When a lifesaving drug — insulin — is used as a murder weapon, medical professionals are likely unprepared to consider that the difficult-to-detect medication was used to commit a crime, according to a forensic pathologist who worked on the recent case of a West Virginia pharmacist convicted of fatally dosing her husband.
Dr. Paul Uribe, a former military medical examiner who consults as a pathologist across the United States and helped solve a string of insulin murders at a West Virginia veterans hospital, told NBC News that there appear to be few protocols showing pathologists and emergency room doctors how to best handle the cases.
“You’re not going to stumble across an insulin homicide,” Uribe said. “You have to have a suspect and you have to look for it, because if you’re not looking for it, you’re not going to find it.”
For more on the West Virginia murder, tune in to “Devil’s in the Details” on “Dateline” on April 25 at 9 ET/8 CT tonight.
While such crimes are rare, Uribe said, some recent cases in the U.S. have had a staggering number of victims. In Pennsylvania, a nurse confessed to trying to kill 19 people with insulin at five facilities between 2020 and 2023. Seventeen of her patients died. At the West Virginia veterans hospital, a nurse admitted in 2021 to killing seven elderly patients with insulin.
Uribe said he knows of no protocols promoted by organizations for ER doctors or medical examiners and knows of only one state — West Virginia — where lawmakers have sought to reckon with this apparent lack of awareness. A bill introduced this year in the state Legislature seeks to require emergency rooms to test patients for insulin when they’re admitted with possible symptoms of insulin poisoning.
Jonathan Jones, the former president of the American Academy of Emergency Medicine, said that while the organization is concerned about insulin overdoses, it does not believe in “legislating medical care.”
“The best medical care is provided by properly educated, trained and board-certified physicians and not by legislators,” he said in an email to NBC News. “We believe in continuing medical education around this issue and all others applicable to the physician’s specialty but oppose treatment mandates and repercussions.”
He did not respond to a request for comment about whether ERs need stronger guidelines.
Asked if forensic pathologists need better protocols, Reade Quinton, president of the National Association of Medical Examiners, said: “I am not sure that is the right question. What medical examiners need is unobstructed access to scene information, witness statements and medical records so we can perform a complete and independent death investigation.”
The lead sponsor of the West Virginia bill did not respond to requests for comment. But the parents of Michael Cochran — who was killed by his pharmacist wife and for whom the bill is named — believe the legislation could serve as a model for the country. And it could help others avoid the gut-wrenching search for answers that they endured for years.
“They won’t have to wait for a result like we had to wait,” Cochran’s mother, Donna Bolt, told “Dateline.” “Six years.”
Seven dead patients at VA hospital
Uribe’s first insulin homicide case was at the veterans hospital in Clarksburg, West Virginia. Then a pathologist with the Armed Forces Medical Examiner System, Uribe said he was asked in late 2018 to examine a series of mysterious deaths among elderly patients, all of whom were found to have had severe hypoglycemia, or low blood sugar.
The condition can be caused by excessively high doses of insulin, which acts as a lifesaving regulator of blood sugar for people with diabetes.
Some of the veterans were diabetic, Uribe recalled, but others were not. He said he was asked to find a “smoking gun” that could prove insulin was the murder weapon.
For emergency room physicians and pathologists, he said, this can be a difficult task because of how quickly the body metabolizes insulin. The test cited in the West Virginia legislation — known as a “c-peptide” test — can measure insulin, Uribe said, but timing is key: It has to be conducted before doctors provide treatment for low blood sugar, he said.
“Because once you give that person glucose, that triggers the body’s natural release of insulin, and it’ll throw off the insulin c-peptide measure,” he said.
Many smaller hospitals often do not have the tests available, he added.
Uribe cited two possible methods for pathologists to document insulin. One of the most common ways of administering the medication is through an injection, and it can briefly linger in the body’s tissue at an injection site, he said. Researchers have also documented insulin in postmortem vitreous fluid, a substance found in the eyeball, he said.
In West Virginia, the bodies of seven veterans were exhumed and Uribe tested injection site tissue samples, he said. The tests revealed trace amounts of insulin in some of the victims, including those who were not diabetic and had never been prescribed the medication, he said.
“That was the definitive proof they had been injected with insulin,” he said.
Reta Mays, a nursing assistant at the hospital, was eventually identified as a suspect in the killings. She admitted to administering the lethal doses, pleading guilty to seven counts of second-degree murder and one count of assault with intent to commit murder in connection with the death of an eighth man. Mays was sentenced to seven life sentences.
A fatal dose from a pharmacist
In Uribe’s second case, pharmacist Natalie Cochran was convicted in January of giving her husband a fatal dose of the drug in a plot that prosecutors said was aimed at covering up a multimillion-dollar fraud that she perpetrated on friends and family.
But it took years for the case to be resolved.
In February 2019, Michael Cochran was hospitalized in an unresponsive state before he was removed from a ventilator and placed in hospice. He was 38. His death certificate listed his manner of death as “natural.”
Michael Cochran’s emergency room records showed that when he was admitted to the hospital, his blood sugar had plummeted, even though he had no history of diabetes, Uribe said. No insulin test was done at the time, he said.
But Tim Bledsoe, a detective with the West Virginia State Police, came to suspect that Natalie Cochran may have played a role in her husband’s death, and during a search of her home, he discovered a partially used vial of insulin in her fridge.
Knowing that no one in the home was diabetic, he asked Natalie Cochran about the vial, Bledsoe told “Dateline.” She told the detective she kept it there for a neighbor’s diabetic son, Bledsoe said. But the neighbor, Jennifer Davis, denied this and told “Dateline” that Natalie Cochran said she’d asked for the insulin for herself, claiming that she was using it to recover from a cancer diagnosis that prosecutors later said she faked.
She asked for the insulin the morning Michael Cochran first became sick, Davis said.
Two years after Michael Cochran’s death, his wife was indicted on a murder charge. An autopsy had been performed seven months after his death, but by then his body was in an advanced state of decomposition and the medical examiner ruled his cause of death undetermined, Bledsoe said.
It isn’t clear why an autopsy was not done immediately after his death, nor is it clear if any steps were taken in the examination to try and document postmortem insulin. The West Virginia Department of Health and Human Resources, which oversees the state medical examiner, did not respond to a request for comment.
Uribe said it’s unlikely any postmortem evidence of insulin could have been found given how much time passed between when Michael Cochran would have been given the drug and when he died.
The undetermined finding, combined with a lack of physical evidence, led the Raleigh County district attorney to drop the case, according to the county’s current top prosecutor, Tom Truman.
“If you don’t have the medical examiner saying homicide, you’ve got a big problem,” he told “Dateline.”
Another exhumation — and then a conviction
But two years later, the charge was refiled after Uribe was asked to examine the case. During a second exhumation and autopsy, Uribe said that he searched for possible injection sites but that Michael Cochran’s remains were skeletal by that point and the examination yielded nothing.
Still, Uribe said no other reason that could explain Michael Cochran’s plummeting blood sugar — such as sepsis or a rampant infection — had been documented in his medical records. Combined with other circumstances surrounding Michael Cochran’s death, Uribe ruled the death an insulin homicide.
At trial, an endocrinologist who testified for the prosecution agreed that no other explanation could account for Michael Cochran’s hypoglycemia.
Natalie Cochran’s lawyers acknowledged that she defrauded friends and relatives — she’d pleaded guilty in a separate federal fraud and money laundering case — but they said she had nothing to do with her husband’s death, which they attributed to a lethal mix of workout supplements, steroids and possibly his own use of insulin.
On Jan. 29, after two hours of deliberation, a jury convicted Natalie Cochran of first-degree murder. She was sentenced to life without the possibility of parole.
To Uribe, this case and the killings at the veteran’s hospital underscore the need for better insulin overdose guidelines.
For physicians, he said, those protocols could include watching out for red flags like severely low, unexplained blood sugar in a nondiabetic person, or unexplained low potassium, known as hypokalemia, which can also be fatal and caused by excessive insulin.
And they need to ensure that they administer a c-peptide test before treatment, he said.
Pathologists should search for possible injection sites, he said, and they should try testing vitreous fluid, he said.
“If you’re able to detect that in the vitreous fluid of someone who’s not a diabetic, who’s never been prescribed this medication and has no history of them being injected, that could legitimately tell you something,” he said.
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