Investigation of VA deaths creeping along

Death certificates might be changed to read ‘natural causes’ instead of ‘homicide.’
Thursday, August 14, 2003 | 12:00 a.m. CDT; updated 10:49 a.m. CDT, Thursday, July 17, 2008

Clifford Eubanks’ death certificate originally listed chronic obstructive pulmonary disease exacerbation as his cause of death in 1992.

Alfred Robbins’ said he died of metastatic lung cancer.

Franklin Selbe died of asystole, chronic renal insufficiency and congestive heart failure, according to the 1992 record.

And Carl Gilmore was said to have died from hypotension.

A decade later, on July 19, 2002, former Boone County Medical Examiner Jay Dix crossed out natural causes of death for those patients and six others from Truman Veterans Hospital, ruling they were homicides caused by “acute intoxication by succinylcholine” injected by an assailant.

Now, the science that led Dix to that conclusion has been undermined and former nurse Richard Williams, who was accused in the deaths, is out of jail and facing no charges. Because the investigation into the VA deaths has apparently come to a standstill, the death certificates might soon be changed back to indicate the original natural causes of death, said Eddie Adelstein, acting medical examiner for Boone County.

“I think we would be obligated to change that,” Adelstein said.

Charges against Williams were dropped Aug. 6 because of questions surrounding the succinylcholine testing — conducted by National Medical Services Laboratories — that led to his arrest. Absent that key evidence, the investigation is muddled by multiple theories. Though Boone County Prosecuting Attorney Kevin Crane said the investigation is ongoing, there appears to be little activity.

“If you’re envisioning a team of investigators poring over the country looking for new evidence, you’re just not going to find it,” Crane said.

The Veterans Affairs Office of the Inspector General is leading the investigation, Crane said. But Deputy Inspector General Dan Petroli won’t discuss the case.

“The investigation is ongoing,” Petroli said, adding it is VA policy not to discuss open investigations. Petroli declined to say whether the VA had anyone actively working on the case, saying only that “when a case is open, it has an agent assigned to it.”

Crane said he expects to be informed of any advancement in the facts or the science of the case.

Gordon Christensen, the former VA doctor who acted as whistle-blower in the case, said the FBI has been conducting the investigation since it began.

Jeff Landsa, spokesman for the FBI in Kansas City, said the FBI has an agent assigned to help the VA with the case, but he would not say how much time is being spent on the investigation.

“Whenever assistance is required, we provide it,” Landsa said. FBI agent Phil Williams, who has worked on the case, could not be reached for comment. FBI policy discourages agents from discussing open investigations.

Succinylcholine poisoning is not the first or only theory on what caused the deaths. In July 1997, National Medical Services named codeine poisoning as the cause of death for Elzie Havrum, another of the VA victims. The lab withdrew that statement two weeks later after learning from Havrum’s medical records that he was given codeine in the form of Tylenol 3, Christensen said.

Despite that retraction, U.S. District Judge Nanette Laughrey awarded Havrum’s family $450,000 in a 1998 wrongful-death suit against the VA and said in her ruling that she believed Williams killed the veteran with codeine. Christensen said codeine levels in tissue samples from Havrum’s body were too high for a normal dose of Tylenol 3.

Meanwhile, both Christensen and Adelstein have said injections of air into the veterans’ bloodstreams might also have caused the suspicious deaths. Extra air in the bloodstream would be “exceedingly difficult” to detect, Christensen said.

Christensen said it is also possible the patients were poisoned with excess amounts of drugs they were legally receiving, so foreign drugs wouldn’t be found in testing.

The uncertainty creates an awkward situation for Adelstein, who faces the possibility of having to change the death certificates to reflect natural causes even though he, the VA, the FBI and Crane still regard the deaths as highly suspicious. With little more than circumstantial and statistical evidence to go on, the investigation crawls along.

“The truth will set you free,” Adelstein said. “And now, we’re still looking for the truth.”

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