VAmalpractice.info-Information about medical malpractice by VA doctors, & VA nurses & how the VA handles medical malpractice tort claims, section 151 benefits, lawyers who represent veterans with malpractice claims and other things that adversely affect the quality of medical care that veterans receive from the Department of Veterans Affairs.
Information on medical malpractice by VA, or Veterans Administration hospitals, physicians, and clinics run by the Department of Veterans Affairs. While many veterans receive satisfactory medical care from the VA, others do not. This site is designed to provide information to those veterans, who have received negligent medical care, from a Veterans Administration hospital, doctor, physician’s assistant, surgeon or other VA medical provider and to encourage discussion about this problem. The VA is responsible for the US paying out millions of dollars a week for medical malpractice claims under the Federal Tort Claims Act. It would be better for our veterans, and for the taxpayers, if the VA chose to provide better medical care instead.
The popular press has provided extensive coverage of the fact that Cathedral Henderson has been indicted on 50 counts of improperly closing a veteran’s medical consult request. What is even more shocking is that the indictment indicates that more than 50 veterans were involved. a whole lot more, in fact according to the US Attorney there were more than 2,700 instances of this occurring. Read the complete indictment below.
VA OIG confirms medical malpractice at the Lebanon VA, when a veteran bursts into flames during surgery!
West Haven VA hires physician who is on 5 years of probation due to improper contact with female patients.
$21,000, 000 verdict entered against the Department of Veterans Affairs for medical malpractice at the Manchester VA
In what has to be one of the largest medical malpractice verdicts ever against the VA the District of New Hampshire has awarded a veteran more than $24,000,000 to veteran who suffered two strokes as a result of medical malpractice at the Manchester VA.
MEMORANDUM AND ORDER
In October of 2010, Michael Farley experienced symptoms including the loss of his peripheral vision and a painful headache. A veteran of the United States Navy, Mr. Farley sought treatment at the Veterans Administration Medical Center in Manchester, New Hampshire (“Manchester VA”). There, Mr. Farley was examined and given a series of tests, and he learned that he had suffered a stroke.
It is a basic principle of medicine that a patient who has suffered a stroke is generally at an elevated risk of suffering a second stroke. Therefore, doctors who are treating stroke patients must be cognizant of this risk, and they must take steps to prevent a second stroke from occurring. As such, the established standard of care requires that a stroke patient undergo a thorough diagnostic evaluation to determine the cause of his stroke, and it requires that the patient be prescribed certain medication to treat the underlying condition that caused the stroke to occur.
Unfortunately, Mr. Farley’s doctors at the Manchester VA did not adhere to this standard of care. They failed to provide him with an adequate diagnostic evaluation, and as a result, they carelessly prescribed him the wrong medication. In the words of one of the expert witnesses, Mr. Farley was “medically abandoned” by his doctors.
Approximately six weeks after his initial visit to the Manchester VA, Mr. Farley suffered a second stroke. This second stroke was massive, and it left Mr. Farley with “locked-in” syndrome, meaning that he remains fully conscious, but has no voluntary muscle movement other than the very limited ability to move his eyes and his head….
…IV. Observations Regarding the Presentation of Evidence
The government presented what can only be described as an internally inconsistent case. On the issue of the likely cause of Mr. Farley’s strokes, the government’s expert witnesses disagreed with one another on the stand, and several of them openly disagreed with the government’s own pre-trial stipulations regarding cardioembolic blood clots and the recent timing of Mr. Farley’s heart attack.
To illustrate the point, whereas the government’s pre-trial proposed findings of fact sought a finding that Mr. Farley’s strokes were cardioembolic in nature, the post-trial proposed findings of fact ask the court to find that Mr. Farley’s strokes were caused by atherosclerotic plaque or a dissection. The inconsistency served to undermine the credibility of the government’s expert witnesses, as well as the credibility of the government’s theory of the case. This is particularly true when considered in light of the Farleys’ case, which was clearly presented and remarkably consistent…
I. Damages for Medical Care
Dr. Eilers and Ms. Newick were both highly credible witnesses. Dr. Eilers offered practical insight regarding Mr. Farley’s likely future medical needs based on several decades of relevant experience. His testimony was clear and succinct, and his testimony regarding the mental and physical health benefits associated with allowing Mr. Farley to move home with his family was compelling. Likewise, Ms. Newick’s testimony was highly credible, and assisted the court in understanding the issues involved in complex cost projection.
Curiously, the government effectively conceded the issue of damages and did not offer expert testimony on Mr. Farley’s future medical care. Nor did the government spend much time at trial challenging Dr. Eilers’s testimony on cross examination. Rather, at points during the trial, the government invited the court to conduct a line-by-line analysis of Dr. Eilers’s care plan, and to eliminate unnecessary expenses. For example, during closing arguments, counsel for the government stated that “[t]here are a number of things in the [care plan] that this court may well find to be more than reasonably necessary.”
The court declines to second guess Dr. Eilers’s care plan. The government offered no evidence whatsoever that Dr. Eilers was unqualified to prepare the care plan, or that a single one of the projected expenses that his care plan contains is unnecessary. In the absence of any evidentiary guidance, it is far beyond this court’s purview to undertake a line-item vetoing exercise where the subject matter involves the necessarily sophisticated care that must be provided for a patient with complex medical needs such as Mr. Farley.
To challenge Dr. Eilers’s life expectancy projections, the government offered the deposition testimony of Dr. Kim. During his deposition, Dr. Kim discussed a report that he had authored regarding decreases in life expectancy that result from catastrophic strokes. Based on that study, Dr. Kim concluded that Mr. Farley is likely to live 3.32 years for every five years that a white male who had not suffered a catastrophic stroke would be likely to live. Although Dr. Kim’s testimony on this issue was brief, the court found Dr. Kim’s theory regarding decreases in average life expectancy for catastrophic stroke victims credible and persuasive. After consideration of the life expectancy projections offered by both Drs. Eilers and Kim, the court finds that Mr. Farley’s life expectancy is 15 years.
The sum of $1,368,710.62 is reasonable and medically necessary to cover the upfront, one-time costs of Mr. Farley’s past medical expenses, his contracture surgery, and the purchase or conversion of a home to accommodate his needs.19
The sum of $12,000,000.00 in future medical care costs is reasonable and medically necessary. The court arrived at this figure by reducing the Farleys’ proposed future medical costs award of $16,580,898.00 (which was premised on a 22.2-year life expectancy) to account for a 15-year life expectancy. In arriving at this figure, the court carefully considered the individual expenses forecasted in Dr. Eilers’s care plan, as well as the annualized costs and present value figures set forth in Ms. Newick’s report.
The government asserts that the court must deduct the amount of medical benefits paid in the past from any award made under the FTCA. Indeed, “where the Veterans Administration has paid the hospital expenses incurred in connection with the injury no award is to be made therefor in a federal tort claims action.” United States v. Hayashi, 282 F.2d 599, 603 (9th Cir. 1960). The rule from Hayashi is inapposite, as the Farleys do not seek compensation for amounts previously paid by the Veterans Administration for Mr. Farley’s care. Rather, they seek compensation for amounts previously billed to Mr. Farley personally, as well as for future medical expenses.
The court has corrected for two errors that the government identified in Ms. Newick’s report. First, Ms. Newick failed to calculate the present value of a rehabilitation case manager. The court has made that calculation in accordance with Ms. Newick’s testimony at trial acknowledging the error and explaining the fix. The second error concerned the Baclofen pump, which Mr. Farley does not presently need, but will likely need at some point in the future. With regard to this expense, Ms. Newick used the life expectancy of the pump (seven years) to calculate the age at which Mr. Farley would need to begin using
II. Non-Economic Damages
The court turns to the question of non-economic damages. As stated by the New Hampshire Supreme Court:
No one to our knowledge has been able to devise a formula by which compensation for pain and suffering can be determined with precision. Pain and suffering are too subjective to lend themselves to such exactness. Consequently, we do not permit any formula or mathematical tool to be used in computing such damages.
Steel v. Bemis, 121 N.H. 425, 428 (1981). The question is left to the factfinder, who hears the testimony and weighs the facts. Id. The goal is “to reach a just result” with such an award. Id.
The evidence of Mr. Farley’s pain and suffering from locked-in syndrome was undisputed.21 The harrowing psychological trauma of locked-in syndrome was brought home to Mr. Farley in the earliest moments after his second stroke. At the hospital, the doctors originally believed Mr. Farley was in a coma and
it. Ms. Newick’s use of that number was unsupported by the medical evidence. Although Dr. Eilers testified that he did not know exactly when Mr. Farley would need to begin treatment with a Baclofen pump, he included the cost of that treatment in his report as one that Mr. Farley would incur in the near future. Absent evidence to the contrary, the court credits Dr. Eilers’s report and includes the cost of the Baclofen pump as detailed by Dr. Eilers.
The court uses the term “pain and suffering”as inclusive of pain, suffering, mental anguish, disfigurement, and loss of enjoyment of life.would not recover. The truth was otherwise. Mr. Farley lay trapped inside his paralyzed body, lucid and mentally alive, but he could not communicate that to his caregivers and family — who were in his hospital room discussing end-of-life scenarios. Mr. Farley’s adult children did not believe he was in a coma; they thought that he was moving his eyes in an effort to communicate with them. The caregivers assured them that they were wrong and that his eye movement was merely a symptom of his comatose state. At some point, a nurse noticed that Mr. Farley’s eyes were tracking her as she walked in and out of his hospital room. The diagnosis of locked-in syndrome followed. While Mr. Farley has learned to communicate using eye movements, he remains unable to speak.
The testimony included that of his wife, his adult children, Kimberly-Rae and James, and Dr. Eilers. During Dr. Eilers’s testimony, a “day-in-the-life” video of Mr. Farley was shown, and Dr. Eilers narrated and explained to the court the various physical and emotional challenges Mr. Farley faces on a daily basis.
What follows is a brief, bulleted summary of some of the evidence that Mr. Farley presented concerning his pain and suffering:
Mr. Farley’s locked-in syndrome is permanent. Although the stroke left Mr. Farley all but completely paralyzed, the evidence established that he can still feel pain, pressure, numbness, and other sensations. By way of example, Mr. Farley knows when he is going to defecate and urinate, but he can do nothing about it.
Mr. Farley has painful contractures of his upper and lower extremities. His elbow, for example, is contracted 90 degrees. His hands are fisted in a position that cause his fingernails to dig into his palms, causing him pain. His legs are also criss-crossed as a result of these contractures, which prevents him from sitting without pain, and renders him unable to sit in a wheelchair for any more than a short period of time.22
Mr. Farley has two feeding tubes and a tracheotomy. The tracheotomy is a tube in Mr. Farley’s throat through which he breathes. When there is build-up in his tracheotomy, he regurgitates sputum. He must always wear a bib or towel around his neck to catch the discharge. As described by Dr. Eilers: “If he’s choking, he has to hope that they come quickly because he can’t yell, ‘I’m choking.’ He’s basically unable to control his world environment at all.”
For the four years preceding trial, due to the challenges his current caregivers face in transporting him, Mr. Farley has not been taken outside except for transportation related to medical visits. Due to the distance between his current placement in Pittsfield, Massachusetts and Keene, New Hampshire, where his family lives (up to a six-hour, round-trip drive), Mr. Farley does not see his family very often.
The damages award for Mr. Farley’s future medical care includes the cost of certain surgeries and home care that will reduce his pain and suffering. For example, the award includes the cost of surgeries to correct his joint contractures. The court’s award for pain and suffering thus takes into account differences between his past pain and suffering and the anticipated relief to him in the future due to the medical care he will receive pursuant to the medical care award.
Mr. Farley’s family testified about Mr. Farley’s life before the second stroke. Mr. Farley loved the outdoors. He hiked with his dogs almost daily; he loved to fish; he camped regularly; and more than anything he enjoyed spending time with his family and especially his children. Mr. Farley’s children, Kimberly-Rae and James, testified about how active and present Mr. Farley was as a father.
The testimony of Kimberly-Rae, about how her relationship with her father and the way in which he encouraged her to accomplish whatever she set her mind to, was particularly compelling. Mr. Farley’s loss of enjoyment of life has been, and will continue to be, profound.
In deciding on the appropriate figure for non-economic damages, the court has carefully considered the entire record, including the comparison verdicts provided by the government and Mr. Farley. See doc. nos. 43 and 53. Mr. Farley provided published verdicts from six jurisdictions across the country in cases involving plaintiffs who had locked-in syndrome. It is not clear in each case what portion was allocated for pain and suffering. However, in those cases where pain and suffering was clearly allocated, the awards range from $15,000,000.00 to $65,000,000.00. Mr. Farley also provided a lengthy list of exemplar verdicts in FTCA cases involving catastrophic injuries. The pain and suffering awards in those cases range from $4,500,000.00 to $31,000,000.00. Finally, Mr. Farley provided a list of exemplar verdicts from various jurisdictions, including several in the First Circuit and in New England, in cases involving non-economic damages for injuries similar to locked-in syndrome. Those awards range from $5,000,000.00 to $58,000,000.00.23 The government provided two pain and suffering verdicts: one from Pennsylvania involving a plaintiff with locked-in syndrome ($100,000.00) and one from New Hampshire involving a 78-year-old plaintiff with left-side paralysis ($1,400,000.00).
The court has evaluated the government’s objection to the Farleys’ request for a total of $17,000,000.00 in non-economic damages. In the court’s view, the non-economic damages award the Farleys seek is unreasonably high. After careful consideration, the court finds that Mrs. Farley, on behalf of Mr. Farley, is entitled to non-economic damages in the amount of $8,100,000.00. The court finds that this sum is reasonable in light of the evidence offered at trial and the complete record in this case
This list of comparator awards for injuries similar to locked-in syndrome contained total verdicts as high as $121,000,000.00, however, it was impossible for the court to discern what portion was allocated for pain and suffering for many of those awards. Thus, the court disregarded any ambiguous figures for comparison purposes.
Included in the $8,100,000.00 figure is $100,000.00 in loss of consortium damages for Mr. Farley. The court declines to award the full $1,300,000.00 for loss of consortium that Mr. Farley seeks. The uncontroverted evidence established that Mr. and Mrs. Farley had separated several years prior to the events in this case, and that Mr. Farley was living apart from his family at the time of his strokes. Nevertheless, the evidence also established that Mr. Farley maintained an amicable relationship with Mrs. Farley during this time, as demonstrated by the compelling testimony of Mrs. Farley, as well as Mr. Farley’s son, James, and his daughter, Kimberly-Rae. Finally, the evidence established that Mrs. Farley has now become one of Mr. Farley’s primary caregivers.
Finally, the court finds that Mrs. Farley, individually, is entitled to $100,000.00 for loss of consortium. For the same reasons as those described above, the court declines to award Mrs. Farley the full $1,300,000.00 that she seeks.
III. Form of Award
The government has filed a motion seeking an order requiring that the future medical care award be placed in a reversionary trust, funded by the government where the remainder of the trust would revert to the government in the event that
Mr. Farley dies before he has spent the full amount of his award for medical care. Mr. Farley objects, arguing that a First Circuit case, Reilly v. United States, 863 F.2d 149 (1st Cir. 1988), prohibits such reversionary trusts. The court disagrees with Mr. Farley.
In Reilly, the First Circuit held that a court did not have the power to order the government to pay an FTCA damages award in anything other than a lump-sum payment. 863 F.2d at 170. The government argued that the district court erred in not requiring the future medical damages to be awarded via a structured, periodic payment (such as an annuity). The First Circuit held that payment of damages in installments was not permitted under the FTCA. Once the government makes a lump-sum payment, however, the First Circuit made clear that a district court has an obligation to protect the intended beneficiary of that award, particularly where, as here, it goes to a third party on behalf of the injured plaintiff. The First Circuit explained:
When a tortfeasor loses at trial . . . it must pay the judgment in one fell swoop. After the wrongdoer and its funds have been parted, the focus shifts: it cannot be doubted that the court has power (1) to ensure that the recovery benefits the victim, and (2) to exercise strict supervision over investment and use of the funds if the victim is a legal incompetent or otherwise in need of protection. But these verities in no manner support the proposition that the wrongdoer has a right to pay in installments where the plaintiffs are unwilling. Nor does the court have a right to impose a periodic payment paradigm on the parties, over protest, solely to ease the tortfeasor’s burden or to suit some fancied notion of equity. Reilly, 863 F.2d at 170.
The court intends to order the government to place Mr. Farley’s entire medical care award into a trust administered by a person completely independent of both the government and Mr. Farley’s relatives. A trust where the government has no control over the administration, but retains only a reversionary interest as the remainder beneficiary (in the event of Mr. Farley’s premature death) may well serve the best interests of Mr. Farley. Such an arrangement would maximize the possibility that the corpus of the trust would be used to provide Mr. Farley with the best care as soon as possible. This is especially important in Mr. Farley’s case because his need for home health care is urgent, and the early, upfront costs of his care plan (as drafted by Dr. Eilers), which are largely directed to the goal of bringing Mr. Farley home, are substantial, amounting to well over $1,000,000.00. A trust from which the corpus reverts to the government minimizes any incentive his caregivers might
have to drag their feet with regard to incurring those expenses.
The clerk of the court is instructed to enter judgment against the United States in favor of Mrs. Farley, on behalf of Mr. Farley, in the amount of $21,468,710.62, and in favor of Mrs. Farley, individually, in the amount of $100,000.00. The judgment shall be paid in a lump sum. The portion of the lump-sum payment to Mr. Farley that is devoted to Mr. Farley’s medical care ($13,368,710.62) shall be placed into a trust for the benefit of Mr. Farley. The parties are ordered to meet and confer, and to file, on or before April 22, 2015, a proposed order setting up the terms of such a trust. The goal of such trust shall be to maximize the likelihood that the medical care
Attached to the government’s motion for a reversionary trust is a proposed order establishing such a trust (doc. no. 54-2). That document reads as though it were a document the government had negotiated with Mr. Farley to settle the case. It reads that way because it gives the government control over decisions related to the expenditure of Mr. Farley’s medical care award. But, of course, the government would have a clear interest in minimizing the amount spent on Mr. Farley’s medical care by virtue of its reversionary interest. While the court is inclined to approve a reversionary trust, any such trust should not give the government power to control the disposition of trust funds. The sole role for the government should be that of remainder beneficiary.award will be spent solely on Mr. Farley’s medical care during the remainder of his life and in a manner that maximizes his physical and mental wellbeing. Should the parties fail to file a proposed order that meets this goal, the court will appoint, on an expedited basis, an expert to advise the court on trust law so that the court can design a trust instrument that best protects Mr. Farley’s interests.
Pursuant to 28 U.S.C. § 2678, attorneys’ fees are limited to 25% of the judgment, which the court finds to be a reasonable fee in this case. Post-judgment interest shall be awarded in accordance with 31 U.S.C. § 1304(b)(1).25
The complete opinion can be found at:
The GAO’s recent report that medical care at the VA is a high risk activity is nothing new. The Rocky movie series has had fewer remakes than the GAO’s studies into medical malpractice at the Department of Veterans Affairs.
Who can forget these predecessors to the current GAO report about the poor quality of medical care at the VA?
If you think that medical malpractice is a new issue at the Department of medical affairs then you should read this New York Times Article from 1946!
REHABILITATION; Improved VA Medical Services Under Direction of Bradley Along Lines Urged by Baruch Win Praise of the Disabled
By HOWARD A. RUSK, M.D. ;
February 03, 1946,
In demanding the ouster of Gen. Omar Bradley as Veterans Administrator, John Stelle, head of the American Legion, charged the Veterans Administration with failure to use available hospital beds and indicated that thousands of veterans …
If you are contemplating suing the Department of Veterans Affairs for medical malpractice at a VA medical center, it is extremely important that you obtain all of your records. The VA rarely turns over its complete file to either claimants or attorneys, without a fight. Read this training that the VA gives its employees so that you understand what is innvolved in getting a medical record from the VA if it is going to be used in a medical malpractice case against the Department of Veterans Affairs.
Why are veterans frequently subjected to medical malpractice at the VA?
Maybe it has something to do with the qualifications of the doctors who work at the Department of Veterans Affairs? Look at this recent example from a major VA medical center, where a doctor who had been disciplined the state medical board ended up getting an important position with the VA medical center.
A top physician for the Miami Veterans Affairs healthcare system surrendered his medical license in New York and faced sanctions in Florida one year before he was tapped for his current position
A top physician for the Miami Veterans Affairs healthcare system surrendered his medical license in New York and faced sanctions in Florida one year before he was tapped for his current position. The 2010 sanctions resulted from the case of a patient with a torn large intestine, who died under the care of Dr. Vincent A. DeGennaro, at a Fort Lauderdale hospital.
The Miami Herald reported that a 2008 complaint filed with the Florida Board of Medicine by Florida’s department of health alleges that DeGennaro misinterpreted his patient’s x-rays and failed to do proper follow up, resulting in the patient’s 2003 death.
DeGennaro, 68, did not answer a phone listed for his home in Pompano Beach Saturday. A recorded greeting said messages would not be returned.
It was not immediately clear why the complaint was filed so many years after the incident.
In 2010 DeGennaro surrendered his medical license in New York in an agreement stemming from the 2003 case. He agreed never to reapply for a physician’s license or again practice medicine in the state. DeGennaro could have had his license also suspended in Florida, but instead the Board of Medicine censured him and fined him $5,000, as well as charging him legal costs and 50 hours of community service.
DeGennaro’s case comes as the nation has increasingly scrutinized the Veterans Administration’s healthcare system for extensive delays and other problems in Florida and nationwide.
Why is medical care at the VA not as good as it could be? Maybe its because the VA employs an army of “public affairs officers” who are really nothing more than spin doctors who manage to feed the popular media warm fuzzy press releases about the VA, which the popular media regurgitate to the public.
David Cowgill VISN 4 PAO receives “I don’t care award” for declaring victory of VISN 4′s quality of care issues during the height of the Pittsburgh VA’s Legionella debacle!
Its time for VAmalpractice.info to recognize those who have contributed the most to covering up what has been going on at the VA. Few people realize that the VA spends millions of dollars each year on its publicity machine. In fact the VA employs a group of spin doctors who make big tobbaco’s publicity efforts seem honorable. The VA probably does have some legitimate need to have a staff who can respond to media inquires and compose informational public service announcements, but do the taxpayers really benefit when the VA advertises that its” better than the best?”
Our first winner is David Cowgill whose efforts included producing a series of TV ads advertising that VISN 4 was “Better than the best.”Let’s face it takes guts to claim that your “better than the best” when your the subject of a Congressional investigation into an outbreak of Legionnaires’ disease, but then again this is the way the VA publicity machine deals with the VA’s problems: declare victory and go home!
During the height of the Legionalla outbreak these ads featured Michael Moreland claiming that the VA had taken on the leading hospitals in the country and had beaten them in various measurements.
When VISN 4 compared its ability to provide quality health care with the best hospitals in the United States, we equaled or exceeded our competition in every category. This is proof that our nation’s heroes are being provided the quality of health care that they richly deserve.
The measurement of things like “patient satisfaction” is subjective and comparison with surveys conducted at nonVA hospitals is difficult and gave the VISN 4 free reign to use fuzzy math at its finest! Interestingly the spots never mentioned that VISN 4 has the worst ventilator acquired pneumonia rate in the VA system. In fact it was far worse than the 22 other VISNS in the VA, but when your ads are not accountable to any agency for false advertising you can get away with things like this!
If this wasn’t enough his department made liberal use of the VA’s police department to keep Anderson Cooper’s colleagues out of the Pittsburgh VA and prevented members of the media from using recorders when they interviewed Michael E. Moreland, to record the interview. This is a standard reporting practice, which allows reporters to double check to make sure that they are actually quoting someone correctly, was prohibited by Mr. Cowgill and enforced by the VA’s armed police officers! So much for freedom of the press in VISN 4.
VA declares victory over quality of care issues, despite the facts: or
“Maybe they’re drinking too much of their own Kool-Aid”
The September 25, 2013, VA OIG’s report “Quality of Care Issues: Erie VAMC & VA Pittsburgh Health System” is yet another in a series which should be called “More news from Michael Moreland and VISN 4.” The OIG’s 11 page report tells a sorry story about the medical treatment that a veteran received from August 15, 2102 through October 1, 2012 for his liver cancer, it tells an even sorrier tale about the “treatment” that this veteran and his family received from an institution that has the audacity to spend the taxpayer’s money to advertise that “it is better than the best.” These six weeks turned out to be the only medical care that the veteran would ever receive from the VA, as he died on October 6, 2012. The OIG found: We substantiated the allegation that VA providers did not diagnose the patient’s cancer.. We found VA providers missed opportunities to identify the patient’s cancer and determined several factors that may have contributed to providers not making the cancer diagnosis… We substantiated the allegation that the patient’s pain was not fully addressed… We substantiated the allegation that there were scheduling delays in the patient’s referrals and follow-up care… We substantiated the allegation that this patient did not receive comprehensive oversight through the continuum of his care… During interviews, many referring providers from the CBOC, Erie VAMC, and Pittsburgh HSC told us it was difficult to communicate with the gastroenterology and Hematology Clinic specialists. They told us their phones calls occasionally go unanswered and the specialists did not always return phone messages. Unfortunately none of these finding are surprising; but what is amazing is the indifference to reality that allows the VISN 4 leadership to continue their tireless campaign of self-promotion and disinformation at the expense of the taxpayers. Let’s look at the dates of this veteran’s treatment and a few other things that were happening in VISN 4:
- 8/15/2012 Veteran’s first contact with VA system
- 9/30/2012 End of VA’s fiscal 2012 year (This is the year that Michael Moreland received the $63,000 presidential award for)
- 9/30/2012 VISN 4 is rated the worst in the country using the VA’s own ASPIRE quality measurement system for Ventilator Acquired Pneumonia
- 10/01/2012 Veteran’s last of 13 contacts with VA system since 8/15
- 10/06/2012 Veteran Dies
- Fall 2012 VISN 4 “Vision for Excellence” features stories proclaiming that healthcare provided to veterans in VISN 4 is better than the health care provided by the top 5 hospitals in the nation.
Despite the tragic care that this veteran received, the fall 2012 “Vision for Excellence” had no trouble extolling the quality of the medical that VISN 4 delivered to veterans and pointed out that its ad campaign “Better than the Best,” informed Veterans that the quality of VISN 4’s care is equal to, or better than, the top five hospitals in the Nation. I’ve seen this ad and it unilaterally declares that VISN 4 “beat” the competition in vague areas like “patient satisfaction” by statistically insignificant percentages. With no explanation if these figures were gathered in the same manner at VA and nonVA institutions, Mr. Moreland enthusiastically claims that VISN 4 took on the likes of Johns Hopkins and won! The odds are pretty good that the veteran in this OIG report, along with a few who died from Legionnaires’ disease probably didn’t return their patient satisfaction surveys, but if they did they might disagree with Mr. Moreland’s evaluation. No matter what you’ve got to give Mr. Moreland credit, not everyone can get up and say that we are better than the best when you’re in the midst of a Legionnaires’ disease outbreak, a congressional investigation and you have the worst record in the entire VA ventilator‐associated pneumonias.
Ironically, nowhere in this “public service announcement” does Mr. Moreland mention that VISN 4 had the worst ventilator acquired pneumonia rate in the entire VA system. Out of the VA’s 23 VISNs, VISN 4’s record was twice as bad as the second worst VISN. This sort of head to head meaningful comparison would have provided veterans with meaningful information and would have been a “public service” because it would have warned veterans that they would have been better off going to any VISN besides VISN 4 if they were concerned about possibly getting ventilator‐associated pneumonia. Instead Michael Moreland just uses a lot of fuzzy math and unilaterally declares victory over all quality of care issues in VISN 4 and led veterans to believe that all is well. This superior level of chicanery did not go unnoticed in Washington, where this sort of thing is considered career enhancing and resulted in appropriated recognition:
…“Better than the Best,” informed Veterans that the quality of VISN 4’s care is equal to, or better than, the top five hospitals in the Nation. This campaign won first prize in VHA’s annual communications awards program in 2012.
- 9/6/2013 Michael E. Moreland endorses the OIG report for the veteran who was treated so poorly at the Erie, VA, prior to his testimony at the 9/9/2013 HVAC hearing to examine preventable deaths and accountability at the VA. That must have put him in the right mood for the hearing. Maybe that’s why he looked so green?
Despite the overwhelming evidence contained numerous VA OIG reports and congressional investigations confirming patient safety lapses in VISN 4, during the last five years, VISN 4 continues to spend money explaining how it has done such a wonderful job dealing with patient safety.The VISN 4 web site continues to boldly state:
When VISN 4 compared its ability to provide quality health care with the best hospitals in the United States, we equaled or exceeded our competition in every category. This is proof that our nation’s heroes are being provided the quality of health care that they richly deserve.
Its most recent issue of “Vision for Excellence” it again extols how much VISN 4 has done in this area. This will be the subject of a future post called “VISN 4’s medical care “quality” publicity blitz, twisting the facts: Delusional fantasy, or indictable fraud?
Malpractice isn’t new at the VA. The reason why malpractice at the VA is now getting attention is that the public is more concerned about veterans from Iraq and Afghanistan than they were with Viet Nam era veterans.
Why has the quality of care at the VA received so much attention lately? While some will argue that it is as a result of things that have gone wrong over the last decade, I doubt that is the cause. The quality of of medical care at the Department of Veterans Affairs, and its predecessor the Veterans Administration has always been variable. The VA has always had many good health care providers who have provided outstanding medical care; unfortunately, the ability of the VA’s heath care providers has always been adversely affected by the VA’s administrators who manage to mismanage veterans ability to actually access the healthcare providers.
The VA’s insular bureaucracy is controlled by a group of entrenched self-serving bureaucrats, who have placed their needs ahead of the need of the citizens for years. What other branch of the government so routinely ignores requests for information from Congress with impunity?
The reason why the VA’s failures appear so glaring now have nothing to do with any change in the quality of medical care at the VA. What has changed is now the status of veterans in our country has improved. During the 1970s and 1980s the VA primarily took care of Viet Nam veterans. A large part of our society did not care for the Viet Nam war and many individuals were openly hostile to those who served in that war. Caring for a Viet Nam veteran was something that few individuals wanted to do as it was likely invoke criticism; therefore, the care that veterans received at the VA was just not something that most people, the press and politicians were concerned about. Individuals like Michael E. Moreland, were able to go to work at the VA knowing that they ran they show at the VA and were really accountable to no one but other VA bureaucrats. Now after another decade of war, there are many post Viet Nam veterans who receive their care at the VA. These individuals served their country at a time when members of the service were generally held in high esteem by their fellow citizens. When these veterans don’t get good care, it is something that the public, press and politicians are finally concerned with.
We will also be posting other information about crime, fraud and other things that adversely affect the quality of medical care that veterans receive from the VA, so if you have any information about medical malpractice at the Veterans Administration, or by a VA doctor, nurse or other health care provider please let us know about it.
The information on this web site is designed to encourage a discussion about Veterans Administration medical malpractice, malpractice claims and procedures. It is not intended to be legal advice. Legal advice can only be obtained from an attorney. If you have a medical malpractice claim against the Veterans Administration, you should consult with an attorney who is familiar with handling medical malpractice claims against the Veterans Administration and the Federal Tort Claims Act.
In the event that you have a Veterans Administration medical malpractice claim, you should immediately seek representation from an attorney who is experienced with litigating medical malpractice cases against the Veterans Administration or the VA.