So SA Plante burrowed his way to records department in the basement of the VAMC and began digging through the thousands of medical files, looking for Thomas Callahan’s case history. He knew that each VA hospital had a separate EKG department where a patient’s entire EKG history was stored. All he had to do was look up January 22 to see what Wall was referring to.
When Plante located Callahan’s file, his EKG for January 22—the day he had coded—was missing.
CHAPTER 34
The biggest worry John Wall, Kathy Rix and Renee Walsh faced right away was the VAMC’s own security office. Timothy O’Donnell and his crew were involved from day one, and Rix, Walsh and Wall worried themselves sick that Gilbert would somehow find out what they had been saying. With Gilbert practically living with Perrault, there was a strong possibility he was acting as her mole. Whatever he learned at work, they assumed, he was likely taking home and sharing with Gilbert.
Little did they know at the time how right they were.
“Keep your eyes and ears open,” Gilbert told Perrault one night in early March. “Report back to me anything important you hear. Make sure you find out who the investigators are talking to and how long those interviews are.”
Perrault, of course, obliged.
David Levin, the head of the VAMC’s Quality Management Department, had requested a meeting with Wall, Rix and Walsh a day or so after they had met with Melodie Turner. Chief O’Donnell said he wanted to meet with them, too, separately, and tape-record each interview.
They refused. Either they met as a group, or forget it. And no one was going to tape-record anything.
On March 1, Dell Levy sat down with Walsh and wanted to know what her main concerns were.
For about an hour, Walsh told Levy exactly what she had told Melodie Turner a few weeks back, but went into more detail where specific patients were concerned.
The HCI was designed to keep track of patient care and make sure VA patients were receiving proper care from medical personnel employed by the VA. But Walsh didn’t know this. She thought she was talking to a criminal investigator.
As Levy continued asking questions, Walsh became irritated, feeling that Levy wasn’t the person Walsh thought she was. Levy’s questions were geared more toward whether the nurses had been following proper procedures and giving out medications correctly.
“When,” Walsh asked, interrupting Levy, “are we going to get around to talking about what I’m really concerned about?”
“Well, Ms. Walsh, what is it that you’re so worried about?”
“The reason why I wanted to talk to somebody in the first place was because I’m worried that this nurse I work with . . . Kristen Gilbert . . . I think she may be killing people. I’m worried, Miss Levy, that something is happening . . . our cardiac arrest rate is out of sight.”
“Maybe, Ms. Walsh, we should have you talk to somebody else. That’s not really my field.”
After three days on the scene, Levy was summoned back to Washington to report to her superiors what she had learned. After telling her boss upon returning that she needed more time and the assistance of another healthcare inspector, Levy’s boss sent her back to Northampton with colleagues Rayda Nadal and Irene Trowell-Harris. A day or so after they arrived, on March 5, Sandra Willis, yet another HCI inspector, joined them.
At first, Levy thought they would be there only another two or three days. But as they began to conduct interviews, it became clear they needed more time.
Meanwhile, SA Plante began to throw around his authority.
“Any interview you conduct,” he told Levy upon her return, “from now on, I want to be there.”
Because he was a criminal investigator, SA Plante had jurisdiction over everyone. Anyone in the VAMC, even the director of the hospital, had to answer to him. All it took was one phone call.
During the next week, a horrifying picture began to emerge from the wreckage of medical records and interviews SA Plante and inspectors Dell Levy, Rayda Nadal and Sandra Willis conducted. Levy didn’t see it at first, but Plante picked up on it immediately: Kristen Gilbert was running in circles trying to cover up one lie after the next.
During one interview with Nadal and Levy, Gilbert denied even being involved in the care of many of the patients in question. She said her name was on the code notes only because she had been summoned to the codes by other nurses and nursing assistants—and because she was more experienced in code situations and had a reputation for being a “conscientious” code nurse, the nurses had asked her to document the codes, which she said she gladly did.
But as the nurses filed in and told their stories, not one said he or she had sought Gilbert out during codes because of her “supposed” talents. Furthermore, many of the nurses said that even if they had wanted to, there were many times where Gilbert couldn’t be found, because she was always off somewhere smooching it up with Perrault. Besides, it was Gilbert who had been calling most of the codes in the first place.
Already armed with testimony from several of Gilbert’s colleagues who had admitted to knowing exactly where ampoules of 1:1000 strength epinephrine had been kept on the ward, SA Plante, after being briefed by the HCI inspectors, asked Gilbert during one interview if she had ever used the drug in her career at the VAMC.
“I didn’t even know they had it in the hospital,” Gilbert said.
CHAPTER 35
Like many of the nurses on Ward C, Lisa Baronas had developed her own suspicions about Gilbert. In her late twenties, Baronas had been a nursing assistant at the VAMC for years. She liked her job. It was satisfying, and she felt as if she was making a difference in the lives of those patients she had touched. Her coworkers considered her a “hard worker” and “very dependable.”
While Baronas was working one day in March, to her surprise, she looked up from what she was doing and spied Gilbert standing by the elevators. Gilbert didn’t know it then, but Baronas had just come from an interview with HCI inspector Dell Levy.
“What are you doing here?” Baronas asked.
“I’m going for an interview with the investigators. Listen, Lisa. They’re probably going to ask you about Ed Skwira,” Gilbert said. “Now, you remember being in the room with me when he coded, don’t you, Lisa?”
“No. I wasn’t, Kristen.”
“Don’t you remember? You were in the room with me at the time,” Gilbert insisted.
“No, Kristen. I wasn’t!”
Gilbert then walked into the elevator without saying anything more as Baronas, amazed by what she had just heard, went back to work.
The day after Gilbert had approached Baronas, SA Plante called Baronas in for a second interview. He now wanted her version of Ed Skwira’s code.
Baronas didn’t think she had much to offer.
“I wasn’t even there,” she said. Yes, she had helped Gilbert transport Skwira to Radiology. Yes, she then helped Gilbert transport him back to his room. “But I plugged in his blood pressure machine, locked the wheels on his stretcher, and left.”
“I would have remembered if I was there when somebody coded,” Baronas later recalled.
When SA Plante realized Gilbert had lied to him, he first wondered what she was trying to hide. People, Plante knew, wouldn’t generally lie unless there was a payoff. But at the same time, he worked hard to maintain an impartial perspective. Baronas, he thought, could be stretching the truth as well. He had to make sure there wasn’t an obvious solution for all the codes, medical emergencies and deaths, maybe something in the ventilation system, a healthcare issue, or malpractice. For all Plante knew, some of the nurses could have been handing out the wrong medications and trying to cover their tracks.
So he began looking into things even deeper.
Still wearing a sling and bandage from the injuries she had supposedly sustained on February 17, Gilbert began calling and e-mailing anyone and everyone she used to work with to see what she could find out about the investigation.
“What are t
hey asking you?” was one of her favorite questions. Along with, “Who else is being interviewed? Tell me what you know.”
Around the same time, she also began keeping a detailed notebook on the progress of the investigation. Her first entry, dated the “end of February,” indicated that the two inspectors from HCI who had interviewed her had asked questions “mostly about policy and procedure.”
Her notes regarding her second interview a few days later were more detailed, however. The same two investigators were asking questions, she noted, along with SA Plante, about the bomb scare back in 1993 and several fires that had occurred throughout the years on Ward C. Between March 10, 1990, and May 6, 1993, there had been eleven fires on Ward C, and Gilbert was on duty for eight of them—even though her shift had changed several times during that same period.
After looking further, Plante found out that Gilbert had found eight of the fires herself and even extinguished a few of them. In one instance, she had even received an award for putting out a fire that had gutted an entire bathroom. Plante, along with many nurses, speculated it was Gilbert who had started the fires in the first place.
Why?
So she could extinguish them and be the hero.
Next to her notes about the fires and bomb scare, Gilbert wrote that Plante had asked her if she had a “theory” about the recent rash of codes and deaths; then he told her that “125 epinephrines [ampoules] were missing”; asked her to “review [the code] note in Skwira’s chart,” explaining in detail the “sequence of events”; and, finally, she wrote that Plante had asked her to take a polygraph test, which she refused.
During that same interview, Plante revealed to Gilbert perhaps his most compelling piece of evidence to date. Regarding the sequence of events surrounding Ed Skwira’s death, Gilbert’s notes indicated that Plante posed a hypothetical question at one point during the interview: “What if I were to say that I have somebody who counted the [EPI ampoules] before you came on duty . . . ?” Plante then acknowledged there had been “three ampoules.” And when “this person” checked the medicine cabinet, “this person” saw that they went missing, but then later spotted the broken ampoules in the needle-disposal bucket.
Gilbert didn’t write any conclusion to SA Plante’s query. Instead, her notes about that part of the interview ended abruptly.
On another page, under the heading, “What other people have told me was asked,” Gilbert kept a list of the nurses she had spoken to and the information they had given her. Under the title “Lori” [Naumowitz], for example, Gilbert noted that Lori “said somebody saw pills in my coat pocket . . .” Then she wrote “who was angry at me,” regarding her divorce. Ending Lori’s heading, Gilbert wrote that Melodie Turner had asked Lori if she and Gilbert were still friends. When Lori said she was, Turner, according to Gilbert’s recollection, then told Lori to “rethink that—you wouldn’t want to go down with a sinking ship.”
Under the heading “David [Rejniak],” Gilbert listed the same items as she had for Lori, except it was obvious that Rejniak had been a little bit more open with Gilbert about what he had discussed with SAs Plante and Levy. Rejniak, according to Gilbert, said “the investigators tried very hard to convince him that [she] was capable of wrongdoing in order [to] illicit [sic] info from him.” Rejniak also told Gilbert that he felt the investigators “had convinced other people” of the same thing.
If Gilbert had been keeping a tally of the people she could and could not trust, the last page of her notes sprang to life with two nurses Gilbert hadn’t really paid any attention to throughout the seven years she had worked at the VAMC: Carole Osman and Ann French.
At the time, French, who was nicknamed “Yosemite Ann,” in her late fifties, was a member of the NRA whose one highlight in life was hunting. It was odd that Gilbert and French had anything in common. Plus, many of the nurses said she had no love for Gilbert whatsoever.
Under the heading “Carole,” Gilbert noted that Osman had “refused to answer personal questions,” and that the investigators had asked her to “speculate” and “theorize.”
Ann French, who had already warned SA Plante that if he wanted to speak with her about anything, it had better not affect the upcoming hunting season, Gilbert wrote, “refused to take a polygraph.”
It was clear Kristen Gilbert was keeping a scorecard. The mistake she was making, possibly without even realizing it, was that she was helping Plante document a potential murder case against her, effectively giving away her entire game plan.
When Renee Walsh finally heard about the broken and missing ampoules of epinephrine Kathy Rix had discovered, she felt a bit disappointed that Rix hadn’t shared the information with her sooner. Walsh didn’t even think that Gilbert might have been using epinephrine. She had always assumed it was potassium, as she had told SA Plante. Yet now that she knew, it made more sense why so many of the patients in question had screamed out in pain right before their codes. Epinephrine, when injected in the arm, is extremely painful. It burns. The area around the shot goes numb. The heart races. Blood pressure skyrockets.
By March 5, it was clear that the focus of the investigation was now centered on Gilbert and dozens of missing ampoules of epinephrine. In fact, as the second week of March approached, most of the questions now being asked were straight to that point: “What type of drug do you think [Gilbert] used? How does epinephrine come [packaged] on to the ward? Where is it stocked? The IV push [bristo-jet], is that the only way [the drug] comes?”
When Walsh heard this question, she immediately said no.
“It also comes in a much smaller concentrated version [1:1000]. But I’ve never given it here.”
“You’ve never given it?” SA Plante asked.
“No.”
“Let me ask you this: What would happen if you gave it to someone in an IV?”
“Nothing good, I would imagine.”
“You’ve never known anyone to give it in an IV?”
“No.”
“Is it available on Ward C?”
“I’ve never had to go and look for it, so I really don’t know,” Walsh said.
SA Plante kept asking if Walsh had ever—think hard, think really, really hard—given it to anyone at anytime. But Walsh kept insisting that she hadn’t.
“I have never even seen an order for it.”
SA Plante got up from his seat and extended his hand.
“Ms. Walsh, you’ve been a big help to us. I’ll be in touch.”
When Plante closed the door and thought about the interview, a sigh of relief washed over him. Walsh had stood up to his grilling and kept her ground. She was certain about what she had seen. She hadn’t been intimidated. That meant only one thing to Plante: She was telling the truth.
Things were beginning to point in one direction—a direction, SA Plante would soon learn, the boys in Washington wouldn’t be too happy about once they found out.
CHAPTER 36
At about 8:00 P.M. on March 6, after attending a Lenten service at her local church, Renee Walsh opened the door to her apartment to the sound of a ringing telephone. Without even turning on the lights or taking off her coat, she picked up the receiver.
“Hi, Renee. It’s Kristen.”
Walsh was breathless. She hadn’t seen nor heard from Gilbert since before she had turned her in.
Act normal . . . act normal, she told herself. Just take it easy and see what she wants.
“Kristen? Oh, you caught me off guard . . . I just got home.”
Gilbert didn’t waste any time.
“What did they talk to you about? What do they want to know?”
What can I say that will sound right?
With her mind racing, Walsh said, as calmly as she could, “Well . . . they are asking a lot of questions regarding policy and procedure. They wanted to know about certain drugs we use during codes.”
As Walsh said this, she turned on the light and took a piece of paper out of the drawer and began jotting down what Gilber
t was saying.
“There’s been an increase of codes, Kristen,” Walsh said when Gilbert fell silent. “And they felt the need to look into it.”
“They talked to you for three hours about that?”
“How do you know they had me in there for three hours?”
“Carole [Osman] told me.”
Walsh remembered seeing Osman on the ward as she got called down to talk to SA Plante. She made a mental note: Tell Kathy and John to stay the hell away from Carole Osman.
“Well, Kristen, I don’t know what else to say,” Walsh said.
Gilbert’s tone became more aggressive. She spoke fast.
“I have to tell you this makes me paranoid as hell, Renee. If they start looking at the records, my name is all over seventy-five percent of the deaths.”
“There are a lot of other names are on those charts, Kristen. It’s not just yours.”
“I wonder why they feel they have to investigate this now.”
“I have no idea.”
“You don’t think that the family of one of the patients [who] died filed a wrongful death suit, do you?”
“I haven’t heard anything like that, Kristen.”
“You know how everyone always jokes and teases me about being the angel of death and always being there when someone has a cardiac arrest? You don’t think anyone would be stupid enough to say something like that to the inspectors, do you?”
“No, no, no,” Walsh said. “None of the questions have [lent] themselves to that. That’s not what they talked to me about, anyway.”
Gilbert wouldn’t let up.
“What did they ask you about then . . . for three hours?”
“Just a broad range of things. You know, Kristen, they wanted to know how well we’re staffed. How things work on the ward. Stuff like that.”
“But why? Why do they want to know this?”
“There’s been an increase in the number of deaths lately, Kristen. That’s no secret.”
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