The Army inspector general's office has faulted three medical officers and the former commander of Walter Reed Army Medical Center for their pivotal roles in the botched probe of a Fairfax County teenager's 1998 death after what was to have been routine surgery there.
Its report portrays a hospital ill-prepared to investigate the quality of its medical care and demand accountability in complex events. The problems then and now could extend well beyond Walter Reed, the report suggests, and "could be systemic through the Army medical system."
For the 16-year-old's father, William Tyra, the findings are too little, too late. He and six relatives from Connecticut, New York and Texas were flown to Washington last week for a two-hour briefing at the Pentagon. The retired Marine colonel said he quickly realized, with dismay, that the report was silent on how those involved should be held accountable for the troubled investigation into Katie Tyra's death.
"I was hoping I could walk away from this," said Tyra, who early on had alleged a military coverup of the tragedy. "The Army has failed to hold anyone accountable . . . and presented no evidence that the systems that failed to protect Katie have changed."
The 200-plus-page report followed the inspector general agency's review of thousands of pages of medical records, court martial material and interviews with nearly 100 witnesses.
It ultimately substantiated six allegations against Walter Reed's top doctor, a surgeon and anesthesiologist involved in the case and the physician brought in to determine what had gone wrong.
The inspector general's office also confirmed eight broader problems at the Army's premier medical facility, including its failure to ensure the accuracy and timeliness of medical records and assess quality of care. One of the hospital's initial internal reviews lasted less than an hour, and those conducting it did not question any medical staff members who had been part of Katie's care and incorrectly decided that her care had adhered to proper standards, the inspector general said.
The Army released a short statement late Tuesday in response to the report. "Appropriate action has or will be taken in the case of personal failures," the statement said. "Systemic issues are being addressed by the surgeon general."
Officials declined to elaborate yesterday on the statement.
Katie was a healthy sophomore at Hayfield Secondary School in Fairfax when she went to Walter Reed in April 1998 to have a benign cyst excised from her neck. She never got into surgery. Instead, minutes after kissing her parents goodbye in the operating room, she went into cardiac arrest when an anesthesiologist improperly administered a major dose of antibiotic.
Michael G. Hamner, then a captain in his third year of residency, lied for months about how much clindamycin he had given Katie and how quickly. He subsequently pleaded guilty at a 2001 court-martial to falsifying statements and was found guilty of dereliction of duty. Though he faced up to 26 years behind bars, he was not sentenced to prison but dismissed dishonorably from the service. He was not barred from practicing medicine.
The next year, the Army settled a civil case brought by the Tyra family for $1 million.
The inspector general's report focused on four other people. It found "a willful failure" on the part of Hamner's immediate superior, Maj. Byron Edmond, to ensure that Katie's medical records were accurate and complete. Edmond, who is still on staff at Walter Reed, deferred comment to his attorney, who did not return a call to his office yesterday.
The report also cited Katie's surgeon, Air Force Lt. Col. Eric Mair, saying "a preponderance of evidence" showed that he had improperly altered her records after her death so that it appeared she had received significantly less clindamycin. Mair, now stationed at Wilford Hall Medical Center in Texas, declined to comment through a spokesman at the center, who cited "the possibility of future litigation."
The inspector general said anesthesiologist Thomas Pennington, the now-retired Army colonel selected by Walter Reed's top commander to look into the case in late 1998, "improperly failed to ascertain and consider the evidence on all sides of each issue." The report also found that he knowingly made false oral or written statements to other military authorities. Pennington, also now at Wilford Hall, declined through the center's spokesman to comment.
Retired Col. Frederick Erdtmann, who led Walter Reed at the time, was cited for failing to "take appropriate actions" after Hamner's admission of his mistakes. His military attorney, Lt. Col. Victor Hansen, defended Erdtmann's "very aggressive" measures in initiating a probe and said the substantiated allegation dealt narrowly with the lag time before Hamner was relieved of medical duties. Hansen said he had yet to see the full report.
William Tyra has pushed for a full accounting of his daughter's death and has pressed the American Board of Anesthesiology to review Hamner's board certification in anesthesia, citing, among other details, the physician's military conviction.
Tyra received a reply last week. "After reviewing the evidence and considering these facts in this tragic situation," the organization's letter read, "the ABA Board of Directors determined not to initiate proceedings to revoke Dr. Hamner's certification." The president of the board did not return calls yesterday.