENSE HEALTH AGEN CY 15 PURPLE HEART DRIVE DOVER AIR FORCE BASE, DELAWARE 19902 u? Armed Forces Medical Examiner System AUTOPSY REPORT Autopsy Number: MESH-0013 Name: Shaw, George Nelson Grade: Retiree Date of Birth: 18 October 1936 Date of Death: 10 April 2018 Place of Death: Louis A. Johnson VA Medical Center, Clarksburg, WV Date/Time of Autopsy: 16 January 2019 0730 Place of Autopsy: Dover AFB, DE Date Report Signed: 3 July 20.19 Circumstances of Death: By report, this 81 year-old Retiree was admitted 01122 March 2018 for an acute exacerbation of congestive heart failure. On 26 March 2018, he experienced an episode of hypoglycemia in which his glucose levels ranged from 17?40 mg/dL between 7:22 am and. 9:53 am. After the hypoglycemic event, he never returned to his clinical baseline and his clinical course continued to deteriorate. He was discharged to a nursing home for hospice care on 28 March 2018, but was readmitted to the hospital on 4 April 201.8 for combativeness, poor oral intake, and dehydration. He was placed on comfort care measures on 5 April 2018- and he died on 10 April 2018-. An autopsy was performed by the VA hospital on 11 April 2018 as requested by the family. The cause of death was determined to be congestiVe heart failure with coronary atherosclerosis. Under authorization of the VA Office of the Inspector General, the remains were disinterred and brought to Dover AFB for a second autopsy. Authorization for Autopsy: Armed Forces Medical Examiner, IAW 10 USC 1471. Identification: Positive identi?cation by ante-mortem and postumortem ?ngerprint comparisons. C: I CAUSE OF DEATH: Exogenous insulin ad ministration. OTHER CONTRIBUTING FACTORS: Congestive heart failure, atherosclerotic cardiovascular disease, dementia, chronic renal disease. MANNER OF DEATH: Homicide. FOR OFFICIAL USE ONLY and may be exempt. from mandatory disclosure under FOIA. DOD 5400.7R, Freedom of Information Act Program?, DOD Directive 5230.9, ?Clearance of DOD Information for Public Release?, and DOD Instruction 5230.29, ?Sensitivity and Policy Review of mm Information for Public Release? apply. AUTOPSY REPORT: ME19-0013 Page 2 of 10' Shaw, George Nelson EXTERNAL EXAMINATION The body is received in a casket. Five desiccated ?owers are received with the casket. The previously embalmed and autopsied body is clad in the clothing listed. below. An AFMES tag labeled "with the deceased's demographic information is attached to the left ankle. The body is that of a well-developed, well-nourished, previously autopsied and embalmed male and appears compatible with the reported age. The body is approximately 73 inches in length and weighs 111 pounds. injuries are described in the section ?Evidence of Injury? and medical therapy is described in the section ?Medical Intervention." Rigor and lividity are unable to be assessed. There is diffuse gray-brown skin discoloration of the torso and lower extremities with skin slippage. The scalp hair is brown-gray and measures up to 4 1/2 inches in length. The face is clean shaven. covers are covering the ?attened optic globes. The irides appear blue. The comeae are cloudy. The conjunctivae are pale and without petechiae. The sclerae are white and without petechiae. The ears are normally formed and set. The external auditory canals are clear and both earlobes are not pierced. The nasal skeleton and maxilla are palpably intact. The mandible is wired closed. The external nares and mouth are free of abnormal secretions. The lips are without evident injury. The teeth are absent and dentures are in place. See ?Medical Intervention? for description of the anterior torso. The abdomen is ?at. The posterior torso is unremarkable. The genitalia are those of an adult male. The anus and perineum are unremarkable. The extremities show no evidence of fractures or lacerations. The ?ngernails are intact. No scars or tattoos are noted. CLOTHING AND PERSONAL EFFECTS At the time of autopsy, the body is clad in an Air Force coat with nameplate and ribbon rack, white shirt, blue shirt, blue tie, white underwear, blue Air Force pants, and socks. Received in the casket is a white blanket, Air Force dress cover, and 8 miscellaneous papers and drawings. NEEDICAL INTERVENTION There is evidence of previ0us autopsy including sutured incision of the skull, previous removal of the skull cap, vertically oriented midline sutured incision of the neck, ?Y-shaped? sutured incision of the anterior torso, previous removal of the chest plate, vertically oriented 3 inch sutured incision on the right upper abdomen, and removal of the brain and viscera of the torso. The thoracic and peritoneal cavities contain cotton? like and granular packing material and a plastic bag with a zipper. The intracranial cavity contains cotton?like and granular packing material. was Postmortem radiograp?hs are obtained and show no radiographic evidence of acute traumatic injury. Artifacts of previous autopsy and embalrning are identi?ed. The mandible is. wired closed. There is extensive peripheral calci?c atherosclerosis of the femoral arteries and distal branches. FOR OFFICIAL USE ONLY AUTOPSY REPORT: ME19-0013 Page 3 of 10 Shaw, George Nelson EVIDENCE OF INJURY A inch contusion is on the left side of the forehead. See ?Musculoskeletal System.? INTERNAL EXAMINATION BODY CAVITIES: See ?Medical Intervention.? The body is opened by the usual thoracoabdominal incision and the chest plate is removed. The ribs, sternum, and vertebral bodies are visibly and palpably intact. HEAD (CENTRAL NERVOUS SYSTEM) and NECK: See ?Medical Intervention? and ?Neuropathology Consultation.? CARDIOVASCULAR SYSTEM: See ?Reassociated remains.? RESPIRATORY SYSTEM: See ?Re-associated remains.? HEPATOBILLARY SYSTEM: See ?Re~associated remains.? GASTROINTESTINAL SYSTEM: See ?Re-associated remains.? GENITOURINARY SYSTEM: See ?Re-associated remains.? SYSTEM: See ?Re-associated remains.? ENDOCRINE. See ?Re-associated remains.? MUSCULOSKBLETAL SYSTEM: See ?Medical Intervention." Super?cial skin and soft tissue dissection of the abdomen, buttocks, arms, and thighs demonstrate the followed: Grossly unremarkable skin and soft tissue are representatively sampled from the right buttock (represented in microscopic slide 23). - A 0.6 0.5 centimeter area of discoloration in the super?cial adipose tissue of the lateral right arm (represented in microscopic slide 24). No overlying cutaneous is present. - A 1.5 centimeter area of intramuscular discoloration in the lateral left arm (represented in microscopic slide 25). No overlying cutaneous is present. - A 1.5 0.8 centimeter area of discoloration in the subcutaneous tissue of the left side of the abdomen (represented in microscopic slide 26). No overlying cutaneous is present. FOR OFFICIAL USE ONLY AUTOPSY REPORT: Page 4 of 1-0 Shaw, George Nelson - A 2.5 0.8 centimeter area of discoloration in the subcutaneous tissue of the left side of the abdomen adjacent to the midline (represented in microscopic slide 27). No overlying cutaneous is present. Grossly normal skin and subcutaneous tissue are sampled from the right anterior thigh (represented in microscopic slide 28). - A 2 2 inch area of cutaneous and subcutaneous hemorrhage in the left antecubital fossa (represented in microscopic slide 29). A 3 3 centimeter area of cutaneous and associated subcutaneous hemorrhage on the anterior aspect of the left forearm (represented in microscopic slide 30). NEUROPATHOLOGY CONSULTATION See Joint Pathology Center Consultation report (JPC accession number 41 16272-00). Diagnosis: AU 18 4 Brain, autopsy examination: 1. Alzheimer Disease Neuropathologic Change: A3, BB, C3 (National Institute on Aging~ Alzheimer?s Association, 2012). 2. Cerebral amyloid angiopathy, slight. 3. Lewy body disease, neocortical (diffuse). 4. Scattered TDP-43-positive neuronal cytoplasmic inclusions identi?ed in hippocampal formation and amygdala. 5. lntracranial atherosclerosis, slight; intracerebral arteriolosclerosis, slight. REMAINS Received separately from the body and casket are two evidence envelopes and three evidence boxes with. appropriate chain of custody evidence vouchers associating these with the previous autopsy 18 4? on George Shaw. One evidence envelope contains 22 histology slides labeled 18 4, slide l-22?. The second evidence envelope contains 22 corresponding tissue blocks. The ?rst evidence box contains a foam cooler containing a white plastic bucket labeled #1 containing four individually labeled sealed bags 4) containing formalin ?xed. tissue. The second evidence box contains a foam cooler containing a white plastic bucket labeled #2 and containing three individually labeled sealed bags. containing formalin ?xed tissue. The third evidence box contains a foam cooler containing a white- plastic bucket labeled #3 and containing four individually labeled sealed bags containing formalin ?xed tissue. The labeled bags contain the following formalin fixed tissues: Heart Eight sections of heart tissue weighing 540 grams in aggregate. The heart tissue demonstrates a smooth epicardial surface. The coronary arteries are present in a normal distribution and demonstrate marked calcific atherosclerosis of the proximal left anterior descending coronary artery (approximately 90% narrowed.) and right coronary artery (approximately 90% narrowed). The myocardinm is ?rm with a 5 0.6 centimeter area of darkened along the posterior wall of the left ventricle. The valve lea?ets are thin and mobile. The walls of the left ventricle, interventricular septum, and right ventricle measure 1.4, 1.4, and 0.7 centimeters thick, respectively. The endocardium is smooth and glistening. FOR OFFICIAL USE ONLY AUTOPSY REPORT: MEI9-0013 Page 5 of 10 Shaw, George Nelson Liver Two sections of passively congested liver measuring 140 grams in aggregate. Gallbladder A previously opened gallbladder weighing 20 grams with a tan- yellow surface and. green velvety .mucosal surface. Bladderlprostate A 100 gram portion of bladder with a tan, smooth mucosa surface; a 20 gram portion. of nodular prostate gland tissue. A 20 gram portion of trachea including the bifurcation into the right and left main bronchus, a 20 gram portion of grossly unremarkable thyroid tissue; three sections of grossly unremarkable lung tissue weighing 160 grams in aggregate. Pancreas/spleen Two fragments of grossly unremarkable spleen weighing 20 grams in aggregate; three fragments of autolyzed pancreatic tissue Wei ghin 80 grams in aggregate. Large intestine/small intestine/appendix One fragment of large bowel with several diverticuli measuring up to 0.6 centimeters and weighing 100 grams; two fragments of grossly unremarkable small bowel weighing 20 grams in aggregate; two fragments of grossly unremarkable appendix weighing less than 10 grams in aggregate. Acrta Two fragments of aortic tissue with marked calcific atherosclerosis and weighing 120 grams in aggregate. Kidney Eleven fragments of kidney with gross cortiCal nephro?sclerosis and mild dilation of the renal pelves; weighing 100 grams in aggregate. Esophagus/stomach #10: Fragment of grossly unremarkable esophagus, gastroesophageal junction, and stomach weighing 60 grams. Miscellaneous tissue #11: Multiple fragments of miscellaneous formalin fixed tissues measuring 15 12 3 centimeters in aggregate dimension and weighing 100 grams in aggregate. MICROSCOPIC EXAMINATION Tissue blocks 1-22 received as evidence are recut at AF MES, and the original tissue blocks are returned as evidence. See Louis A. Johnson VAMC autopsy report AU 18 4 for correlation. Selected portions of skin/soil tissue and the examined retained organ tissue are retained in formalin with the preparation of slides (blocks 23-32). Immunohistochemicai stains are examined with appropriately staining positive and negative internal controls. Slide I (thyroid/trachea): section of the trachea shows mild acute and chronic in?ammation. Section of the thyroid shows foci of thyroiditis. FOR OFFICIAL USE ONLY AUTOPSY REPORT: ME19-0013 Page '6 of 10- Shaw, George Nelson Slide 2 (right lung/bronchus) and slide 3 (left lung/bronchus): sections show mild acute and chronic in?ammation, changes, and pigmented macrophages 7 consistent with respiratory bronchiolitis. Slide 4 (liver/gallbladder): section of the liver shows passive congestion with mild periportal in?ammation and ?brosis. Section of the gallbladder shows autolyzed mucosa. Slide 5 (right kidney) and slide 6 (left kidney): sections show interstitial ?brosis, glomerulosclerosis, hyaline arterioleSclerosis, and patchy interstitial nephritis. There is duplication of the internal elastic lamina of the arterioles. Slide 7 (adrenal glands): sections show partial autolysis. Slide 8 (aorta): section shows calci?c atherosclerosis. Slide 9 (spleen): section shows congestion and partial autolysis. Slide 10 (pancreas), slide 22 and slide 32 (additional pancreas): sections show partial autolysis with appropriate immunohistochemical staining for insulin. Slide ll (esophagus/stomach): section of the esophagus shows unremarkable squamous epithelium. Section of the stomach shows autolyzed gastric mucosa. Slide 12 (small bowel, large bowel, and appendix): sections show unremarkable bowel and appendix with partially autolyzed mucosa. Slide 13 (prostate/bladder) and slide 21 (additional prostate tissue yellowish areas): sections of the prostate show benign prostatic hyperplasia. Section of the bladder show unremarkable muscularis with partially autolyzed mucosa. Slide 14 (right atrium/pulmonic valve), slide 15 (right ventricle), slide 16 (cardiac septum), slide. 17 (left atrium), and slide 18 (left ventricle), and. slide 31 (posterior left ventricle, heart): sections of the heart Show myocyte hypertrophy with patchy perivascular and interstitial ?brosis. Slide 19 (left anterior descending coronary artery) and slide 20 (right coronary artery): sections show marked calci?c- atherosclerosis. Slide 23 (skin/soft tissue, right buttock): section shows partially autolyzed skin without underlying hemorrhage within the subcutaneous ?broadipose tissue. Hematoidin pigment is identi?ed. No de?nitive immunohistochemical staining for insulin or associated polarizable are identified. FOR 0F ICIAL USE ONLY AUTOPSY REPORT: ME19-0013 Page 7 of 0 Shaw, George Nelson Slide 24 (skin/soft tissue, lateral right arm): section shows partially autolyzed skin with underlying hemorrhage within the subcutaneous ?broadipose tissue. lrnmunohistochemical staining for insulin is positive in predominantly a perimembranous pattern of the subcutaneous adipocytes. Fine polarizabl?e material is present in the areas of insulin positivity. Slide 25 (skin/soft tissue lateral left arm): section shows partially autolyzed skin without underlying hemorrhage within the subcutaneous ?broadipose tissue. Immunohistochemical staining for insulin 13 positive predominantly between the myofibrils. Fine polarizable material is present in the areas of insulin positivity. Slide .26 (skin/soft tissue, left abdomen): section shows partially autolyzed skin without underlying hemorrhage within the subcutaneous ?broadipose tissue. No de?nitive iummunohistochemical staining for insulin is identi?ed. Large chunky polarizable are identi?ed. Slide 27 (skin/soft tissue, left medial abdomen): section shows partially autolyzed skin without underlying hemorrhage within the subcutaneous ?broadipose tissue. No definitive iummunohistochemical staining for insulin IS identi?ed. Large chunky polarizible are identi?ed. Interpretation is limited by poor sectioning. Slide 28 (skin/soft tissue, right anterior thigh). section shows partially autolyzed skin without underlying hemorrhage within the subcutaneous ?broadipose tissue. Immunohistochemical staining for insulin is positive predominantly between the myo?brils. Polarization demonstrates tine polarizable material 111 the areas of insulin positivity. Slide 29 (skin/soft tissue, left antecubital fossa): section shows partially autolyzed skin 1 with underlying hemorrhage within the subcutaneous ?broadipose tissue No de?nitive immunohistochemical staining for insulin or associated polarizable are identi?ed. Slide 30 (skin/soft tissue, left anterior forearm): section shows partially autolyzed skin with underlying hemorrhage within the subcutaneous ?broadipose tissue. Immunohistochemical staining for insulin. is positive predominantly between the - myo?'brils with associated ?ne polarizable material upon polarization. FOR OFFICIAL USE ONLY AUTOPSY REPORT: Page 8 of 10 Shaw, George Nelson ADDITIONAL REMARKS Documentary photographs are taken by an AFMES Mortuary Affairs Specialist. (92M). Representatives from VA 01G attended the autopsy. A complete list of all individuals in attendance is on ?le. 2. Selected portions of skin/subcutaneous tissue and organs are retained for toxicology and/or DNA identi?cation. 3. Personal effects and organ tissue received as evidence are reieased with the body. The tissue blocks received as evidence are meat at AFMES, and returned with the received slides to the Investigative Agents in attendance. 4. No evidence is recovered at autopsy. FOR OFFICIAL USE ONLY AUTOPSY REPORT: Page 9 of 10 Shaw, George Nelson FINAL AUTOPSY 1. Evidence of exogenous insulin administration: A. B. C. Four subcutaneous areas (lateral right arm, lateral left am, left anterior forearm, and right anterior thigh) with immunohistochemically positive for insulin and corresponding ?ne polarizable formation. Hypoglycemic event on 26 March 2018 with glucose levels of 17-40 mg/dL with subsequent signi?cant decline in clinical condition. No medical history of diabetes or prescribed insulin administration. II. Previous autopsy ?ndings (see Louis A. Johnson VAMC report AU 18 4): A. B. scene 9 Cardiomegaly (662 grams) with biventricular hypertrophy and biatrial hypertrophy with atrial dilation; clinical history of pulmonic valve insuf?ciency. Significant coronary atherosclerosis with 90% stenosis of the proximal left anterior descending coronary artery and right coronary artery by complicated atherosclerosis. Complicated aortic atherosclerosis (mainly infrarenal but focally involving arch). Chronic tracheitis and bronchitis. Bilateral serous pleural effusions (250 mL each side). Hepatic chronic passive congestion. Clinical history of dementia with clinically suspected vascular etiology. Clinical history of acute and chronic state 111 kidney disease; prominent arteriolonephroscierosis; several bilateral simple renal up to l. cm. Sigmoi'd colon diverticula. Partial thickness sacral decubitus ulcer. Neuropathology Consultation from previous autopsy (JPC report 4116272- 00): A. F11 3093 Alzheimer Disease Neuropathologic Change: A3, B3, C3 (National Institute on Aging- Alzheimer?s Association, 2012). Cerebral amyloid angiopathy, slight. Lewy body disease, neocortical (dif?ise). Scattered TDP-43-positive neuronal cytoplasmic inclusions identi?ed in hippocampal formation and amygdala. Intracranial atherosclerosis, slight; intracerebral arteriolosclerosis, slight. 1v. Toxicology (arms #190161): A. B. VOLATILES: methanol, ethanol, and isopropanol detected in the liver. DRUGS: l. Cyclobenzaprine detected in the liver (27 ng/g). 2. Sertraline, memantine, and donezepil detected in liver by liquid chromatrography time of ?ight mass spectrometry; none detected in heart blood clot. FOR OFF USE ONLY AUTOPSY REPORT: ME19-0013 Page 10 of 10 Shaw, George Nelson This 81 year old Retiree, George Nelson Shaw, died of exogenous administration of insulin. Congestive heart failure, atherosclerotic cardiovascular disease, dementia, chronic renal disease were contributing factors. The ?ndings of the previous autopsy are corroborated and represent signi?cant natural disease. The toxicology screen is positive for cyclobenzaprine and artifacts of embalming. Mr. Shaw experienced a significant hypoglycemic event on 26 March 2018 in which he had blood glucose levels of 17-40 mg/dL between 7:22 am and 9:53 am. ?He was not a diabetic and had no history of insulin administration or prescribed insulin injections. There was no natural etiology that would explain this degree of sudden hypoglycemia in a non?diabetic individual. Examination demonstrated four subcutaneous areas that were immunohistochemically positive for insulin and had corresponding fine polarizable These sites are consistent with insulin injection sites described in. the literatm'e.I These injection sites represent unprescribed exogenous insulin administration in a hospitai setting, which provide an explanation for this hypoglycemic event. Two additional injection sites on the left side of the abdomen were identi?ed by the presence of larger polarizable but were immunohist?ochemically negative for insulin. These sites likely represent subcutaneous injection. sites of medication during his hospitalization. The hypoglycemic event occurred on 26 March 2018 and he died on 10 April 2018. Per review of the medical record and statements provided by the family, Mr. Shaw never returned to his clinical baseline between this hypoglycemic event and his death. Despite the length of time between this hypoglycemic event and his death, the medical record and family statements demonstrate that this hypoglycemic event was the precipitating event for his terminai clinical decline. Based on the investigative and autopsy ?ndings, the manner of death is homicide. URIBE.PAUL.S Digitally signed by URIBEPAULSHANEJ 'l HANE.1 1 7608 36087826 A ate: 2019.07.03 7826 15:10:15 ?04'00' Paul Uribe LTC, MC, USA Deputy Meditaal Examiner Lutz R, Pedal .1, Wetzel C, and Mattern R. Insulin injection sites: morphology and immunohistochemistry. Forensic Science International; 90 (1997); 93-101. FOR OFFICIAL USE ONLY DEFENSE HEALTH AGENCY 1 l5 PURPLE HEART DRIVE DOVER AIR FORCE BASE, DELAWARE W902 Armed Forces Medics! Examiner System 1 July 2019 TO: MEDICAL EXAMINER Name: SHAW, GEORGE N. ARMED FORCES MEDICAL EXAMINER SYSTEM $894190!) ID: 23468-5436 115 PURPLE HEART DRIVE Toxicology Accessionit: 19016! DOVER AFB, DE [9902 Autopsy?: 1519?0013 Condition of Specimens: GOOD incident Date: 04/10/2018 REPORT OF TOXICOLOGIQ AL EXAMINATION VOLATILES: The LIVER was examined for the presence of methanol, ethanol, acetone and isopropanol by headspace gas chromatography ?ame. ionization detection with an ethanol reportable limit of 0-020 The following volatiles were detected: Methanol . Ethanol I sopropanol LIVER Present Present Present NF ?None Found? DRUGS: The LIVER was screened for amphetamines, barbiturates, benzodiazepines, cannabinoids, cocaine, opioids, sympathomimetic amines, acidic, neutral and alkaline extractable drugs by immunoassay, gas chromatography/full scan?mass spectrometry or liquid chromatography time of ?ight mass Spectrometry. The following drugs were detected: Positive Cyclobenzaprine: Cyclobenzaprine was detected in the liver by liquid chromatography time of ?ight mass spectrometry and confirmed by liquid chromatography tandem'rnass. spectrometry. The. liver contained 27 rig/g of cyclobenzaprine as quantitated by liquid chromatography tandem mass spectrometry. Positive Sertraline: Sertraiine was detected in the liver by liquid chromatography time of ?ight mass spectrometry. The heart blood clot was sent to NMS Labs for continuation. Please see the attached external laboratory testing report for additional toxicological results. This document contains in?rmatian EXEMPT FROM MANDA TOR l" DISCLOSURE under the FREEDOM OF TION ACT Exemption N0. 6nd Applies FOR OFFICIAL USE ONLY DEFENSE HEALTH AGENCY 3.5 PURPLE HEART DRIVE DOVER AIR FORCE BASE, DELAWARE W902 Armed Forces Medical Examiner System REPORT OF TOXICOLOGICAL EXAMINATION CONTINUED 19?0161 Positive Mementine: Mementine was detected in the liver by liquid chromatography timeof ?ight mass spectrometry. The heart blood clot was sent to NMS Labs for con?rmation. Please see the attached external laboratory testing report for additional toxicological results. Positive Donezepil: Donezepii was detected in the liver by liquid chromatography time of ?ight mass spectrometry. The heart blood clot was sent to NMS Labs for con?rmation. Please see the attached external laboratory testing report for additional toxicological results. JEFFR P. WALTERSCHEID, F-ABF-T ERIC SHIMOMURA, Chief Toxicologist Certifying Scientist Forensic Toxicology Laboratory Forensic Toxicology Laboratory Armed Forces Medical Examiner System Armed Forces Medical Examiner System- GEORGE F. JACKSON, F-ABFT Certifying Scientist Certifying Scientist Forensic Toxicology Laboratory Forensic Toxicology Laboratory Armed Forces Medical Examiner System Artned Forces Medical Examiner System I NMS Labs CONFIDENTIAL . . 3701 Welsh Road, PO Box 4331??. Willow Grove, PA 191390-043? Fm- Phone: (2?15) 657-4900 Fax: (215) 657-2972 A 3 e?maii: nms?nmsiabecom RobertA. Middieberg, F-ABFT, DABCC-TC. Laboratory Director Report '?atient same NP Patient {8 19?0161 Report Issued 021262019 13.00 Chain 19031238 Age Not Given DOB Not Given To: 99099 Send? M33213 3 Armed Forces Medical Examiner, Div of Ferensic 1? 3 mm: Jessica Knittei 115 Purple Heart Drive Dover AFB, DE 19902 Page 1 0?3 Positive Findings: None Detected See Detailed Findings section for additionai information Testing Requested; Analysis Code Description 77343A Special Request Memantine in Tissue 77358.4. Special Request: Denepezil in Tissue 4195'?! Seriraiine and Damethyisertraiine, Tissue Specimens Received: in 'i'uhelContainer Volume! Coiiection Matrix Source Miscelianenus Mass Datemme mfonnation 001 Biue Piastic Container 7335 9 Not Given Tissue DRIED HEART BLOOD 002 Hemogenate Container Not Given Not Given Tissue BLOOD sampie voiumesiweights are approximations. Specimens received on 0210112019. NMS ?18.0 CONFIDENTEAL Workorder 19031238 MS Chain 19031238 7 Patient lD 19?0151 Page 2 of 3 Detailed Findings: Rpt. Analysis and Comments Resutt Units Limit Specimen Source Analysis By Speciai Request Finding(s) None Detected I 002 - Tissue [Depending on request] 'Memantine? None Detected Reporting Limit 4.0 ngig Anaiysis by Liquid Chromatography Tandem Mass Spectrometry Special Request Finding(s) None Detected 002 - "lissue {Depending on - request] Donepezil None Detected Reporting Limit 4.0 ng/g Analysis by Liquid Chromatography Tandem Mass Spectrometry Other than the above ?ndings, examination of the speciments) submitted did not reveat any positive ?ndings of toxicotogicalsigni?cance by procedures outlined in the accompanying Analysis Summary. Sample Comments: 001 Tissue specimen required homogenization: 190312384301 002 NMS Labs generated homogenized Tissue sample: 19031 238-002 002 Select testing may have been performed at: 200 Welsh Road, Horsham, PA 19044?2298 Chain of custody documentation has been maintained for the analyses performed by Labs. Unless alternate arrangements are made by you, the remainder of the submitted specimens will be discarded six (6) weeks from the date of this report and generated data will be discarded five (5) years from the date the anatyses were performed. 19031238 was electronically- signed on 0212612019 12:09 by: Daniel S. Phil, Forensic Toxicologist Analysis Summary and Reporting Limits: All of the following tests were?performect for this case. For each test, the compounds listed were included in the scope. The Reporting Limit listed for each compound represents the lowest concentration of the compound that will be reported as being positive; it the compound is listed as None Detected, it is not present above the Reporting Limit. Please refer to the Positive Findings section of the report for these compounds that were identi?ed as being present. Aoode 419511 - Sertraiine and Tissue - Tissue Analysis by High Performance Liquid Chromatography! Tandem Mass Spectrometry (LC-MSIMS) for: 480 Sertraiine 200 ng/g Acacia Special Request: Mementine in ?tissue Tissue -Analysis by [Depending on request]. for: Slammed BeLLimit Emmott 3mm Special Request Findings) NIA NMS 118.0