Bill Nutter was very sick. Not only had he just lost his second leg to diabetes, but he also suffered from a condition that could cause his heart to stop beating without warning.
But his daughter, Brigitte Darton, felt reassured because her mother had found a bed for the ailing Vietnam veteran and retired police detective at the Bedford VA Medical Center. He would be under the watchful eyes of the staff at a hospital ranked by the Veterans Administration as one of its best nationwide.
So Darton went on a long-planned family vacation in July 2016, only to get a shocking call from her mother the next day. “Your father passed away,” Carol Nutter said. “He didn’t wake up.”
A doctor eventually told Carol Nutter that a staff member on the night shift had failed to check on him hourly, as she should have.
But that was not the full story: The aide, Patricia Waible, eventually admitted that she was playing video games on her computer and didn’t check on Nutter at all, according to someone with firsthand knowledge. And when a nurse discovered Nutter dead the next morning, the hospital’s internal report shows she announced it to her boss with a crude gesture signifying a slit throat.
Now, the VA inspector general has launched a criminal investigation, working with the US attorney’s office and the FBI to identify systemic failings that may have led to Nutter’s death.
And after the Globe contacted Veterans Affairs Secretary David Shulkin’s office about the case on Sept. 22, the agency suspended Waible with pay from her job in the cafeteria where she had been transferred after Nutter’s death. The secretary’s office plans to seek her permanent removal.
But Brigitte Darton can’t understand why it took the hospital so long to take action — and why she discovered what happened to her father from a journalist.
“I hold the VA responsible for all of this. They’re responsible for their employees,” said Darton. “How many other people did this lady cause issues with?”
Waible has not returned multiple text messages and phone calls from the Globe.
The revelations about Bill Nutter’s poor care threaten to open a Pandora’s box of problems for the Bedford VA Medical Center. Although the hospital has received the highest possible five-star rating from the VA, the Globe reported last month that several employees have come forward to raise serious patient-safety concerns.
Whistle-blowers and families of veterans have claimed that relatively healthy patients deteriorate within months after being admitted to the Bedford VA. Others say that veterans living in long-term care buildings on the campus sometimes go without food for many hours, or they’re left in soiled clothes or bed linens. And buildings are laced with asbestos, a Bedford electrician charges, exposing everyone to the cancer-causing material.
In written responses to some of the whistle-blowers’ complaints and other outside reviews, the Bedford VA leaders acknowledged some of the problems but said they are working to improve conditions, where improvement is warranted. Bedford VA spokeswoman Maureen Heard declined to comment on Nutter’s care.
Shulkin has already demonstrated that he’s willing to take tough action if he believes veterans are not getting high quality care. Within 24 hours of a Spotlight report this summer detailing serious problems at the Manchester, N.H., veterans hospital, Shulkin dismissed the top two administrators.
“Secretary Shulkin has made clear that VA will hold employees accountable when the facts demonstrate that they have failed to live up to the high standards taxpayers expect from us,” said a statement from Shulkin’s spokesman, Curtis Cashour, in late September, citing Waible’s suspension as proof.
In Vietnam, Nutter was a door gunner, shooting at the enemy from the open door of a helicopter. On the ground, Agent Orange, a highly toxic herbicide used to strip foliage from the trees to make it harder for the enemy to hide, poured down like rain, his wife said, and he and his fellow soldiers would seek protection under a tarp. Even then, they feared the chemical was dangerous.
When he returned to the United States in 1969 he was greeted by jeers from anti-war protesters and was so traumatized he would sleep with his arm poised as if he were holding a gun. “He’d literally shake and I’d hold him.” said his wife. “During his last year, he started getting the flashbacks back.”
He channeled his anguish into hard work and enrolled at Northeastern, where he received a degree in criminology and made the dean’s list. He worked as a detective and photographer at the Concord Police Department and started an investigation business on the side.
But after 20 years, the effects of his Agent Orange poisoning surfaced and his health began to deteriorate. He got diabetes, a condition the VA presumes was caused by his exposure to the herbicide. The diabetes, in turn, badly damaged Nutter’s kidneys and forced the amputation of one leg years ago and the second leg in 2016 at the West Roxbury VA. He also suffered severe respiratory problems, which his doctors also attributed to Agent Orange.
But when he was finally stabilized and sent to the Bedford VA in early June, his family thought he had turned a corner.
“He seemed fine, healthy,” said Brigitte Darton. He was just getting out of Lowell General Hospital after fighting off a severe case of pneumonia and his family thought the Bedford VA was the best place for him, in part because Darton was a civilian working with the Air Force and had just returned from a tour of Afghanistan.
“I was hoping the VA would give him the care that non-VA facilities didn’t,” said Darton, who was working nearby at the Hanscom Air Force base and could visit him daily for lunch. “My dad and I were very close.”
But Bill Nutter, 68, was a very vulnerable patient, in danger of cardiac arrest at any given moment due to an arrhythmia. He couldn’t get out of bed on his own, and his hands were so crippled with neuropathy as a result of his diabetes that it was almost impossible for him to press the call button if he was in trouble. Plus, his wife said, his voice was barely a whisper after the surgery, and his roommate was deaf. Even if he could have tried to summon help, no one would have heard him, she said.
His doctors agreed that someone should check on him at least once an hour.
A nurse beginning her morning shift on July 3, 2016, found Bill Nutter unresponsive in his bed, according to the hospital’s report. When she saw her supervisor, she slid her fingers across her throat, indicating he was dead, according to internal hospital reports. “Mr. N9041 is gone,” the nurse explained, using Nutter’s VA patient number.
Carol Nutter recalled that someone from the hospital called that day to tell her that her husband had died, giving her the impression that his heart stopped between one scheduled check and the next, and that his death could not have been prevented.
”They said he went into cardiac arrest and [they] couldn’t do anything about it,” recalled Carol Nutter.
However, a few days later, a doctor called and gave her a better idea of what had actually happened, though he wasn’t specific. Nutter said the doctor was repeating what a woman in the background was telling him.
The woman said “they weren’t doing their job, and if they had done what I told them to, he could have possibly been alive because I told them to check on him once or twice an hour,” Nutter quoted her as saying.
The official medical records described the conversation this way: “Condolences were offered to wife and she was informed that we were calling because we did not believe care was up to our standards.”
Carol Nutter said she heard the words, but didn’t fully grasp what she was being told. Though the report said she was informed of her right to file a “tort claim,” or a potential lawsuit, she insisted she was never given that information.
Bedford VA officials immediately reassigned Waible, who had failed to check on Nutter, while the nurse who made the “cut-throat” sign, still in her probationary period, was terminated. The Office of the Inspector General launched an investigation.
At first, Waible insisted she had made the required checks on Nutter, even initialing paperwork that purported to document her visits. But she eventually confessed when an OIG investigator told her the hospital’s cameras showed she never left her computer for her entire shift, according to someone with direct knowledge. None of these facts were shared with the Nutters, family members said.
Now, Nutter’s family has consulted a lawyer and is trying to figure out whether to take legal action against the VA, after all.
“My dad might not have lived another five months, who knows? But if we could have had another month with him — this lady took that away,” his daughter said.
On the evening before he died, Bill Nutter feasted on pasta and meatballs. The hospital had served him fish, but it sat on the plate for several hours while he was at dialysis. His wife ran out to Papa Gino’s to give him a meal he would enjoy.
“Poor Bill, I fought to keep him alive,” she said. “We were married for 47 years. I was always with him. He wanted me there. But I wasn’t able to watch over him at the end.”
“You want to hear something?” she asked. She played a message, which her husband left on her phone three days before he died.
“Hello. Hurry up. Get here. I need your help — now, bad. In a hurry. Please, please, please. Thank you.”Andrea Estes can be reached at firstname.lastname@example.org.