Edward Skwira was 68 when he was admitted to the Veterans Affairs Medical Center in Northampton, Massachusetts, for treatment of chronic alcoholism on February 15, 1996. Three days later, on February 18, he died; his death certificate listed dissecting aneurysm, inferior wall myocardial infarction, and arrhythmia as immediate causes, and his death was initially considered natural.

Staff were already concerned about an unusual number of patient deaths on the ward. When Skwira’s heart stopped on February 15, nurse Kristen Gilbert was the only nurse on duty in the ICU and he was her sole patient. A nurse had noticed three ampules of the heart stimulant epinephrine in the medicine cabinet before the arrest; after the event the vials were missing, and there was no record that the drug had been administered to Skwira. That and other incidents prompted a federal investigation.

Investigators exhumed Skwira’s body in October 1996; autopsy and toxicology tests found a lethal dose of epinephrine and the unexplained presence of ketamine. In March 2001 a federal jury convicted Kristen Gilbert of the first-degree murder of Edward Skwira and others; she received life without parole. Did anyone on the ward at the time notice other unusual medication discrepancies or patient reactions?