September 16, 2019 | Mark Paradies

VA Facility: Root Cause Analysis or Homicide Investigation?

RCA Investigation/Homicide Investigation at VA

The death of a retired vet has become a homicide investigation four months after he died at a VA Medical Center in West Virginia.

An unexplained death should trigger a root cause analysis. This should have caused the VA to look into the reasons why a non-diabetic patient would have a sudden and unexpected drop in blood sugar. A drop so large that he died. The goal of the RCA would be to implement or strengthen Safeguards to prevent a repeat incident.

Four months after the unexplained death, the vet’s body was exhumed and a federal medical examiner determined that the death was caused by an unauthorized and unnecessary injection of insulin into the patient’s abdomen.

The investigation has turned into an FBI homicide investigation.

This seems like an unusual turn of events.

But there’s MORE … 8, 9, or 10 More!

This isn’t the first of these suspicious deaths. What? Yes, there are more! How many more? Reports indicate that it could have been 8, 9, or 10 deaths by injection over a period of perhaps a year.

When should a trend in fatalities be noticed?

What would you do if you had a string of fatalities (homicides) at your facility?

When would the root cause analysis become a homicide investigation?

When would you put Safeguards in place to make sure the string of fatalities (homicides) stopped (even if you didn’t know the root cause)?

All good questions.

Do you think a thorough and credible root cause analysis on the very FIRST fatality (homicide) would have found the suspicious circumstances and prevented 7, 8 or 9 more homicides?

Does it indicate a problem with the VA’s root cause analysis if this many repeat fatalities are solved (and homicides identified) over such a long period of time?

Leave your comments below if you have ideas.

Learn Advanced Root Cause Analysis

If you wouk at a healthcare facility and want to learn thorough and credible root cause analysis to prevent Patient Safety Incidents, you should plan to attend the 2-Day TapRooT® Root Cause Analysis for Patient Safety Improvement Training at the Horseshoe Bay Resort near Austin, Texas, on March 9-10. See:

And also attend the 2020 Global TapRooT® Summit at the same location on March 11-13. See:

Current Events, Interviewing & Evidence Collection, Investigations, Patient Safety & Healthcare
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