As the others went out to get some coffee, or just take a break from the emotion of being in Skwira’s room, Phillip watched as his father forced himself up in bed, looked straight up at the ceiling, and said, “I don’t want to die,” before falling back into bed, as if he had just taken his last breath.
Skwira had suffered a tremendous amount of pain the entire day. He would sit up, lie down, and move around. No matter what he did, he just couldn’t seem to get comfortable. And the hallucinations continued.
“He was agitated,” Phillip recalled later. “He was in a lot of agony . . . a lot of pain.”
Two days later, on February 18, 1996, Edward Skwira died early in the morning, shortly before his family, who were planning on visiting him, had a chance to make it to the hospital.
A year later, toxicology tests determined that Ed Skwira’s system was loaded with the drug ketamine. Ketamine is an anesthetic used therapeutically for children and adult asthma patients. On the street, it’s commonly referred to as “Special K,” and kids take it mainly for its hallucinatory side effects. Given to someone improperly, ketamine can cause hallucinations, which Skwira clearly suffered from during his final days.
More of a concern to investigators, however, was that the VAMC had never purchased or stocked ketamine, and not a single doctor or nurse—from AdCare, in Worcester, where Skwira had been detoxed, to Baystate—had prescribed or authorized the drug.
CHAPTER 32
With all that had happened at the VAMC the past seven months, Kristen Gilbert would have to step up to the plate sooner or later and explain herself—because Renee Walsh, Kathy Rix and John Wall were en route to a meeting with Melodie Turner and there wasn’t anything Gilbert could do to stop it.
Melodie Turner insisted the meeting take place in the office of her boss, Priscilla McDonald. Tucked away in the back of Building Two, McDonald’s office was off the beaten path. It being a Saturday, the hospital was deserted anyway. There was a good chance no one would see them entering or leaving the building.
With Renee Walsh off, Wall and Rix were scheduled to work later that day, as was Gilbert.
It was about one P.M. when the meeting began.
“Would one of you like to start?” Turner asked as she closed the door.
With that, the accusations began.
All three nurses laid out their concerns where the frequency of medical emergencies and percentage of cardiac arrests occurring on Ward C and its ICU were concerned—and that most of the cardiac arrests happened more often when Gilbert was the patient’s primary nurse, when she was alone with a patient in ICU, or when she relieved another nurse for dinner or break.
Turner looked as if someone had drained the blood from her body and replaced it with milk.
“We want to emphasize, Melodie, that none of us has any proof,” Walsh wanted to make clear.
Rix and Wall nodded.
“None of us have witnessed her doing anything,” Walsh added, “. . . but, nevertheless, we’re worried.”
“Read [Angelo] Vella’s code note,” Wall spit out.
Turner made a note.
“There have been more codes on the ward than I have ever seen in my career,” Rix said.
“We request that a study be done as soon as possible,” Walsh urged. “We want someone to look at the percentage of cardiac arrests occurring on the ward when Kristen was on, as opposed to any other nurse.”
They waited for Turner to respond, but she didn’t have much to say. There was no doubt she was concerned, as they had figured she would be. And Walsh could tell by looking at her face that she knew they were serious.
“I will take this information directly to my superiors,” Turner said. “But we want to keep Kristen away from the patients as much as possible.”
They agreed. But the question was, how?
For the next few minutes, they devised a plan whereby John Wall would try to convince Gilbert to be the charge nurse when she showed up for work. Being charge nurse would strap Gilbert down to the nurse’s station. If she wasn’t sitting, doing paperwork and going through patient files, she would be answering phones and ordering supplies. If by some chance she decided to go roaming around the ward, John said he would tail her.
It was the perfect plan. All they had to do was get Gilbert to agree to it.
“I’ll take care of staffing on the ward,” Turner said. “John, you go to the ward, and I want Kristen to be off . . . we’re going to get her off duty.” In Turner’s mind, she wasn’t going to allow Gilbert, who was scheduled to come in at four, to work at all.
Before the meeting was over, Turner had one more suggestion.
“Go out and get attorneys for yourselves.”
After Wall, Rix and Walsh left the meeting, Turner picked up the phone and called Ward C. It was shortly after four o’clock.
As fate would have it, Gilbert answered.
“Kristen, when John comes in, the two of you can work it out, but one of you can take the night off.”
This must have tipped Gilbert off that something was going on because Turner had just scolded Gilbert a few days before for taking Saturdays off, and here she was now offering her the night off on a silver platter. It was totally out of character for Turner.
“Okay,” Gilbert said, and hung up.
For the next hour or so, Turner wondered how she was going to get Gilbert off the ward.
When Wall finally ran into Gilbert at about 4:30, he just flat out asked her if she wanted to be the charge nurse for the night.
“No!”
Wall asked again.
“No!” Gilbert said. “I want to be Team Leader.”
This meant she would be in charge of handing out meds—the last thing Wall wanted to hear.
As Gilbert worked her way around the ward, handing out meds, Wall made sure to be right around the corner from wherever she was. He felt responsible for the well-being of her patients. He had been having nightmares for weeks now. There had been enough death in the past several months on Ward C to last a lifetime.
No more.
But as he stealthily made his way in Gilbert’s shadow, Wall felt she knew what he was up to.
Meanwhile, Turner was in her office stewing over the fact that a serial killer could be wandering through her ward at that very moment and there wasn’t a damn thing she could do about it.
No sooner had Turner thought about calling another RN in to cover for Gilbert, than the evening coordinator called her office to say that Gilbert had just gotten injured.
Injured?
Shortly before 6:30, Gilbert had walked into Joseph Gallante’s room to give him his nightly injection of medicine. Within a few moments of being in the room, crying hysterically, Gilbert came running out.
“John,” she said holding her arm, “look what happened.”
Wall came around the corner, and Gilbert came up to him. She claimed that Gallante, all of about five-foot-six, one hundred and forty pounds, had, like a bully on a schoolyard playground, “grabbed her right arm, rotated it inward, and twisted it up behind her back.” When that happened, Gilbert claimed, not only did she hear something in her shoulder pop and a separation occur, but she said the needle she was holding had pricked “the lower thumb area of her right palm.”
Although it seemed all too perfect, Wall wasn’t going to argue with her.
Next, Wall had her fill out an accident report. While she was doing that, Karen Abderhalden called Perrault at home and told him what had just happened.
“I’ll be right there,” Perrault said.
During the ride home, Gilbert explained to Perrault how she had awakened Gallante to give him his medication, but must have startled him somehow. Already in a sling, Gilbert went on and on about how violent he had become.
After he was sure Gilbert had left the building, Wall went into Gallante’s room to see if he could find out what happened.
Wall was overwhelmed, he later said, to see the seventy- two-year-old Gallante
“lying on his back, supinely, in soft restraints.” Gallante was an Alzheimer’s patient who had suffered from dementia for years. Many of the nurses who had cared for him described him later as a “very docile individual who did not have a history of violence.” No one could believe he could overpower Gilbert.
As time went on, the nurses put it all together.
Gilbert was famous for putting on grotesque contortionist displays in front of the nurses as they stood around during coffee break. Even James Perrault would later explain how he had seen her do it a number of times just for the fun of it, or, as he recalled, “like Mel Gibson in the movie Lethal Weapon.”
Obviously double-jointed, Gilbert would pop her arm out of its socket at the shoulder and let it hang until someone told her to put it back in. She would laugh about it. It was a joke.
As her story unfurled during the coming days, Gilbert claimed to have sustained the needle prick in her right palm during the altercation she’d had with Gallante. But because Gilbert was right-handed, many would later find this difficult to believe, since she claimed Gallante grabbed her right arm and twisted it behind her back.
The more pressing question of the moment, however, was: Who had tipped Gilbert off someone was on to her? And now that she’d been fingered, what would she do next?
Within the next few days, special agents from the Washington and Boston Veterans Affairs’ Inspector General Offices converged like paratroopers down on Northampton and began to unravel what had been going on inside Ward C for the past seven years.
PART TWO
Fire-brand (fir’brand’) n. 1 : a piece of burning wood; 2 : a person who creates unrest or strife: AGITATOR
—The New Merriam-Webster Dictionary
In every life, joy flashes gay and radiant across the sorrows of all sorts of which the web of our life is woven....
—Nikolai Gogol, Dead Souls
CHAPTER 33
When John Wall, Kathy Rix and Renee Walsh, nurses with more than fifty years of cumulative experience, met with their nursing manager on February 17, 1996, and voiced their concerns regarding the possibility of a colleague’s harming patients, they had no idea they had cast a stone into a pond that, they would soon learn, seemed to have no bottom.
The ripple effect created by that stone, however, was just now being felt by anyone who had ever come in contact with twenty-nine-year-old Kristen Gilbert. Word had hit Ward C like a pinball, ricocheting off anyone who had ever worked with Gilbert throughout the years. Gilbert was being investigated for murder, people were whispering.
Yes . . . murder!
Not a series of accidents or mercy killings, but cold-blooded murder. Kathy Rix had found broken ampoules of epinephrine. The rash of codes and medical emergencies. Gilbert’s affair with James Perrault. Glenn Gilbert’s being sick back in November.
It was all adding up.
But Gilbert took to the offensive right away, beginning a phone campaign to proclaim her innocence: There were people—nurses! —she pleaded during one phone call after the other, out to frame her. They were upset, she repeated to anyone who would listen, because she had cheated on Glenn with James Perrault. Gilbert’s only problem, however, was that her plea of innocence was drowned out by one lie after the next.
It started with the injury she said had been sustained on February 17. She changed her story three times. Mr. Gallante, Gilbert had first claimed, had “grabbed her arm, tugged it, and then twisted it.” Then, a few days later, she told someone else he “grabbed her wrist, forced it behind her back until it touched the back of her neck.” Her most bizarre claim came later, when she said that Gallante had “. . . flung her across the room.”
The initial report detailed the needle stick in her right palm; and then later, in an official report to the Labor Board, Gilbert wrote that it happened in her left palm.
James Perrault’s boss, Timothy O’Donnell, the VAMC Chief of Security, wasn’t going to waste any time. There needed to be some type of criminal investigator on the scene—and fast. Things were spiraling out of control. Accusations and rumors were flying around like buzzards, tainting the integrity of potential witnesses.
O’Donnell wanted order.
Several agents from the quality-control side of the VA’s Inspector General’s Office (IGO), in Washington, DC, were already en route to the VAMC, based on information O’Donnell had received concerning the meeting Melodie Turner had had with Wall, Rix and Walsh. O’Donnell placed a call to the VA’s Bedford, Massachusetts, IGO early in the morning on February 29, 1996.
Special Agent Steve Plante, after being briefed about the call, phoned O’Donnell right away.
“Listen,” O’Donnell said, “there are several agents coming in from Washington to investigate a recent rash of medical emergencies and deaths up here at the Leeds Medical Center. They’re having a meeting later on today. You might want to be here.”
“I’m on my way,” SA Plante said.
The VA-IGO was broken down into several groups, each with its own set of responsibilities. The Criminal Investigations Division (CID), for example, investigated fraud, waste, criminal conduct and abuse within its own agency, similar to that of the internal affairs division in any police department.
Thirty-nine years old, in perfect physical shape at five-five, one hundred and forty pounds, with a full shock of thick black hair and a flawlessly trimmed mustache to match, SA Plante had worked for the CID as a criminal investigator out of the IGO’s Bedford office for the past six years.
Living in Bedford with his wife and kids, Plante had normally been assigned cases in and around the eastern New England area: Providence, Rhode Island; West Haven, Connecticut; Worcester, Massachusetts. Northampton was a world away from Bedford. On top of that, he had broken his leg while on a skiing trip just weeks before and was sporting a full leg cast. The thought of dropping everything and going to Northampton might have never occurred to a less experienced agent. But O’Donnell’s phone call interested Plante. He had never investigated the type of case O’Donnell had described, and he wasn’t about to let his leg, or a massive Nor’easter snowstorm that had pummeled the region for the past few days, stop him.
After graduating from Dartmouth High School in the late seventies and spending four years in the Coast Guard, where he was bitten by the law enforcement bug while patrolling a two-hundred-mile stretch of water out in the wide-open Atlantic, boarding and searching boats from all over the world, Special Agent Steve Plante enrolled at Stonehill College, just outside Boston, in 1979. He was the first and only one of his siblings to attend college and, under the GI Bill, received a bachelor’s degree in criminal justice. Following a two-year stint in the INS from 1983 to 1985, Plante transferred to the Department of Agriculture’s IGO and spent the next four years learning how the feds investigated all sorts of crimes against the public.
In 1988, Plante entered the VA-CID and fell in love with the work. Soon his superiors noticed he had a meticulous knack for studying documents and records, and they started assigning him fiduciary cases, white-collar crimes: fraud and embezzlement.
It was obvious to SA Plante when he arrived at the VAMC that the nurses were reluctant to talk. Many were scared, he later said. “But the three main players”—Kathy Rix, John Wall and Renee Walsh—“all good people, definitely wanted to tell their story.”
Later that same day, Dell Levy, a ten-year healthcare inspector from the Washington, DC, Office of Healthcare Inspection (HCI), showed up. Separately, she interviewed Wall, Rix and Walsh. Seeing that SA Plante was already on the scene when she arrived, Levy knew her role: to make sure policy and procedure had been followed correctly by staff members, nothing else. It wasn’t the HCI’s job to conduct investigations. It was more interested, Levy later said, in the “overall running of the medical center” in the same way FDA inspectors kept tabs on the public food supply.
The first thing SA Plante did when he got there was gather together as many medical records of dead patients as
he could, secure a room to store them in, and get started going through them to see if something stood out right away. He was looking for clusters of deaths: several deaths on the same ward, signed off by the same nurse.
Plante’s next job was to develop a rapport with his three main sources, Wall, Rix and Walsh. He wanted them to know right away he was on their side and that they shouldn’t feel threatened in any way. Plante’s style wasn’t to bully witnesses. He wasn’t brassy and demanding. He just wanted to know the facts.
Meanwhile, Levy began to bring in VAMC personnel so she could ask the appropriate medical procedure questions. Kathy Rix, during her first interview, wouldn’t stop crying, Levy later recalled.
“Relax, Ms. Rix. It’s okay,” Levy reassured her. “You know, it’s okay to talk to me.”
But Rix continued to cry.
“I’m scared,” she whispered. “I’m scared.”
As the investigation progressed over the course of the first few days of March, Walsh, Rix and Wall began to grow increasingly impatient. SA Plante aside, the HCI inspectors, Walsh insisted, were more concerned with procedure and the overall behavior of the staff rather than looking into what the three of them were accusing Gilbert of.
They were confused and didn’t know the difference between the HCI and the VA-IGO’s Criminal Investigations Division, assuming HCI inspectors carried the same authority as SA Plante and his office.
But as Walsh and the others would soon find out, there was a big difference.
SA Plante was on to something from the get-go. From speaking with Rix and Wall, SA Plante and Dell Levy kept hearing the same name pop up: Thomas Callahan. John Wall, often uneasy and restless during his interviews, would say, “Check Callahan’s chart for January twenty-second. Please. Check it out!”
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