Insulin as a Murder Weapon

NBC reported on the use of insulin as a murder weapon by nurses. How do you know if it is an honest mistake as opposed to attempted murder?

Medical professionals are usually unprepared when having to consider that the lifesaving drug-insulin- can be used as a murder weapon. This is exactly the case, according to a forensic pathologist who worked on the most recent case of a West Virginia pharmacist who was convicted of fatally dosing her husband.

Dr. Paul Uribe, a former military medical examiner who consults as a pathologist across the United States, states that there appear to be few protocols for pathologists and emergency room doctors on how to handle cases best.

“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.”

Although these crimes are rare, recent cases in the U.S. have had a “staggering number of victims.” For example, In Pennsylvania, a nurse confessed to attempting to kill 19 people with insulin at five different facilities between 2020 and 2023. Seventeen of her patients died.

While at a West Virginia veterans hospital, a nurse admitted to killing seven elderly patients with insulin.

Uribe said that he is not aware of any protocols promoted by organizations for ER doctors or medical examiners but knows of only one state—West Virginia—where lawmakers have taken action to address this apparent lack of awareness. A bill was introduced earlier this year in the state Legislature that seeks to require emergency rooms to rest patients for insulin levels upon admission and 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.” He said in an email to NBC News that “The best medical care is provided by properly educated, trained and board-certified physicians and not by legislators,” and “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 comments discussing whether ERs need stronger guidelines.

Reade Quinton, president of the National Association of Medical Examiners, was asked if forensic pathologists need better protocols. He said he was “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 parents of Michael Cochran, who was killed by his pharmacist wife and whom this bill is named after, believe that the legislation could serve as a “model” for the country and could help others avoid the “gut-wrenching” search for answers that they looked for years. The family waited six years for answers.

Uribe’s first insulin homicide case was in Clarksburg, West Virginia, at a veterans hospital. Uribe was previously a pathologist with the Armed Forces Medical Examiner System when he was asked to examine a series of mysterious deaths among elderly patients in 2018. All the patients were found to have severe hypoglycemia or low blood sugar. Excessive amounts of high doses of insulin will cause this condition.

Uribe was told to find a “smoking gun” that proved that insulin was the murder weapon. This can be difficult for emergency room physicians and pathologists because of how quickly the body metabolizes insulin. A test cited in the West Virginia legislation, the “c-peptide” test, can measure insulin, but timing is
crucial. The test must be conducted before doctors provide treatment for low blood sugar.

“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 do not have this test available. Uribe cited two possible methods for pathologists to document insulin: deterring it at an injection site as it remains briefly in the body’s tissue and identifying it in postmortem vitreous fluid from the eyeball.

In West Virginia, Uribe tested the injection site tissue samples of seven veterans. The tests revealed trace amounts of insulin in some victims, including those who did not have diabetes or had never been prescribed this medication. He said, “That was the definitive proof they had been injected with insulin.” Reta Mays, a nursing assistant at the hospital, was eventually identified as a suspect in these killings. She admitted to administering the lethal doses and pleaded guilty to seven counts of second-degree murder and one count of assault to murder with the death of an eighth man. Mays was sentenced to seven life sentences.

In Uribe’s second case, pharmacist Natalie Cochran was convicted in January of giving her husband a fatal dose of insulin that was aimed to cover up a multimillion-dollar fraud that she perpetuated on friends and family. Michael Cochran, 38, was hospitalized in February 2019 in an unresponsive state before being placed in hospice and taken off the ventilator. His death certificate states his manner of death was “natural.”

Emergency records showed that upon admission, Michael’s blood sugar had plummeted, although he had no history of diabetes. An insulin test was not done at the time. An investigator with the West Virginia State Police, Tim Bledsoe, came to suspect that Michael’s wife, Natalie Cochran, had played a role in her husband’s death. While searching her home, Bledsoe discovered a vial of insulin in her fridge. No one in the home was diabetic.

Two years after Michael’s death, his wife was indicted on a murder charge. An autopsy had been performed seven months after his death, but it was too late to determine his cause of death as the body was in an advanced state of decomposition. The undetermined finding and lack of physical evidence led the Raleigh County district attorney to drop the case. Two years later, the charge was refiled when Uribe was asked to examine the case.

During a second exhumation and autopsy, Uribe said that he searched for possible injection sites, but Michael’s remains were skeletal by that point, and the examination proved nothing. No other reason to explain Michael’s plummeting blood sugar, like sepsis or a rampant infection, was ever documented in his
medical records.

Uribe eventually ruled Michael’s death an insulin homicide. Additionally, an endocrinologist who testified for the prosecution agreed that there was no other explanation that could account for Michael’s hypoglycemia.

On January 29th, after two hours of deliberation, a jury convicted Natalie Cochran of first-degree murder. Natalie was sentenced to life without the possibility of parole.

To Uribe, both this case and the veteran’s hospital killings enforce the need for better insulin overdose guidelines. For physicians, this can include watching out for red flags like low and unexplained blood sugar in a nondiabetic person or unexplained levels of potassium or hypokalemia. A c-peptide test should be administered before treatment, and a pathologist should search for possible injection sites and try testing vitreous fluid.