Hospital Officials Knew of Neglect
Complaints About Walter Reed Were Voiced for Years

By Anne Hull and Dana Priest
Washington Post Staff Writers
Thursday, March 1, 2007

Top officials at Walter Reed Army Medical Center, including the Army's surgeon general, have heard complaints about outpatient neglect from family members, veterans groups and members of Congress for more than three years.

A procession of Pentagon and Walter Reed officials expressed surprise last week about the living conditions and bureaucratic nightmares faced by wounded soldiers staying at the D.C. medical facility. But as far back as 2003, the commander of Walter Reed, Lt. Gen. Kevin C. Kiley, who is now the Army's top medical officer, was told that soldiers who were wounded in Iraq and Afghanistan were languishing and lost on the grounds, according to interviews.

Steve Robinson, director of veterans affairs at Veterans for America, said he ran into Kiley in the foyer of the command headquarters at Walter Reed shortly after the Iraq war began and told him that "there are people in the barracks who are drinking themselves to death and people who are sharing drugs and people not getting the care they need."

"I met guys who weren't going to appointments because the hospital didn't even know they were there," Robinson said. Kiley told him to speak to a sergeant major, a top enlisted officer.

A recent Washington Post series detailed conditions at Walter Reed, including those at Building 18, a dingy former hotel on Georgia Avenue where the wounded were housed among mice, mold, rot and cockroaches.

Kiley lives across the street from Building 18. From his quarters, he can see the scrappy building and busy traffic the soldiers must cross to get to the 113-acre post. At a news conference last week, Kiley, who declined several requests for interviews for this article, said that the problems of Building 18 "weren't serious and there weren't a lot of them." He also said they were not "emblematic of a process of Walter Reed that has abandoned soldiers and their families."

But according to interviews, Kiley, his successive commanders at Walter Reed and various top noncommissioned officers in charge of soldiers' lives have heard a stream of complaints about outpatient treatment over the past several years. The complaints have surfaced at town hall meetings for staff and soldiers, at commanders' "sensing sessions" in which soldiers or officers are encouraged to speak freely, and in several inspector general's reports detailing building conditions, safety issues and other matters.

Retired Maj. Gen. Kenneth L. Farmer Jr., who commanded Walter Reed for two years until last August, said that he was aware of outpatient problems and that there were "ongoing reviews and discussions" about how to fix them when he left. He said he shared many of those issues with Kiley, his immediate commander. Last summer when he turned over command to Maj. Gen. George W. Weightman, Farmer said, "there were a variety of things we identified as opportunities for continued improvement."

In 2004, Rep. C.W. Bill Young (R-Fla.) and his wife stopped visiting the wounded at Walter Reed out of frustration. Young said he voiced concerns to commanders over troubling incidents he witnessed but was rebuffed or ignored. "When Bev or I would bring problems to the attention of authorities of Walter Reed, we were made to feel very uncomfortable," said Young, who began visiting the wounded recuperating at other facilities.

Beverly Young said she complained to Kiley several times. She once visited a soldier who was lying in urine on his mattress pad in the hospital. When a nurse ignored her, Young said, "I went flying down to Kevin Kiley's office again, and got nowhere. He has skirted this stuff for five years and blamed everyone else."

Young said that even after Kiley left Walter Reed to become the Army's surgeon general, "if anything could have been done to correct problems, he could have done it."

Soldiers and family members say their complaints have been ignored by commanders at many levels.

More than a year ago, Chief Warrant Officer Jayson Kendrick, an outpatient, attended a sensing session, the Army's version of a town hall meeting where concerns are raised in front of the chain of command. Kendrick spoke about the deterioration and crowded conditions of the outpatient administrative building, which had secondhand computers and office furniture shoved into cubicles, creating chaos for family members. An inspector general attending the meeting "chuckled and said, 'What do you want, pool tables and Ping-Pong tables in there?' " Kendrick recalled.

Army officials have been at other meetings in which outpatient problems were detailed.

On Feb. 17, 2005, Kiley sat in a congressional hearing room as Sgt. 1st Class John Allen, injured in Afghanistan in 2002, described what he called a "dysfunctional system" at Walter Reed in which "soldiers go months without pay, nowhere to live, their medical appointments canceled." Allen added: "The result is a massive stress and mental pain causing further harm. It would be very easy to correct the situation if the command element climate supported it. The command staff at Walter Reed needs to show their care."

In 2006, Joe Wilson, a clinical social worker in the department of psychiatry, briefed several colonels at Walter Reed about problems and steps that could be taken to improve living conditions at Building 18. Last March, he also shared the findings of a survey his department had conducted.

It found that 75 percent of outpatients said their experience at Walter Reed had been "stressful" and that there was a "significant population of unsatisfied, frustrated, disenfranchised patients." Military commanders played down the findings.

"These people knew about it," Wilson said. "The bottom line is, people knew about it but the culture of the Army didn't allow it to be addressed."

Last October, Joyce Rumsfeld, the wife of then-Defense Secretary Donald H. Rumsfeld, was taken to Walter Reed by a friend concerned about outpatient treatment. She attended a weekly meeting, called Girls Time Out, at which wives, girlfriends and mothers of soldiers exchange stories and offer support.

According to three people who attended the gathering, Rumsfeld listened quietly. Some of the women did not know who she was. At the end of the meeting, Rumsfeld asked one of the staff members whether she thought that the soldiers her husband was meeting on his visits had been handpicked to paint a rosy picture of their time there. The answer was yes.

When Walter Reed officials found out that Rumsfeld had visited, they told the friend who brought her -- a woman who had volunteered there many times -- that she was no longer welcome on the grounds.

Last week, the Army relieved of duty several low-ranking soldiers who managed outpatients. This week, in a move that some soldiers viewed as reprisal for speaking to the media, the wounded troops were told that early-morning room inspections would be held and that further contact with reporters is prohibited.

Yesterday, Walter Reed received an unscheduled inspection by a hospital accreditation agency. Members of the Joint Commission, formerly the Joint Commission on Accreditation of Healthcare Organizations, began a two-day visit "for cause" to examine discharge practices that have allowed soldiers to go missing or unaccounted for after they are released from the hospital.

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