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checked to see who his primary care nurse had been. It was Kristen Gilbert.
    â€œIt was weird because there wasn’t any real reason for him to have died. He wasn’t sick particularly,” a nurse later recalled. “It didn’t dawn on me that night, but years later, after I got to thinking about it, I know Kristen had something to do with it. She was the only nurse around.”

    Later that same year, a VAMC staff physician, while studying the charts of several of his patients who had died during the night-shift hours, realized that RN Gilbert’s name kept showing up repeatedly for a majority of the deaths. By itself, it wouldn’t have been alarming. But Gilbert was generally alone with the patients at the time of their deaths, and, more important, most of them were making good progress and weren’t expected to die.
    One morning, after finding out that another one of his patients had died while under Gilbert’s watch the previous night, the doctor went in to see Melodie Turner, Gilbert’s nursing manager.
    He told her he didn’t want Gilbert taking care of any more of his patients.
    Although no disciplinary action was ever taken, word leaked that the doctor had said something about Gilbert. Shortly after the meeting with Turner, the nursing staff began to shun the doctor.
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    As the coincidences mounted and rumors swirled, Gilbert became known as the “angel of death.” But it was a joke. No one took it seriously. The nurses teased her about the unfortunate luck and Gilbert lapped up the attention.
    Yet, by the winter of 1991, a clerical worker at the VAMC, who was partly in charge of going through patient death records to insure their integrity, noticed a red flag while she was signing off on some of the previous years’ deaths. There it was in black and white: Gilbert’s name as the sole nurse who had found a majority of the patients on Ward C either in cardiac arrest or dead.
    In fact, between 1990 and 1991, on Gilbert’s shift alone, there were thirty-one deaths—more than triple the amount found on any other shift. Even more startling was that of those thirty-one deaths, Gilbert had found twenty-two herself. The next closest nurse had found only five. Which meant Gilbert was on duty and found approximately seventy-five percent of the deaths on her ward.
    These were shocking numbers, by any account.
    Upon a further look, the numbers of codes were even more staggering. Out of roughly forty codes called on Ward C between 1990 and 1991, Gilbert had found half of them: twenty, in fact. In 1990 alone, she had found thirteen, while her eight colleagues, combined, had found only five. Many of the nurses later admitted that throughout their entire tenures as nurses—some as long as twenty years—they had never even called a code, let alone seen them called on an average of one per week.
    A statistician later concluded that the possibility of it being a coincidence that Gilbert had found and called that many codes was one in a million. There was just no way a nurse could have that much bad luck.
    The perceptive VA worker, not sure of what to think, brought her findings to the attention of her supervisor.
    â€œWhat are you accusing this nurse of?” her supervisor asked.
    â€œNothing,” she said. “I’m just pointing out the fact that this nurse’s name is on a majority of these deaths and codes. I’m not saying she did anything. . . .”
    The supervisor told her to go back to doing her job and stop making false accusations against people.
    Years later, when investigators caught up with the supervisor, she couldn’t recall that the conversation had ever taken place.

CHAPTER 5
    In December 1990, as gossip continued to center around her unfortunate luck with patients, a pregnant Kristen Gilbert took maternity leave to give birth to her first child.
    After having a boy, Brian , she returned to work in February 1991.