VA watchdog confirms patients died after receiving poor care


The Department of Veterans Affairs inspector general found widespread problems in patient care at the agency’s hospital in Phoenix, Ariz., including long delays and poor care. (Photo by Christian Petersen/Getty Images)

The Department of Veterans Affairs’ watchdog confirmed Tuesday that numerous veterans died after receiving poor care in a VA hospital in Phoenix, Ariz., adding that there were “unacceptable and troubling lapses” in care.

The investigation followed widely reported allegations that at least 40 veterans died while on a wait list there. The VA inspector general’s office said the whistleblower did not provide them a list of those patients, but it independently found 40 patients who were on an electronic wait list and died between April 2013 and April 2014.

The VA inspector general’s office said in the new report that it also reviewed the records of 3,409 veterans and found 45 cases where patients experienced “unacceptable and troubling lapses” in care. Of those, 28 experienced long delays in care, and six died, the report said. Seventeen other patients experienced care that “deviated from the expected standard independent of delays,” and 14 of them died, the IG found.

The scandal emerged after a whistleblower brought allegations in February against VA officials in Phoenix. The IG’s office said Tuesday that the whistleblower did not provide them with a list of 40 patients who died, making it impossible to substantiate the accusations. The IG said it was “unable to conclusively assert” that poor care caused the deaths it did find, but said the 45 cases it identified “reflect unacceptable and troubling lapses in follow-up, coordination, quality, and continuity of care.”

President Obama, appearing alongside new VA Secretary Bob McDonald on Tuesday, said that his administration is “very clear-eyed about the problems that are still there” in the VA.

“We are gonna get to the bottom of these problems,” Obama said, speaking at the American Legion’s national convention in Charlotte, N.C. “We’re gonna fix what is wrong. We’re gonna do right by you. And we are gonna do right by your families. And that is a solemn pledge and commitment that I’m making to you here.”

After the allegations in Phoenix first emerged, the VA received 225 reports of misconduct in the hospital there and 445 allegations of records being manipulated in other VA facilities across the country, the IG report said. The VA’s IG opened investigations at 93 sites to examine wait list issues, and has found that many of them acted inappropriately.

“This report cannot capture the personal disappointment, frustration, and loss of faith of individual veterans and their family members with a health care system that often could not respond to their mental and physical health needs in a timely manner,” the report said. “Immediate and substantive changes are needed.”

McDonald, who took over his job in July, said Tuesday that two senior officials already have resigned or retired since May, and three other senior officials have been placed on administrative leave while investigations continue. More than two dozen health care officials also have been removed from their positions, and four more officials have been placed on administrative leave, he said.

More than 100 investigations at VA facilities across the country are ongoing by the federal Office of Special Counsel, which investigates whistleblower allegations and complaints of whistleblower retaliation, McDonald said. Other investigations also are underway, in some case jointly with the FBI, he added.

In a written response included in the IG report released Tuesday, McDonald said “the VA is in the midst of a very serious crisis,” and said it must work to get veterans off wait lists, address its cultural and accountability issues and use the resources it has to consistently deliver timely health care.

Veterans' unemployment and homelessness rates have been going down, President Obama told the American Legion's 96th National Conference in Charlotte, N.C., on Tuesday. The president outlined what steps are being taken to continue improving life for veterans in America. (WhiteHouse.gov)

The findings of the IG investigation in Phoenix were released as Obama announced 19 new executive actions that he said will help veterans and active-duty service members who are struggling with traumatic brain injuries, post-traumatic stress or suicidal thoughts. The United States “can’t stand idly by on such a tragedy,” he said.

All 19 actions address mental-health issues, said officials with the Department of Veterans Affairs and Defense Department. They include steps such as launching a new VA pilot program that will add veterans trained to help other veterans to work with primary-care health personnel. The Pentagon also will start a peer support pilot program for active-duty Special Operations troops.

“So long as any service member or veteran is suffering, or feels like they have nowhere to turn, or doesn’t get the support that they need, that means we haven’t done enough,” Obama said while addressing the American Legion’s 96th National Convention in Charlotte, N.C. “Well, we all know we need to do more.”

UPDATE, Aug. 29: This blog post has been updated to correct that the IG’s office found evidence that 40 patients who were on an electronic wait list from April 2013 to April 2014 in Phoenix died. As previously reported, the IG also said it was “unable to conclusively assert” that poor care caused the deaths.

Dan Lamothe covers national security for The Washington Post and anchors its military blog, Checkpoint.
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