Caution! The following post contains spoilers about the above book.
Ava/Ruth was really the person who killed Coach. James just struck the first blow. Coach had molested other girls, too.
Catherine killed James by injecting him with insulin she took from the elderly couple's kitchen. James had been on top of Ava strangling her. They buried James in a forest the next day.
The book ended with Ava reuniting with her brother and father, but also her watching Catherine as she entered the hospital to start her new job. Ava still has her unspoken fear about Catherine's predisposition to becoming a serial killer sets up the perfect opportunity for a sequel.
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