A former nursing aide was sentenced Tuesday to seven consecutive life terms and an additional 20 years in federal prison after confessing to injecting lethal doses of insulin into frail, elderly veterans in her care at a West Virginia Veterans Affairs hospital.

“You’re the monster that no one sees coming,” U.S. District Judge Thomas Kleeh told Reta Mays before announcing the sentence in a courtroom in Clarksburg, W.Va., dismissing her lawyers’ arguments that she deserved leniency because of a long history of medical and mental health issues stemming from her childhood and military service.

Many defendants who appear in his courtroom, particularly veterans such as she, have led hard lives in West Virginia, the judge told Mays, 46, “but you’re not special. None of these folks are killers, let alone serial killers.”

As the sentencing took place, VA Inspector General Michael Missal released a blistering investigative report that concluded that cascading failures by the Louis A. Johnson Medical Center, the Clarksburg hospital that hired Mays in 2015, enabled the nursing aide to target patients for nearly a year.

Missal’s 100-page report cited “serious, pervasive, and deep-rooted clinical and administrative failures” that allowed the murders to go undetected as Mays injected patient after patient with insulin, from July 2017 through June 2018, that she was not authorized to administer, leading to their dying of severe hypoglycemia, or low blood sugar.

“Somebody should have been asking questions and looking into it, and they did not do that,” Missal said at a news conference Tuesday.

The wives, daughters, sons and other family members of Mays’s eight victims — all but one of whom died — gave wrenching testimony Tuesday about the pain she inflicted.

Melanie Proctor, whose father, retired Army Sgt. Felix McDermott, was 82 when he was murdered, called him a “proud Army veteran and ornery character who would give anybody a helping hand.” She said Mays had “taken away any faith in the VA system that my dad held in high esteem.”

“You took some of the greatest men of our time and preyed on them when they were at their weakest,” Proctor said, “and for that you are a coward.”

Mays, a veteran who deployed to Iraq with the Army National Guard from 2003 to 2004, cried as she briefly addressed the court, saying, “I don’t ask anyone for forgiveness because I don’t think I could forgive anyone for doing what I did. I can only say I’m sorry for the pain I caused the families and my family.”

Missal described “missed opportunities” at all leadership levels that caused a failure to stop Mays, eventually leading investigators to exhume several bodies.

Joined by officials from the U.S. attorney’s office for the Northern District of West Virginia and the FBI, he said there was a three-week period when four veterans died under suspicious circumstances on the hospital’s medical surgical unit, known as 3A.

Mays, who had been assigned to monitor veterans in what are known as one-on-one bedside vigils for patients who need extra attention, initially denied any involvement with the deaths in three interviews with investigators.

She ultimately pleaded guilty in July to seven counts of second-degree murder and one count of assault with intent to commit murder. Her victims were men, almost all of them in their 80s, who had been admitted to the hospital with various ailments of old age, including heart problems and dementia. A few had mild diabetes.

None were about to die, and some were on the verge of being released when Mays, working the overnight shift with little supervision, injected them with insulin she found lying unprotected on medicine carts and in supply rooms, investigators found.

Investigators identified similarities in the deaths: Elderly patients in private rooms were injected in their abdomen and limbs with insulin the hospital had not prescribed — some with multiple shots. Within hours, the veterans’ blood-sugar levels plummeted. Despite those commonalities, the medical staff and those with oversight of hospital procedures failed to identify a pattern for months, the inspector general’s office found.

VA, in a statement, called the case “heartbreaking” and pledged to regain the trust of veterans and their families. The agency said it has made improvements to management and patient care at Clarksburg and will begin an outside review of all cases in which patients with whom Mays had contact had negative outcomes.

“While this matter involving an isolated employee does not represent the quality health care tens of thousands of North Central West Virginia Veterans have come to expect from our facility, it has prompted a number of improvements that will strengthen our continuity of care and prevent similar issues from happening in the future,” the agency said in a statement.

VA has reached financial settlements with families of half a dozen victims, paying out about $5 million, it said.

While her murders piled up, Mays searched the Internet for information about female serial killers and watched “Nurses Who Kill” on Netflix, the judge said Tuesday.

She later told investigators that she killed the men because she believed they were suffering and wanted them to pass “gently,” the inspector general’s report said. Prosecutors called that argument absurd, particularly since she then assisted in administering a drug to counteract the insulin, to no avail in some of the cases. Mays also described feeling a sense of control from administering the insulin injections that eased stress and chaos in her life.

Assistant U.S. Attorney Jarod Douglas, the lead prosecutor in the case, called the killings “predatory and planned.”

“These men were not in need of mercy by the defendant,” Douglas said.

Prosecutors and even her lawyer acknowledged that the two-year investigation had failed to lead them to a clear motive.

“Many, many people ask, ‘Why did she do this?’ ” her attorney, Jay McCamic, told the court. “Unfortunately, ‘why’ is not a question that can be answered here. Reta doesn’t know why. What we do know is that Reta Mays had a number of documented mental health issues and a number of stressors piled upon her, brick by brick.”

He asked why the hospital — which he said was treating her for depression, anxiety, post-traumatic stress disorder and military sexual trauma — kept allowing her to return to “an extremely stressful job on the midnight shift.”

A number of family members of the victims on Tuesday shared memories of fathers and grandfathers who served in World War II, Korea and Vietnam before returning to the West Virginia hollers to raise families and work at good-paying blue-collar jobs before retirement.

“I want to talk about your first victim,” Robert Edge Jr., appearing on video, told Mays, describing his father, Navy veteran Robert Edge Sr., 82, as a “kind and gentle man” who could “build anything” and was never without work after he returned from the Korean War.

“You have deprived nine grandkids and 13 great-grandkids of ever knowing that love,” Edge said.

Amanda Edgell, whose father-in-law, Archie, died at Mays’s hands, recalled that she talked to Mays “for hours” while Archie, who had vascular dementia, was a patient on the medical surgical ward.

Mays told the family he had been combative while in restraints, Edgell said, adding: “I feel such guilt that I didn’t know what was happening.”

Investigators described a complicated, circumstantial case that required them to piece together what happened through interviews, documents and disinterments. At the time Mays was working in the facility, the hospital ward did not have cameras in common areas, including the supply room where insulin was kept.

The hospital failed in other basic ways that have only begun to be addressed, the watchdog report released Tuesday found.

No background check was conducted when Mays was hired from a local prison, where she had been the subject of several allegations that she used excessive force on prisoners, investigators found. The hospital did not call references or look at personnel records.

The hospital also failed to do a required security check before giving Mays the secretary’s award for nursing assistant of the year in 2017, which came with a $500 bonus. The employee tasked with conducting the check wrongly stated that it had been favorably completed.

Medication carts and supply rooms were left unlocked and unattended, the report said. The hospital pharmacy did not use the proper system to track its stock of drugs, leading the staff to miss the use of an “extraordinary amount” of a drug used to counteract insulin.

The hospital also failed to do testing to identify the cause of the hypoglycemia deaths, which are rare in patients who are not receiving medication for diabetes. When testing was done on one patient, clinicians ordered the wrong test, the report found.

The insulin deaths were not reported to the hospital’s patient safety department, whose job it is to investigate abnormal patterns. The patient safety manager never trained the staff to identify what “adverse” events should be reported. Tools that track patterns in mortality, basic at any hospital, were not used.

“The facility did not consistently promote a culture that prioritized patient safety as expected of a high reliability organization,” the report concluded, describing failures of leaders at multiple levels and in “virtually all the critical functions and areas required to promote patient safety.”

The result was a combination of clinical and administrative failures that laid the groundwork for Mays “to commit these criminal acts and for them to go undetected for so long,” investigators found.

VA noted in a statement that the inspector general’s report focused on events that occurred between July 2017 and June 2018, and said the agency has “put in place safeguards to enhance patient safety, including medical chart audits, checks and balances within pharmacy quality assurance processes and quality management reviews.”

All of the inspector general’s recommendations will be implemented by the medical center by March 2022, it said.