Medical Malpractice at the VA

Medical Malpractice at the VA


John McKay said “Well, we didn’t block, but we made up for it by not tackling.” The VA makes up for not treating patients with cancer by treating a veteran for cancer when he did not have cancer.

Doesn’t it  just make good sense to clean all of the fecal matter from an instrument that  has been used to examine someone’s prostate?

April 3,2006-Apparently, the  VA didn’t think so, and didn’t bother to do it, because the manufacture didn’t  tell them that they had to. In what may turn out to be one of the “yuckiest”  messes ever, thousands of veterans may have had their prostates examined,  without having the instrument that was inserted, you know where, properly  cleaned between patients. Thousands of veterans may have been exposed to  potential infections including HIV. If you’ve had a prostate exam at the VA you will want to read the whole report.


VA paid 8 families in death lawsuits |

Updated: 11:39 a.m. Sunday, March 11, 2012 | Posted: 9:41 p.m. Saturday, March 10, 2012

VA paid 8 families in death lawsuits

Size of payout Severity of injury Alleged incident Date of incident
$275,000 death Dayton VA allegedly failed to diagnose and treat in a timely manner an infection acquired after a patient underwent hip surgery. 5/3/2006
$150,000 death Dayton VA allegedly failed to recognize and treat hemorrhagic shock following a liver biopsy. Clarice “Chuck” Pennington died 11 hours after the biopsy. 12/11/2007
$130,000 death Nursing staff at the Dayton VA allegedly failed to keep a patient from being assaulted by another patient. The injuries led to the patient’s death on June 21, 2008. 5/11/2008
$125,000 death Dayton VA’s pharmacy allegedly dispensed an incorrect dosage of a chemotherapy medication, resulting in the patient’s death. 1/3/2008
$80,000 death The Dayton VA allegedly failed to treat a patient for profound dehydration and severe infection, leading to his death on April 16, 2006. 4/16/2006
$75,000 major During a procedure, a Dayton VA surgeon negligently divided an artery, resulting in peritonitis with bile leak, according to an allegation. 1/16/2009
$70,000 death A Dayton VA surgeon allegedly performed gall bladder surgery, nicking the bowel and resulting in the patient’s death. 12/11/2008
$60,000 death Dayton VA staff allegedly failed to ensure a patient’s safety when the patient fell out of his wheelchair on May 3, 2007, and died of significant complications less than two weeks later. 5/3/2007
$50,000 death Dayton VA allegedly failed to stop urinary bleeding, resulting in continuous hospitalization and continuous catheterization, which allegedly led to the patient’s death. 9/27/2005
$50,000 major A Dayton VA nurse allegedly failed to safely and properly administer calcium chloride through an IV, allowing it to spill and burn a patient’s hand. 6/1/2010
$10,000 minor Improper performance of a surgical knee procedure at the Dayton VA allegedly led to residual nerve damage. 4/10/2006
$8,000 major A CT technician allegedly abused Lt. Col. James B. Cheney by pushing down on his forehead with all of her weight to try to get his head to fit into a bracket for a CT scan. A metal plate in Cheney’s neck had kept his head from fitting into the bracket. 9/14/2009

DAYTON — The U.S. Department of Veterans Affairs has paid out $940,000 in the deaths of eight patients at the Dayton VA Medical Center between 2005 and 2008, a timespan when VA medical malpractice claims surged, according to records obtained by the Dayton Daily News.

Medical malpractice claims are pending in two more deaths allegedly linked to substandard care at the Dayton VA. Those deaths occurred in 2009 and 2010. Those cases are among 72 medical malpractice claims filed against the hospital since January 2007.

The Dayton Daily News is revealing the deaths linked to medical malpractice at the Dayton VA for the first time. The newspaper requested the medical malpractice database Feb. 15 under the federal Freedom of Information Act, and received it last week.

Virginia “Jenny” Pennington’s husband, Clarice “Chuck” Pennington, 68, was one the eight cases. She expected to hear her husband’s voice when the phone rang in the predawn darkness on Dec. 11, 2007. Instead, a doctor from the Dayton VA Medical Center said her husband was dead.

The cause of death: internal hemorrhage due to a liver biopsy 11 hours earlier.

Pennington, of Kettering, said her husband had been on too much blood thinner prior to and after the procedure.

“The bad thing was, because they didn’t have (our) correct telephone number, when they knew he was dying, they didn’t get ahold of me so I could go in and see him before he died,” she said.

Pennington, who had lost her first husband in a plane crash in 1968, later learned nurses had not regularly checked her husband’s vital signs in the hours prior to his death, contrary to orders.

“If they would have checked on him like they should have … they would have known these things were happening,” she said.

The Dayton VA Medical Center said the 72 tort claims are an “extremely small” fraction of the more than 3 million patient care episodes performed over the timeframe covered by the database: January 2007 through February 2012.

“However small, one is too many,” the Dayton VA said in a prepared statement. “We take all tort claims seriously.”

The VA also said it is committed to accuracy and transparency in providing information about care for veterans, while protecting veterans’ and employees’ privacy interests. The VA said it routinely discloses potential adverse events of care to veterans so they can file timely claims for damages.

The largest single payout, $275,000, stemmed from the Dayton VA’s alleged failure to promptly diagnose and treat an infection after a patient had hip surgery. The patient died in 2006. The payout settled a federal lawsuit.

The remaining payouts were made through the VA’s administrative process for resolving medical malpractice tort claims. The largest administrative award, $150,000, was paid to Pennington’s family.

Another $130,000 was awarded in a case in which a patient allegedly was assaulted by another resident in 2008 and later died of injuries sustained in the assault.

In yet another case, the Dayton VA’s pharmacy allegedly dispensed an incorrect dosage of a chemotherapy medication, resulting in a patient’s death in January 2008. A $125,000 payout resolved that case.

All told, the database details incidents that led to 12 payouts totaling $1.03 million. The database did not include deceased patients’ names, but the newspaper identified some patients based on the circumstances surrounding their deaths and their dates of death.

Of the 72 claims, 22 involved the Dayton VA’s dental clinic. The vast majority, if not all, of those 22 dental clinic tort claims appear to be related to an infection control scandal at the clinic which became public in 2011.

That scandal followed revelations that a dentist in the Dayton VA’s dental clinic allegedly failed to change gloves and sterilize dental equipment between patients. That alleged poor infection control potentially put many veterans at risk between 1992 and 2010.

Sixteen of the dental clinic claims are pending, while six have been dismissed. Those 16 claims seek a total of $6.66 million for alleged damages.

More medical malpractice cases could be filed related to the dental clinic scandal. Claimants have two years to file claims from the time they become aware of an injury and learn the cause of the injury, according to the VA.

Because the database only included claims filed since January 2007, the newspaper was unable to confirm last week whether there were additional deaths in 2005 and 2006 linked to medical malpractice at the Dayton VA. Such deaths could have resulted in tort claims and payouts, but wouldn’t have been included in the database obtained by the newspaper if the claims were filed during 2005 or 2006.

Claims on rise nationwide

The number of federal tort claims filed against the VA has climbed significantly in recent years accross the nation, according to an October report by the Government Accountability Office.

In fiscal 2010, 1,670 such claims were filed, up 33 percent from 1,251 in fiscal 2005. In fiscal 2010, about $30 million was paid for 277 tort claims resolved through VA’s administrative review. Another $49 million was paid for 114 claims resolved through litigation.

The total payout of $79 million in fiscal 2010 was down from $86 million in fiscal 2007, but up from $57 million in fiscal 2005, according to a GAO analysis of VA data.

GAO investigators did not perform an analysis to pinpoint the cause of the surge in claims. But internally, they suspected the increase may have had to do with lapses in sterilizing reusable medical equipment, a problem in recent years at several VA medical centers, said Randall B. Williamson, a director of the GAO’s health care team.

The VA’s Office of Medical-Legal Affairs reviewed 2,109 paid tort claims between fiscal years 2005 and 2010. It found about half of those claims involved substandard care, and reported 785 practitioners to the National Practitioner Data Bank, according to the GAOBut the GAO report also found that some reporting of doctors responsible for substandard care likely fell through the cracks.

The GAO review found 16 percent of paid tort claims — 386 — were not reported to the medical-legal affairs office. That meant the substandard care of an estimated 140 practitioners was not reported to the National Practitioner Data Bank, the GAO said.

Through the accreditation process, the VA must undergo quality assurance processes that may have identified those 140 practitioners through other means. But if the caregivers weren’t reported to the national data bank, Williamson said it’s possible no corrective action was taken against those doctors.

“It comes back to letting people practice who may not be qualified,” he said.


St. Louis veterans’ hospital treated man for cancer that didn’t exist, suit says

…A man from Florida was treated at the John Cochran VA Medical Center in St. Louis with radiation and chemotherapy for months for a cancer that never existed, a federal civil suit filed here Tuesday claims.

The man, Dustin A. Brooks, was treated for lymphoma from July to November of 2009, the suit says. In mid-2010, he was told by the hospital that he never had lymphoma, and that he was now at risk of other cancers because of his treatment, the suit alleges… read the complete article by clicking on the headline.

 Dr. Yue Michelle Wang, Yale resident, incorrectly placed a needle with a local anesthetic “directly into veterans eye instead of behind the eye as was proper. Then, failing to recognize her error, she proceeded to inject so much anesthetic, so quickly, that Veteran’s eye literally exploded

West Haven VA admits that VA surgeon was negligent during routine cataract surgery  veteran's eyeball explodes, a clear case of medical malpractice at the veterans administration
West Haven VA admits that VA surgeon was negligent during routine cataract surgery veterans eyeball explodes

BRIDGEPORT — The U.S. Department of Veterans Affairs agreed Monday to pay $925,000 to a man whose eyeball exploded during a routine outpatient cataract operation at the West Haven Veterans Affairs hospital.

The settlement, on behalf of 60-year-old Jose Goncalves, of Hartford, was reached as the case was being prepared for trial in U.S. District Court here.

Dr. Yue Michelle Wang, the resident, incorrectly placed a needle with a local anesthetic "directly into Jose's eye instead of behind the eye as was proper. Then, failing to recognize her error, she proceeded to inject so much anesthetic, so quickly, that Jose's eye literally explode Yale resident commits medical malpractice that costs veteran his eye when it explodes and taxpayers nearly $1,000,000 in medical malpractice payment under the federal tort claims act a as a result of Dr.  Michelle Wu's medical malpractice in treating a veteran
Dr. Yue Michelle Wang, the resident, incorrectly placed a needle with a local anesthetic “directly into Jose’s eye instead of behind the eye as was proper. Then, failing to recognize her error, she proceeded to inject so much anesthetic, so quickly, that Jose’s eye literally explode


Read more:


via VA pays $925,000 in Bridgeport exploding eyeball suit – Connecticut Post.


 Malpractice Suit Draws Scrutiny to VA Hospital

Andy Meek

UNDER THE MICROSCOPE: The local VA Medical Center is being sued for $6.5 million by two sisters who claim their 60-year-old brother – who died in 2004 – suffered from complications of a botched surgical procedure. The center must respond to the lawsuit within 60 days. — Photograph By Andy Meek

Shortly before 60-year-old James Carmon died in his home in the small town of Luxora in northwest Arkansas, a medical injury had made it so difficult for him to sit in his wheelchair he would have to lie down on his couch or bed after just half an hour to relieve the pain.

Back and forth he went, receiving in-home nursing care, shifting from the wheelchair to his couch and bed. Carmon – a construction worker who had served as an intelligence specialist in the Army during the 1960s – also was a diabetic. Records suggest that being confined to the wheelchair caused his feet to swell and develop sores.

At the time of his death in December 2004, he also had a large hole in his lower back where a surgical device allegedly had left burn marks…. read the complete article by clicking on the headline.


Veteran Awarded $600,000 for VA’s Failure to Refer him for Medical Treatment

from Veterans

All Veterans who currently receive or formerly received VA Medical Care  should read this story to see if this same type of VA Malpractice  happened to them.  If it did, then they may have a Legal Cause of Action
for a Federal Tort Claim.  Even if the Statute of Limitations has  expired you can still file a SECTION 1151 CLAIM for Service-Connected  Disability which has NO TIME LIMIT.  At the end of this story there will be a Link with further information about SECTION 1151 CLAIMS and suing  the VA for Medical Malpractice in a Federal Tort Claim, among other things…… read the complete article by clicking on the headline.

Federal Judge Awards $1.25 Million in First Malpractice Trial against VA Hospital over Contaminated Endoscope

Judge Adalberto Jordan entered his ruling Nov 19th, awarding Robert Metlzer and his wife $1.25 Million for Pain & Suffering and Economic Loss

Miami After 16 months of deliberation, Federal Judge Adalberto Jordan has entered a ruling in favor of the Plaintiff in the first trial in a medical malpractice case against a United States VA Hospital for improperly sanitizing medical equipment and infecting patients with blood borne diseases including HIV, Hepatitis C and Hepatitis B.

The case alleged that Robert Metzler, a 69 year old Air Force Veteran, contracted Hepatitis C at the Miami VA hospital as a result of the hospitals improper sanitation practices. On June 13, 2007, Mr. Metzler underwent a colonoscopy with lesion removal at the Miami VA Healthcare Center. On March 23, 2009, Mr. Metzler was notified by letter from the Department of Veterans Affairs that he should be tested for certain blood borne illnesses, including hepatitis, because some medical equipment used in the endoscopies and colonoscopies at the VA were not properly sanitized in between patient procedures. After receiving the letter, Mr. Metzler was tested on March 27, 2009 and found to have Hepatitis C. Based on his having previously tested negative for Hepatitis in August 2006, Mr. Metzler’s VA doctors determined that this was a “new, active infection….

…“As a result of the negligence of the VA staff and health care providers, Mr. Metzler contracted Hepatitis C during a routine medical procedure because the equipment was not properly cleaned, sterilized, or sanitized,” added Gonzalez. An investigation conducted by the Department of Veterans Affairs reported that more than 11,000 veterans received colonoscopies with improperly-cleaned equipment between 2004 and 2009 at VA hospitals in Miami, Murfreesboro, Tenn., and Augusta, Ga.

Family blames Veterans Affairs for man’s death

August 3, 2011 3:56 PM
By Jessica M. Karmasek

CHARLESTON — The family of a deceased West Virginia veteran is suing the U.S. Department of Veterans Affairs for wrongful death and medical negligence.

Robert L. Bailey Jr., on behalf of the estate of his father Robert L. Bailey, filed a federal tort claim complaint in the U.S. District Court for the Southern District of West Virginia on Friday.

Robert L. Bailey, a veteran and West Virginia resident, was a patient at the Beckley Veterans Hospital. He had complained of symptoms of chest congestion, difficulty breathing, shortness of breath and weakness.

According to his son’s lawsuit, “radiological studies properly reviewed and interpreted placed lung cancer squarely within the differential diagnosis.”

However, diagnostic testing was delayed and follow-up care and investigation into the proper differential diagnosis was not performed, the suit alleges.

Robert L. Bailey died from cancer on Jan. 25, 2007.




GAO Report on Medical Malpractice at the Department of Veterans Affairs



J South Orthop Assoc. 2003 Summer;12(2):56-9.

Orthopaedic malpractice claims in the VA medical system.

Rubin G, Dean A, Schwartz HS.


Department of Veterans Affairs Medical Center, Section of Surgery, Nashville, TN, USA.


This study was undertaken to delineate the outcome of orthopaedic malpractice claims in the Veterans Affairs Medical Center (VAMC) system compared with the private sector. All orthopaedic administrative tort (malpractice) claims handled by the Office of Regional Counsel in Nashville, Tennessee during the 5-year period (8/93-7/98) were analyzed. Attention was directed at: 1) the number and type of claims, 2) the disposition of the claims, 3) the average award or settlement and range in size of awards (indemnity), and 4) the length of time required to process and dispose of each claim. These data were compared to those compiled in that segment of the private sector represented in the database of Physician Insurers Association of America (PIAA) for a similar five years (1/90-12/94). Twenty-six claims were filed in the 5-year study period and 22 were adjudicated by December 1999. Fourteen of 22 (64%) were defended successfully and eight (36%) resulted in an award to the claimant plaintiff. In the private sector those figures were 69% and 31%, respectively. The VAMC average indemnity was 20,404 dollars (range, 3500-100,000 dollars) versus 145,200 dollars in the private sector. Approximately 1% of all awards in the private sector were greater than 1,000,000 dollars. The length of time required by the VAMC to process and dispose of each claim ranged from 6 to 59 months and averaged 15.2 months. The settlement rate of orthopaedic medical malpractice claims involving the VAMC and the private sector is similar. It appears that the average award is greater in the private sector. This may reflect more claims and lesser awards in the VAMC. In both systems, most claims do not result in an indemnity.

John M. Eisenberg Patient Safety Awards. Advocacy: the Lexington Veterans Affairs Medical Center.

Kraman SS, Cranfill L, Hamm G, Woodard T.


Veterans Affairs Medical Center (VAMC), 1101 Veterans Drive, Lexington, KY 40502.



After the Veterans Affairs Medical Center (VAMC) in Lexington, Kentucky, lost two major malpractice cases in the mid-1980s, leaders started taking a more proactive approach to identifying and investigating incidents that could result in litigation. An informal risk management team met regularly to discuss litigation-prone incidents. During one in-depth review, the team learned that a medication error had caused the patient’s death. Although the family would probably never have found out, the team decided to honestly inform the family of exactly what had happened and assist in filing for any financial settlement that might be appropriate. This decision evolved into an organization wide full disclosure policy and procedure.


The Lexington VAMC’s policy on full disclosure includes informing patients and/or their families of adverse events known to have caused harm or injury to the patient as a result of medical error or negligence. The disclosure includes discussions of liability and also includes apology and discussion of remedy and compensation.


Full disclosure is the right thing to do and the moral and ethical thing to do. Moreover, doing the right thing actually seems to have mitigated the financial repercussions of inevitable adverse events that result in injury to patients. As reported in 1999, Lexington VAMC was in the top quarter of medical centers for number of tort claims filed but was in the lowest quarter for malpractice payouts resulting from these torts


He made peace with God but waged war on the VA


Sunday, January 28, 2001



Cleveland, Ohio

Though his pastor told mourners that Terry Soles had made his peace with God, his war with the veterans’ hospital was a different matter. That’s something he passed on like an inheritance to his wife, Dee, and their five children.

“He made me promise I would fight them,” Dee Soles said.

Soles’ ordeal is an example of what many veterans claim is substandard medical care at veterans’ hospitals.

Soles’ war began in 1998 when his family doctor suggested he go to the Cleveland veterans’ hospital for tests to find out what was causing his intense pain and diarrhea. That sounded like a good idea to the uninsured owner of a small Minerva construction business.

VA doctors found what was described in his medical records as a small cancer at the bottom of his esophagus and the top of his stomach. They cut it out in October 1998, but the pain and the diarrhea persisted.

As the months passed, the 54-year-old Soles shed pounds and watched while tests were done and lost and done again and lost again. He waited hours for scheduled appointments, and when he left, he was tagged a problem patient.

“I’ve had 999 rectal exams,” he said last summer, several months before he died in October. “It’s enough.”

Cancer, according to Terry and Dee Soles, was never mentioned by the scores of doctors who saw him as a possible cause of his continuing problems. And they believed that the operation had cured him.

“We asked them at the VA time and time again about the cancer,” Terry Soles said….

Last August he stopped a surgery while in the operating room when hospital workers there began arguing over what part of his body needed to be numbed for the procedure.

Several weeks later, he stopped another operation to possibly remove a portion of damaged small bowel when he was told moments before being wheeled in that the risky surgery was unlikely to do any good.

On Oct. 8, Soles, beyond frail with unhealed sores covering his body, was taken by ambulance to Aultman Hospital in Canton suffering from hypothermia. Once 220 pounds, his weight had dropped to 100 pounds.

There, doctors soon found a large, cancerous mass that started at his trachea, engulfed his esophagus and pressed against his heart. A lesion was seen in his kidney. They offered hospice care.

But the campaign Soles had waged for good medical care at the veterans hospital didn’t wane, even at the end….

On Oct. 15, Soles died in his living room in the hospital bed the VA wouldn’t give him until he was eligible for Medicare in August.

Today, his widow is still in the middle of his war. Bill collectors have been hounding her, trying to get her to pay a $41,000 medical bill from the Cleveland Clinic where VA doctors had sent him so that a morphine

pump could be implanted in Soles’ abdomen to relieve his pain.

“The VA tells me they are going to pay,” Dee Soles said. “I called the Clinic and they said the charge has been denied.”

While she takes a pragmatic view of her financial situation, Dee Soles said that fighting against the VA is what is keeping her going.

She recently obtained a letter, after months of trying, in which a top VA administrator wrote to a non-VA doctor, “We believe that there is a significant psychosomatic overlay to Mr. Soles’ symptoms and he has not been compliant with the outlined management regimens.” The letter was written nine months before his death.




VA patients encounter tangled web of doctors in training, long waits for appointments, resistance to change in troubled system

Sunday, January 28, 2001



Cleveland, Ohio


Veterans who offered their lives for their country now may be putting them on the line again in the very hospitals established to heal them.

Nearly 4 million people depend on the nation’s Veterans Affairs hospitals and clinics, but an investigation by The Plain Dealer discovered that the largest full-service health system in the country is operating under many rules that would not be allowed elsewhere, sometimes with disastrous results.

Among the findings:

Veterans often are treated by residents – doctors in training – who rotate through VA hospitals usually every three months.

While residents are working on patients, supervising physicians are sometimes elsewhere, treating other, privately insured patients while they’re being paid to be at the VA.

The VA allows supervising doctors to guide residents over the telephone.

Even using residents and hiring foreign doctors, many veterans hospitals are so understaffed that patients can wait close to a year to see a doctor.

Any major change in the system is certain to meet full-scale resistance from not only the doctors and hospitals, but also from veterans groups and members of Congress.

The Plain Dealer also found that the federal Office of Inspector General, which inspects VA care and other VA programs, has so few investigators that it can’t begin to properly handle the 15,000 complaints it gets each year.

For example, it has been 18 months since investigators began looking into the care that 78-year-old Halver Durbin received at the Cleveland veterans’ hospital.

In July 1999, the then 78-year-old Army veteran was transferred to Cleveland from Dayton for bypass surgery. His surgery was successful, but his chest wound wouldn’t heal.

Over the following weeks, doctors twice removed dead tissue and breast bone, until his sternum was gone. They then moved a piece of muscle to cover his heart.

That failed, and three weeks later plastic surgeons again were trying to close his chest when they found that his abdomen was badly infected.

They called for a general surgeon.

Dr. John Raaf, chief of surgery at the veterans hospital, was supposed to be in charge of surgery that day. But his usual routine was Mondays at University Hospitals, Fridays at the University Suburban Health Center – the same days he scheduled himself to be at the VA from noon to 5 p.m….


“I have experienced an unacceptable compromise of my own personal standards of care and have been faced with several situations in which I was required to assume care of patients that I felt were either neglected or mismanaged by another physician,” White-Owen wrote to Dr. Jerry Shuck. “In good conscience I can no longer participate in this flagrant itinerant surgical care.

“It is my understanding that I am not the first surgeon, and may not be the last one, to resign for the reasons mentioned here.”…

…After World War II, the 98 veterans hospitals had a fraction of the number of doctors needed to care for the returning veterans. Medical schools began sending interns and residents to the veterans hospitals. In the 1970s, the VA took care of its shortages by hiring foreign doctors.

But the shortage of full-time doctors continues today.

A review of the staffing levels found some of the nation’s largest veterans hospitals – Cleveland (including the Brecksville campus), Pittsburgh, St. Louis, Atlanta, and Hines VA Hospital outside Chicago – have about half of their medical staffs employed part-time. In New Orleans, about two-thirds of the staff doctors are part-time. In Omaha, Neb., the figure is more than 92 percent.

Because of the shortage, patients often must wait for care, some nearly a year.

Last year, veterans at the North Texas system, which includes Dallas, had waits of 228 days to be evaluated for orthopedic surgery and 193 days for neurology.

Waiting 85 days At the Fresno, Calif., veterans hospital, patients had to wait 85 days for a neurosurgery appointment. Patients at the Omaha veterans’ hospital had similar long waits to see cardiologists and primary care doctors.

In Maine, veterans recently picketed the hospital because of long waits and inadequate staffing.


Settlements and verdicts are increasing, with injured veterans and grieving families being awarded nearly $500 million in the past decade.

Watchdogs post reports The VA’s watchdogs, the Office of Inspector General and Congress’ General Accounting Office, have put out hundreds of reports over the last several years detailing problems, such as patients left for days lying in their own feces or on gurneys in hallways, or reports on doctors being AWOL when they were being paid to care for patients and supervise residents.

And veterans hospital administrators have been hauled before Congress to explain why no one noticed when a dialysis patient in Miami bled to death or how a surgery patient in Boston was given the wrong blood and died.

“The authority to act on it does not rest with us,” said Richard Ehrlichman, deputy assistant inspector general for management and administration. “There are senior executives that are well compensated and are accountable for these programs. It should be their responsibility.”

Federal officials have been to the Louis Stokes Cleveland VA Medical Center at least five times in last few years, including this past December, investigating problems and complaints.

Problems in the anesthesiology department alone have brought out investigators at least twice in the last three years.

….The most recent federal investigation found that there were anesthesia providers “who are functioning beyond their level of competence,” the inspectors wrote last April.

Five of the busiest surgeons had signed affidavits stating they were concerned about the capabilities of the anesthesia providers, and some said they refused to use a particular provider during their operations.

The lead investigator wrote that the stopgap measures the Cleveland veterans hospital has undertaken “because of the lack of adequate number of skilled staff … has forced compromises in quality of care over the 24-hour-a-day service that must be provided.” …

But, at least in the world of public and private hospitals, the best programs are not permitted to leave residents alone in the emergency room with a patient. Tomorrow we see what happened to a 73-year-old patient when he went to the Hines veterans hospital near Chicago, complaining of a pain in his leg.


World War II hero suffocated when tube put in lung

Monday, January 29, 2001



Cleveland, Ohio

San Antonio’s Audie Murphy veterans hospital, named after the most decorated soldier in World War II, seemed a fitting place for Alvin LaRoque to get care.

LaRoque, a Minnesota firefighter for 30 years, received a Bronze Star for bravery during World War II.

Initially, LaRoque was recovering nicely at the veterans hospital after doctors successfully snipped away the beginnings of throat cancer.

One day a resident doctor inserted a feeding tube, and, as is the routine, had it X-rayed. Had she checked the X-ray, she would have seen the tube in LaRoque’s lung instead of his stomach. The feeding was started. LaRoque, 75, suffocated.

The family’s medical expert put it like this: “Mr. LaRoque’s final blood gas shows that he asphyxiated. In this condition, a person will try more and more desperately to breathe as the carbon dioxide level in the blood rises.

“This is a particularly unpleasant way to die. It is very likely that sometime before the end, he realized that his demise was imminent.”

His children looked for an apology and an explanation. Receiving neither, they said, they sued the United States, the owner of the nation’s 172 VA hospitals.

The case was settled for $350,000, though the government denied any liability. Their expert witness gave LaRoque, at most, “no more than a few years” if he hadn’t suffocated. LaRoque’s family would have taken that.

“I remember going to some fires he was fighting in the winter and seeing the icicles coming off his helmet,” his son Douglas LaRoque said. “He had such a dangerous job and then to die like he did.”





VA cardiac surgery units suffer higher death rates
Wednesday, January 31, 2001 – By JOAN MAZZOLINI


The Department of Veterans Affairs clings to its heart surgery programs even though its patients die more frequently than heart patients in private and public hospitals. The VA acknowledges that some of those programs don’t do enough surgeries each year to guarantee proficiency. Some of those hospitals just don’t have enough heart surgeons willing to work for them, the VA says. This is costing taxpayers millions of dollars each year and risking the lives of veterans. Many of them qualify for Medicare coverage and could go elsewhere if they knew their VA hospital had a troubled heart surgery program. A Plain Dealer investigation found that: More than one-third of the 42 veterans hospitals performing heart surgery don’t do at least 150 heart surgeries a year, the minimum the VA requires and experts recommend. …. ”

Problem years Over the last six years, nearly half of the veterans hospitals with cardiac programs have been either monitored or put on probation. Monitoring entails reviewing each patient death. Probation indicates more serious problems that if not corrected quickly could prompt the VA to end the program. The VA shut down the Lexington, Ky., program in late 1996, after death rates reached more than 10 percent. The VA also shut down programs in Brooklyn, East Orange, N.J., and Long Beach, Calif., in the late 1980s.The Little Rock, Ark., program stopped doing heart surgeries in 1997 when its death rate reached nearly 10 percent. … The study isn’t completed, but one of the researchers has concluded that the low volume of heart surgeries at VA facilities may have led to “poorer patient outcomes, in terms of both cost to the VA health system and the quality of care provided. “Shipping heart patients to other hospitals, he wrote, “may be a beneficial and cost-effective strategy.

Phone: 216-999-4563 ©2001 THE PLAIN DEALER. Used with permission.


VA patients paint picture of neglect
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DOUG J. SWANSON, Dallas Morning News
Posted 2005-02-16 05:56:00.0

VA patients paint picture of neglect
Director acknowledges problems, says Dallas hospital is improving

on Sunday, February 13, 2005

By DOUG J. SWANSON / The Dallas Morning News
John Hahn lay marooned in his bed last year at the Dallas veterans’ hospital, desperately seeking a nurse. An Air Force vet whose terminal bone cancer had made him a paraplegic, Mr. Hahn required turning every two hours.

That day, March 21, he started at 5:30 a.m. pushing his call button, which rang at the nearby nurse’s station. No one came. He pushed it throughout the morning and into the afternoon, and still nothing.

“Called/Requested help for the past 8 hrs,” he wrote in his journal.


Finally, in anger and frustration, Mr. Hahn used his bedside phone to summon the police.

An officer arrived within minutes, and nurses said they had in fact checked on Mr. Hahn several times. When the officer left, a hospital aide gave the patient the relief he sought.

“Took 5 min,” Mr. Hahn, 61, wrote in his journal. “Within an 8 hr period of time they couldn’t find 5 mins. to turn me.”

Although his solution was unusual, Mr. Hahn’s story of neglect at the Dallas Veterans Affairs Medical Center is not…


…Stephanie Canada of Dallas remembered her husband’s hospitalization last year for a stroke. “The nurses there do not care if people live or die,” she said. “There was plenty of staff, but they’d rather play cards.” …

…Officials with the U.S. Department of Veterans Affairs said they are aware of problems at the medical center, which ranked last among all veterans hospitals in its adherence to federal performance standards in 2004…

Over the last three weeks, a reporter for The Dallas Morning News has spoken to, or exchanged e-mails with, more than 150 Dallas VA patients or their families. …

…But many of those interviewed also described deliberate mistreatment at the hands of nurses and support staff. They portrayed much of the medical center as a dirty and ill-equipped institution where patients cry out vainly for aid and others are left to die alone.

Ms. Pritchett, for example, said nurses and aides routinely ignored her bed-ridden father, an 81-year-old Marine veteran of World War II who won the Navy Cross. He wasn’t alone in his suffering at the hospital’s Transitional Care Unit.

“I would be walking down the hall, and patients would be calling out for me to get help, because the nurses wouldn’t answer,” Ms. Pritchett said. When she went to nurses to complain, she said, she found them “sitting there having lunch.”

Steve Van Note, a Plano police officer, said his stepfather, an Army veteran of World War II, checked into the Dallas VA in late 2003 for treatment of breathing problems. In his bathroom “there was feces splattered on the wall,” Mr. Van Note said. “In one week alone there were three or four days when they didn’t feed him.”

Aides told the family the patient had been set for medical tests that required them to withhold food. Actually, Mr. Van Note said, no tests had been scheduled.

Not only patients and families find fault. Dr. Dell Simmons, a resident physician in emergency medicine at the Dallas VA, said patients are dying needlessly.

“Lives are being lost unnecessarily due to the mismanagement of this facility,” Dr. Simmons said. “We’re constantly in a battle to get care accomplished. … They have an under trained and undermanned staff, and it’s poorly deployed.”

Dr. Simmons, who is in the second month of his residency, said many patients face long delays in receiving routine tests and procedures, especially on nights and weekends. “Those kinds of things can turn a problem that can be easily treated into a disaster,” he said, adding that he sees little hope for improvement. “People here have really kind of given up fixing problems.”


Low marks

…The inspector general for the Department of Veterans Affairs, in a report completed in November 2004, gave the Dallas hospital low marks in many areas, including sanitation, management and patient safety. …

But Robert Faulkner of Abilene, an Air Force veteran and safety engineer, said he was admitted to the hospital in November and found his room filthy. A urine-soaked pad had been left under his bed, he said. He discovered another pad in the nightstand drawer, this one smeared with excrement.

“There was bloody gauze all over the floor,” Mr. Faulkner said. “I showed it to the nurse, and she said, ‘What do you expect? This is the VA.’ ”


…Ms. Davis said the man, who asked that he not be identified for fear of retaliation, had a tracheotomy with a breathing tube inserted. Such tubes often need to be suctioned for the removal of mucous and saliva. Many times, she said, nurses refused to perform this procedure.

“I literally had to go in and do the suction for him,” she said. “The nurses would disappear.” …

Last month, The News disclosed results of a federal survey of medical students at the Dallas VA. They said an incompetent and uncaring nursing staff often neglected and abused patients….

…Some nurses and doctors at the Dallas VA pointed to difficulties with poorly performing support staff, such as aides and custodians. Incompetent workers are rarely fired, they said.

“These people are protected by the union,” one nurse said, “and they move from one unit to another because nobody wants them.”


Lack of cooperation


…Many patients and families said hospital management has shown little interest in reacting to problems.

Ms. Turner said she filed an estimated 10 complaints with hospital officials but never received a satisfactory response. “Nobody wants to do anything there,” she said. “Ninety percent of the people, if you ask them to do anything, they act like you asked them to do a flip or something.” …

She conveyed her concerns about such treatment to hospital officials, Ms. Turner said. “They never got back with us on anything. Nothing.”

Lynn Lopez, the daughter of the journal-keeping Mr. Hahn, echoed those sentiments. “We complained at least 15 or 20 times over three months,” she said. “The response was kind of like a brush-off. You never saw anything different.”

For example, she said that despite their complaints, the staff often failed to give Mr. Hahn all his medications. Sometimes they would find his pills dumped into his bed, Mrs. Lopez said.

“We basically turned into the policing agency,” she said. “We had somebody up at that hospital 12 to 14 hours a day, seven days a week.” Mr. Hahn died in June.

…Mr. Watson had been a patient at the medical center about five years before, “and everything was terrific,” he said. This time was different.

He got one bath in two weeks. His teeth were never brushed. An emaciated patient roamed from room to room, stealing food off other patients’ trays. Nurses told Mr. Watson that the man had a tapeworm.

When he needed to urinate, Mr. Watson pressed his call button for help with the bottle. Frequently no one responded. This made little sense to Mr. Watson, who could see the nurse’s station from his bed.

“I could see three or four nurses sitting over there just chatting, having a good time,” he said. “Sometimes they’d let it ring for around a half-hour.”

At times he was left lying in his own waste for hours, and no one would answer his call button. “One night they just turned it off for an hour or more,” he said.

On another occasion he asked a nurse who was in his room to help him move his feet to ease his pain. “I said, ‘ Nurse, could you help me for a second?’ She said no and just kept on going out the door.”

After he returned home, the Watsons complained and received an apology from one of the nursing managers. “He asked that we give him another chance,” Mrs. Watson said. “I would never send Frank back there. Never.” .


A death unnoticed

Expecting a pleasant chat, they walked into his room one night and found him in bed, wearing only a diaper, unattended and not connected to equipment that monitors heart rate and blood pressure. His call button was several feet away on a nightstand.

He had been dead so long his body was cold to the touch. “His ears were blue, and his tongue was black,” said his granddaughter, Teresa Garvin of Coppell. “More than half his body was discolored.”

She went to the nurse’s station about 50 feet down the hall. The time was 8 p.m.

“I asked the nurse, ‘When was the last time you checked on David Sledge?’ ” Ms. Garvin said. “She said, ‘We checked on him about 6:30 [p.m.]. Why?’ ”

An autopsy later showed the cause of death to be cardiac arrest, Ms. Garvin said.

The family was informed that Mr. Sledge had not been connected to monitors because his condition was believed to be stable, which is in accordance with standard practice at many hospitals.

…An attending physician had this explanation for Ms. Garvin of her grandfather’s unattended death: “She stated to me, ‘I apologize, but our nurses are overworked and underpaid, and things like this just happen.’ ” .


Veteran Awarded $600,000 for VA’s Failure to Refer him for Medical Treatment

All Veterans who currently receive or formerly received VA Medical Care should read this story to see if this same type of VA Malpractice happened to them.  If it did, then they may have a Legal Cause of Action for a Federal Tort Claim.  Even if the Statute of Limitations has expired you can still file a SECTION 1151 CLAIM for Service-Connected Disability which has NO TIME LIMIT.  At the end of this story there will be a Link with further information about SECTION 1151 CLAIMS and suing the VA for Medical Malpractice in a Federal Tort Claim, among other things.

Deasy v. US., 99 F.3d 354 (1996)

VA Hospital Malpractice; Failure To Refer Patient

Under Colorado and Maryland law, the evidence supported a district court’s finding that Veterans Administration (VA) psychiatrists committed malpractice by failing to refer a patient for medical treatment for his edema, held the U.S. 10th Circuit Court of Appeals. This was so even though the government claimed the plaintiff’s psychiatrists were not qualified to offer expert opinion on the standard of care required of physicians who treat edema, since the relevant issues in the case were whether it was a breach of the psychiatric standard of care to fail to refer the patient and whether failure to do so increased the patient’s psychiatric symptoms, on which the psychiatrists were qualified to give expert opinions, said the court.

The court also found that the district court’s award of damages to the patient in the form of a reversionary trust for lifetime medical and psychiatric care outside the VA system was not clearly erroneous, as the patient was entitled to a lifetime of free care in government hospitals, but, due to the VA’s malpractice, further treatment in a VA hospital would result in a recurrence of the patient’s serious psychiatric problems.

In addition, the court held that an award of $600,000 to the patient for pain and suffering was not excessive. Failure to treat the patient’s severe case of edema resulted in post-traumatic stress disorder (PTSD).

In this case, a patient brought a Federal Tort Claims Act (FTCA) suit for medical malpractice against the U.S. and VA hospitals. The district court entered judgment for the patient, and the appeals court affirmed.

 VA Facilities Did Not For the seven VA facilities we visited to determine compliance with employment screening requirements for practitioners, we found poor compliance with four of the five requirements we selected for review. Two Employment of these five requirements VA implemented since our March 2004 report- for individuals VA intends to hire, query HIPDB and use an employment Screening checklist to document the completion of employment screening Requirements for requirements. Three other employment screening requirements were long- standing-verify health care practitioners’ state licenses and national Practitioners certificates; complete VA Form 2280, which is used to determine the appropriate type of background investigation needed for each health care practitioner job category; and conduct background investigations. In order to show the variability in the level of compliance among the facilities, we measured their performance against a compliance rate of at least 90 percent for each of the screening requirements, even though VA policy requires 100 percent compliance with these requirements. None of the facilities had a compliance rate of 90 percent or more for all screening requirements we reviewed. Table 1 summarizes the rate of compliance among the seven facilities)

Long Beach VA Fails to Report Malpractice to NPDB and Fails to Advise Patients That they Can File Malpractice Claims

While the VA claims that the VA’s policy is to disclose medical malpractice and advise individuals of their rights to file malpractice claims, this is still another example of a VA simply ignoring the VA’s own policies on malpractice claims. One wonders how many veterans have been subjected to malpractice, yet remain uninformed of their right to file a malpractice claim or have their pension adjusted.

Palo Alto VA Managers Violate VA Policy -Fail to Advise Patients of the Right to File Claims for Malpractice

While the VA claims that the VA’s policy is to disclose medical malpractice and advise individuals of their rights to file malpractice claims, this is yet another example of a VA simply ignoring the VA’s own policies on malpractice claims.



Can government run a health care system?

Robert E. Bauman

OFTEN IGNORED by both sides in the debate over Pres. Clinton’s now comatose national health care proposals was one exceedingly relevant, but, to some, highly discomforting fact. The Federal government already owns, finances, and operates the country’s largest health care system–the Veterans Health Administration (VHA), the principal agency of the U.S. Department of Veterans Affairs (VA).

Undoubtedly, supporters of the Clinton plan would prefer that Americans not dwell on the VA’s unsettling example as predictive of what may lie ahead on the road to compulsory national health care. Those opposed to the President’s plan, mostly Congressional conservatives in both parties, long have supported the VA as an expedient exception to their repeated arguments against big spending, big government, and “socialized medicine.”

The VA provides a cautionary example of what happens when Washington politicians put the Federal government into the national health care business and then try to micromanage the resulting medical system in a continuing attempt to please well-organized consumer constituents. Before any future consideration of yielding control of one-seventh of the U.S. economy and some of Americans’ most personal and private medical decisions to the Federal government, it is essential to examine how well government has managed Federal health care.

The VHA is the biggest health care system, public or private, in the U.S. and one of the largest in the world. With massive annual taxpayer funding, the government operates 171 VA medical centers with 80,000 beds; 362 outpatient and community clinics that receive 23,000,000 patient visits annually; 128 nursing homes with 71,000 patients; and 35 domiciliary facilities that care for 26,000 people each year. There is at least one VA medical center in each of the 48 contiguous states, the District of Columbia, and Puerto Rico.

Few Americans realize how deeply the VA health care system involves the U.S. government in what conservatives used to call “socialized medicine.” In total spending and number of employees, the VA is the second largest Cabinet-level Federal department, behind only the Department of Defense (which has its own extensive medical care system). As of July 30, 1993, the VA had 266,274 employees. The majority (243,028) work in the VHA; more than 7,000 are paid salaries in excess of $100,000; and all are exempted by Federal statute from most personal liability for medical malpractice.

The VA budget for Fiscal Year 1994 was $35,900,000,000, up $1,000,000,000 from 1993. In FY 1970, total VA health care outlays were $1,800,000,000; by 1980, they had grown to $6,500,000,000; today, they are $16,000,000,000.

Defenders of the VA point to its significant medical and research accomplishments: one of the best spinal cord injury centers in the nation (at Palo Alto, Calif.); advanced geriatric care; provision of six percent of all national adult AIDS care; treatment and research on post-traumatic stress disorders; studies of the aging process and Alzheimer’s disease; rehabilitation of the blind; development of the cardiac pacemaker, CT scan, prosthetics, and improved drug therapy for the mentally ill; and major research on drug addiction, alcoholism, and schizophrenia. In addition, the VA has training affiliations with hundreds of medical, dental, and other schools.

Few defenders of the VA would even consider, much less admit, the possibilities raised by a fundamental question: Should the Federal government be engaged at all in those health care and research activities, or could the private sector do it better?

The eligibility quagmire

The VA administers the largest American health care system, but–and this is very important to keep in mind–that care is available only to those veterans who meet certain eligibility criteria established by Federal laws and regulations. The arcane system of determining eligibility for VA medical treatment and the availability of various types of VA medical services can be highly instructive as an example of how Federal bureaucrats can and do control–and ration–medicine.

The VA eligibility system is a patchwork of many levels of possible medical coverage. In general, eligibility is based on personal characteristics of the individual, such as service-connected injuries, entitling the veteran to access to all VA services as either an inpatient or an outpatient. Eligibility also may result from other conditions or illnesses that may have been incurred during service, but are not combat related (such as cancers said to be caused by use of the Agent Orange defoliant in Vietnam or the strange new maladies claimed to have befallen those who fought in the Persian Gulf War). The eligibility of veterans and, in some cases, their dependents may hinge on the type of health service being requested (inpatient or outpatient, for instance) and its availability at any given time or facility. Most people familiar with veterans’ matters agree that there is a dire need for immediate simplification of eligibility rules.

Ninety-seven pages of Title 38, Part 4 of the Code of Federal Regulations and thousands of pages of internal VA departmental medical manuals describe what is, and is not, an officially VA-eligible disease or medical condition. VA medical boards hold thousands of individual hearings (veterans can appeal denials) on the question of eligibility for treatment.

Income status is a major factor; poor veterans are guaranteed what amounts to VA medical welfare. Fifty-two percent of all veterans who receive VA health care do so not because they were wounded in service to their country, but because they once were in the armed services and officially are defined by VA law and regulations as poor.

Just 45% of those who receive VA health care do so on the basis of medical conditions that are service-connected, but their care is, for the most part, free of charge to them–paid for by taxpayers. For those veterans, free treatment would have continued uninterrupted under the Clinton Health Security Act.

In October, 1993, the General Accounting Office (GAO) issued “VA Health Care–Restructuring Ambulatory Care System Would Improve Services to Veterans,” a report to the chairman of the Subcommittee on Oversight and Investigations of the House Committee on Veterans’ Affairs. It raises some interesting questions. For instance, what would the chances for Congressional approval of the Clinton health care plan have been if Americans peered into the future and discovered:

* More than half of the patients with routine medical conditions wait from one to three hours to be seen for a few minutes by an overworked physician struggling with increasing numbers of patients and piles of government forms, regulations, controls, and policy directives?

* One of nine patients identified as suffering “urgent” medical or psychiatric problems is forced to wait up to three hours to see a doctor?

* Because of lengthy waiting lists, patients in need of specialized care, such as cardiac or orthopedic diagnosis, even at the system’s best medical facilities, can not be seen by a specialist for 60 to 90 days and wait months more if surgery or other special testing and procedures are required?

Those real-life scenes are neither scare projections by opponents of Clinton’s plan nor descriptions of the historically inefficient British or Canadian government-run medical systems. They are the disturbing findings of the GAO study that covered 215 VA facilities, including 158 medical centers and 57 satellite and independent outpatient facilities, operated by the VHA during 1993.

The VA has more than seven decades of experience, is financed with hundres of billions of tax dollars, and has an immense professional medical staff. Yet, patients wait hours and even months for needed health care. From 1983 to 1992, American taxpayers bore the tab for $254,806,804 in damages under the Federal Tort Claims Act because of thousands of medical malpractice claims against VA personnel. (In 1993 alone, 801 new claims were filed and $41,000,000 was paid out for past claims, lawsuits, and settlements.)

The VA is the quintessential government bureaucracy–administratively officious, laden with red tape and meddlesome regulatory minutia destructive of both quality patient care and staff conduct. Three volumes of the U.S. Code (Title 38) and a full volume of the Code of Federal Regulations, plus scores of volumes of Federal personnel, medical, and administrative policy restrictions, govern each VA employee’s every move. Thousands of pages are filled with fine print, detailed descriptions of medical conditions, degrees of disability and potential eligibility, even mathematical variations thereof (disabilities are rated from one to 100%)–a maze that is supposed to produce pension benefits and free health care.

Defending malpractice

Small wonder that it requires a phalanx of more than 400 VA attorneys to interpret and reinterpret the arcane substantive and procedural provisions. Along with lawyers from the Civil Division of the U.S. Department of Justice and the U.S. Attorneys’ Offices across the nation, VA lawyers also must defend thousands of malpractice claims filed by injured patients or their bereaved survivors who blame the VA for the wrongful death of a veteran. For example, the following is a partial list of events that occurred at VA medical centers at Tampa and Bay Pines, Fla., from 1991 to 1993:

* For more than three months after abdominal surgery, a hospitalized veteran continued to complain of weakness and stomach pain. A VA radiologist misread the X-ray showing the infection-causing laproscopic sponge overlooked by a VA surgeon. The cost to taxpayers was $100,000 in damages.

* A VA orthopedic specialist misdiagnosed a veteran with severe back pain who was unable to stand up and ordered bed rest. The result was permanent paraplegia and a $1,000,000 settlement.

* An elderly, hard-of-hearing, overworked cardiologist ordered no tests for a veteran who insisted that he was suffering acute coronary pain. The doctor believed the vet was a malingerer and thus delayed lifesaving heart surgery for six months.

* For 20 years, physicians at one VA medical center freely provided Valium to a veteran who became addicted to benzodiazapines. While on vacation, he visited a Florida VA medical center, was abruptly removed from Valium, and went into seizures. He survived, but the incident cost taxpayers a $50,000 settlement.

* Two years of hearings and paperwork were required to remove permanently from duty a depressed VA nurse deemed to be a threat to patients.

VA doctors and other medical personnel have created a self-protective old-boy network. That incestuous relationship is illustrated best by the manner in which a Federal statute meant to protect patients from medical incompetents has been applied (or, rather, not applied) at the VA medical center at Bay Pines, Fla. The Medical Professional Review Act, which became effective in 1991, requires any health care provider to report to a national centralized data bank any doctor whose conduct leads to a payment as a result of a medical malpractice claim or legal action by a patient.

At Bay Pines, the peer review committee of physicians uniformly exonerated their medical colleagues regardless of the charges against them. Even the missing-sponge case mentioned earlier was not deemed malpractice and thus was not reported to the national data bank. Similar no-fault findings were adopted in all other malpractice cases during the time I represented the hospital, even when legal liability was established by VA lawyers and cash settlements were paid to mistreated patients. I was told by lawyers in the VA General Counsel’s Office in Washington that the same “see no evil” data bank nonreporting was rife throughout the VA medical system.

Consider the actions of the long-time medical chief of staff at one of the nation’s largest (and most trouble-prone) VA medical centers. Contrary to Federal and state law, he constantly pushes his personal policy dictating that all incoming patients be designated DNR (do not resuscitate). Simply put, that means that hospital staff are expected to avoid declaring a medical emergency, but if they must, they should not use any extraordinary means to save the patient. The chief doctor views his lethal expedient as a means of rationing scarce hospital beds and reducing budgetary costs at his VA facility.

As evidenced by the GAO report, one of the major problems with the VA system is growing demand for free medical services. Veterans with service-connected disabilities or conditions, and those at the poverty level, are eligible for free VA medical treatment. Others can receive free health care on an “as available” basis, depending on the case load of the facility (which contributes to the long waiting lines). The fewer than 3,000,000 veterans who were treated by the VA in 1992 made more than 23,000,000 individual visits to VA facilities.

Such highly inefficient multiple patient visits occur because the VA generally does not permit patient telephone consultations with medical personnel; usually does not allow refills of prescriptions without a personal appearance by the veteran; and, at most facilities, does not make scheduled appointments for general triage and treatment. That means “first come, first serve,” with a glut of veterans showing up early each morning, then sitting in jammed waiting rooms for hours until they can be seen by physicians. Even before the first aspirin is administered, it usually takes VA staff an hour or longer just to complete the paperwork determining if the prospective patient is eligible to receive VA health benefits. “Be prepared to spend the day there,” retired U.S. Army Maj. Elmer S. Erickson told a Miami Herald reporter at a Florida VA clinic. “You will eventually see a doctor.”

Another reason for increased patient demand at VA facilities is the distortion of “service connection.” The concept has become a political football, its elastic definition snatched away from medical experts by the politicians. A combat-wounded soldier or sailor suffers a definable medical injury that establishes his or her VA eligibility. However, what happens when the U.S. government sprays Agent Orange all over Vietnam and, 30 years later, thousands of veterans claim to be suffering various ailments as a result?

The medically debatable outcome was that Secretary of Veterans Affairs Jesse Brown ruled on Sept. 27, 1993, after years of VA studies costing millions of dollars, that certain types of respiratory cancers suffered by veterans–cancers equally attributable to smog or excessive tobacco use–are to be presumed by law to be based on exposure to Agent Orange. That makes any Vietnam War veteran with those respiratory conditions eligible for a disability pension and free health care. The five-year cost: $350,000,000 and climbing. Pres. Clinton praised Brown’s decision, saying it was “a continuation of the costs of war.”

A similarly costly VA scenario is developing with the “Gulf War Syndrome,” a mysterious malady said to be afflicting thousands of veterans of the Persian Gulf War. Under pressure from the news media, veterans’ groups, and their friends in Congress, the VA has designated a special medical task force to investigate eligibility of the new disease.

There is a far more telling indictment of the massive VA health system. With an estimated 26,700,000 veterans, most of whom are eligible from some degree of VA medical care, fewer than 10% seek VA assistance. The other 90% apparently prefer to go elsewhere when ill. Even many of the VA-eligible poor veterans choose private-sector Medicaid-paid health care providers. Those who can afford their own private physicians invariably avoid the hassle of the VA medical system.

During the first year of the Clinton Administration, the internal circles of the VA, especially top administrative and medical personnel, experienced a deep-seated, widespread anxiety. That malaise was prompted only partially by the change in the White House, although many second-level VA officials, theoretically nonpartisan, had come to power under the regimes of Presidents Reagan and Bush.

Nerves became even more frayed when the Clintons made clear that they were serious about national health care reform. VA bureaucrats wondered where the VA would fit into that brave new world and worried that it might disappear altogether, eaten up by a greater, even more bureaucratic national health system.

They need not have worried. Together with their allies in the organized veterans’ groups, the VA staff provided the talent of no fewer than 33 of its members for Hillary Clinton’s secret health task force, which hammered out the statutory structure for the proposed new system. By the time the Clinton plan actually was reduced to 1,342 pages of proposed legislation in November, 1993, the VA had ensured itself a significant role in health care “reform.” The VA’s massive structure was not to be dismantled, as insiders had feared.

The Clinton proposal projected an expanded VA system treating not only more veterans, but their spouses and dependents as well. Although required to offer a benefits package to all veterans through newly created local health care alliances, the VA would continue to provide free health care to those with service-connected disabilities and to indigent veterans. In addition, Secretary Brown would be given wide powers to draw up rules governing expanded VA benefits for veterans and their families. If the Clinton plan ever should become law, the VA also will be permitted to receive payments for its services from Medicare, Medicaid, and private insurers.

Caring for veterans’ dependents would force VA facilities to provide types of medical services, including pediatrics and obstetrics, that they generally do not offer now. Some argue that such new services could be “contracted out” by the VA to private health care providers, but that raises a logical question: Why can’t all of the VA be contracted out to the private sector?

A soothing prescription for the VA’s future

In spite of the verbal smoke screen of “competition” raised by Brown and White House health consultant Ira Magaziner, the Clinton plan would have allowed the VA to continue as a Federally funded, Cabinetlevel department, essentially independent of, but associated with, the President’s new health scheme. Magaziner soothed participants in a VA senior management conference on Nov. 2, 1993, assuring them that the President’s plan would provide the opportunity for the VA “to compete for the tens of millions of veterans VA does not now serve who would be able to bring their employer and individual contributions to the veterans’ system rather than bring them to some other health plan.”

To entice the 90% of America’s nearly 27,000,000 veterans who presently do not do so to utilize the VA for health care, Magaziner envisioned the VA’s offering them a full range of medical services comparable to those offered by private-sector health care providers. In other words, the VA would “compete” as one of many possible places for consumers to spend their health care dollars and also would continue to receive Federal funding for its traditional veterans’ health programs. Moreover, the VA would be paid by insurance companies for those who chose VA over private-sector health care hospitals or health maintenance organizations.

Magaziner did not explain why millions of veterans would be willing to pay for VA services they already have refused, even though those services are free of charge. Nor did he explain how a system that can not serve 2,600,000 veterans adequately now suddenly would obtain the capacity to treat 26,000,000 veterans and their dependents. Magaziner even held out hope that Congress could reduce annual VA appropriations, replacing taxpayer funding with private insurance payments on behalf of satisfied customers.

That misplaced idealism was shared by the President, who had projected $1,000,000,000 in savings from increased VA efficiency as part of a total $91,000,000,000 in savings (later pared down to $58,000,000,000) under his proposed national health plan. The President’s estimates were blown out of the water in January, 1994, by the Congressional Budget Office’s official estimates for the Clinton plan. They showed zero savings and an increase of more than $74,000,000,000 in the Federal deficit over the next five years, and an increase of $126,000,000,000 by 2004.

As if to underscore the hypocrisy of it all, within days of the Magaziner-VA session, Sen. Jay Rockefeller (D.-W.Va.), chairman of the Committee on Veterans’ Affairs, announced that the President had agreed to establish a special capital improvements fund to renovate ailing VA hospitals with a $1,000,000,000 first installment in FY 1995, $600,000,000 in 1996, and then $1,700,000,000 in 1997. That is in addition to the $1,000,000,000 VA operating fund increase Clinton approved for FY 1994. Rockefeller stated: “We can and must bring spending under control, but we can’t offer veterans the health care they deserve while simultaneously cutting the VA budget to the bone.”

When the President’s budget for FY 1995 was sent to Congress in January, 1994, the total VA budget was upped by another $1,300,000,000 to the highest figure ever–$39,200,000,000. Of that sum, $16,100,000,000 (an increase of $500,000,000 over 1993) would have gone for VA health care for a projected patient case load of 2,800,000, up only 27,000 from 1993. Brown predicted those numbers would permit the VA to build one new medical center, five new nursing homes, and one new outpatient clinic. So much for Clinton’s projected $1,000,000,000 in VA savings.

The existing VA system could have been the precursor of America’s future national health care system. On Nov. 3, 1993, in remarks denouncing the American insurance industry’s opposition to parts of his health care plan, Clinton said, “There’s a lot of money in the health care system that doesn’t have a rip to do with health care; … [it’s] over-complicated, burdensome, bureaucratic.” The President might have been describing the U.S. Department of Veterans Affairs.


San Diego 2006

San Diego VA Fails to advise 16 veterans of their rights, in one year, to file medical malpractice claims, does not meet VA mammography standards and fails to protect patient privacy.


Bay Pines VA Lack of Equipment Forces VA to Cancel and Delay Surgeries and Threatens Patient Safety 2004

More than seventy surgical procedures were canceled at this VA, because of lack of medical equipment. In some cases the procedures were cancelled after the patient had been medicated and was undergoing anesthesia. Most of these cases involve just getting the right supplies to the right doctors and are really nothing more than administrative foul ups, except to the veteran who rearranged their life to go thru an operation, only to have it canceled because the right piece of equipment was not in the operating room. There were times when “sterilized” equipment was discovered to have blood on it.

Bay Pines Dialysis Unit Criticized for Failing to Meet Patient Safety Requirements 2005

….We found that the BPVAMC Dialysis Unit has not developed sufficient internal policies and procedures and lacked an adequate organizational structure to ensure that the quality of care provided to dialysis patients meets acceptable standards.

Although BPVAMC has various procedures relating to several aspects of dialysis patient care, it does not have a comprehensive policy manual, dialysis nursing scope of practice, or standards of nephrology practice. The BPVAMC Chief Nurse, Acute Care, and the Director of Dialysis stated that the Dialysis Unit previously had a policy manual but was unable to locate it during our visit.

Bay Pines Radiology Backlog Unacceptable and Affects Patient Care According to VA OIG-2004

Radiology Service had extensive backlogs for film and image interpretations. Once radiological examinations are completed, a radiologist must review the films or images produced and provide a diagnostic interpretation. The time frame within which a radiological study should be interpreted depends on the type of examination and the urgency of the request. According to facility guidelines, “stat” (emergency) requests require the examination to be performed and its interpretation completed within 1 hour. “Urgent” requests require the examination and interpretation within 2 hours. “Routine” requests require the examination within 30 days and image interpretation within 4 days of examination completion.
Image interpretation backlogs have been a long-standing problem at the BPVAMC. A February 26, 2003, memorandum from the Chief, Clinical Diagnostic Support Service (CDSS) to the Chief of Staff reported that, “As of February 26th, the CDSS Imaging section has reduced the backlog of unread exams from 3000+ to 900 over the past 2 weeks,” and that “…it is our hope that by mid March [2003] the section will be able to perform a 48 hour or less turn around time for all imaging exams.” However, as of February 24, 2004, there remained 1,099 unread examinations, with some routine MRI examinations dating back to December 9, 2003.
The Acting Chief, Radiology Service, reported that delays in image interpretation were the result of management’s failure to listen to his needs and their denial of his repeated requests for resources. In May 2001, Radiology Service phased in various components of the Picture Archive Communication System (PACS) program, which allows radiologists and other providers to view digital images on computer workstations, thus obviating the need for hard copy films. By July 2003, all radiographic images (with the exception of mammograms) were available on and interpreted from PACS. This enhanced technology resulted in an increase in the number images needing interpretation.
Timely interpretations are critical to quality patient care. Delayed interpretations of radiological examinations can result in delayed diagnosis and, for some patients, a delay in instituting potentially life-saving treatment.

Bay Pines VA Physicians Fail to Follow Up on Lung Cancer Cases

There Were Long Delays in Diagnosing Lung Cancer

We reviewed 10 patient medical records that were referred to us to assess the length of time between the first radiological evidence of suspicious lung lesions and definitive diagnosis. In six of these cases, the time elapsed from first detection of a lesion on chest x-ray (CXR) to tissue diagnosis ranged from 49 days to 126 days (mean 82 days). In 2 of the remaining 4 cases, a clinical decision by a physician to monitor the abnormality with serial CT scans was made. In the third of the remaining 4 cases, no physician followed up on the abnormal CXR. In the fourth case, appropriate work-up was scheduled, but the patient did not keep numerous appointments for further evaluation. The clinical presentation and ensuing events for 2 of these 10 cases are detailed below:
• On August 13, 2003, the patient had a CXR that revealed a patchy density in the left upper lung region that suggested the presence of either an inflammatory process or a cancer (or both). The radiologist indicated that this CXR was, “abnormal, needs attention.” On October 23, 2003, the patient had a chest CT scan that was interpreted as showing a lung lesion consistent with malignancy. On November 25, 2003, he was seen by a pulmonologist who scheduled a chest CT scan with biopsy for December 24, 2003. However, on December 13, 2003, before that biopsy was performed, the patient presented to the medical center’s emergency room with a fever, and was admitted to the medical center whereupon a new CXR showed that the lung mass had increased to five times its previous size. On December 17, 2003, he had a chest CT with biopsy that was positive for non-small cell lung cancer. The total elapsed time from the initial suspicious CXR to a definitive diagnosis of non-small cell lung 

Gainesville VA physician doesn’t show up for work and treats her private patient’s while she is supposed to be caring for veterans 2006

…On July 28, 2004, we received a hotline complaint alleging time and attendance abuse by a part-time physician at the medical center. The allegation stated that since her appointment, she had spent less than 5 hours per week at the medical center. The part-time physician was appointed to the medical center on November 3, 2003; she held two part-time appointments, one at the medical center and the other at the affiliated medical school. The part-time physician was required to work 25 hours per week at the medical center and 35 hours per week at the VA affiliate. The part-time physician retains her part-time appointment at the affiliate, but she relinquished her position as supervisor on January 1, 2005, for a staff physician position she currently holds at the medical center. ..

Gainesville VA Managers Have Two Nude Exotic Dancers Perform at VA Medical Center to Celebrate Manager’s Birthday

 No wonder patient care is not as good as it could be. Who has time to pay attention to patients when you can watch the live entertainment instead?


Georgia VA


Georgia VA Medical Researcher Convicted of Fraud, Ordered to Pay $1,100,000 in Restitution , 5 Years in Jail.

Shreveport, LA VA


Shreveport, LA VAMC Director of Respiratory Therapy Pleads Guilty to Extorting Kickbacks from VA Vendors


South Bend, IN VA

Uncredentialed Physicians Treat Veterans At South Bend Indiana VA



Lexington, KY VA

Lexington, KY VA Part Time Doctors Fail to  Show Up & Supervise Resident Doctors in Training

Even though the VA’s own studies have shown that unsupervised residents were responsible for 63 medical malpractice cases against the VA from 1997-2002, the attending physicians are still not showing up at this VA to supervise the residents.

Lexington, KY VA Physicians Gave Their Electronic Passwords to Residents, So That Residents Could Cosign Their Own Records

If the attending physicians are not going to show up to supervise the doctors in training, it only makes sense for the attending physicians to le the students sign of on their own work.


Shreveport, LA VA

Shreveport, LA VAMC Director of Respiratory Therapy Pleads Guilty to Extorting Kickbacks from VA Vendors.

Kenneth R. Atkins, Special Agent in Charge, Southeast Field Office, Department of Veterans Affairs (VA), Office of Inspector General (OIG) announced today that Karen G. Curry, age 43, of Bossier City, LA, pled guilty in United States District Court to one count of soliciting and receiving illegal gratuities.

Atkins stated that the plea was the result of an investigation by his office, with assistance from the VA Police and Security Service in Shreveport, LA.

Curry, Director of Respiratory Care, Overton Brooks VA Medical Center, Shreveport, LA, was previously indicted on June 23, 1999. Curry pled guilty to corruptly demanding and receiving from a VA vendor a color laptop computer for her personal use in exchange for the VA’s purchase of equipment from that vendor.

Curry will resign from her position at the Overton Brooks VA Medical Center and has agreed not to seek employment with any other facility.

Curry faces a maximum penalty of two years’ imprisonment, a $250,000 fine, or both. Sentencing in federal court is governed by the United States Sentencing Guidelines. Parole has been abolished in the Federal system. Curry’s sentencing date is set for December 9, 1999 at 1:15 p.m.


Popular Bluff, MI

Popular Bluff, Missouri VA physician does not show up to care for patients because he was “…feeling lazy”


The VA Office of Inspector General (OIG) received a hotline complaint concerning the time and attendance of a full-time physician. According to the allegation, a full-time physician at the John J. Pershing VA Medical Center did not always adhere to time and attendance policies from January 11, 2004, through September 21, 2005, in fulfilling his VA appointment. Specifically, the allegation was that this physician came to work late, took long lunches, and left work early….




…We substantiated the allegation that the full-time physician exhibited a pattern of time and attendance abuse during his scheduled tour of duty at the VA medical center. We determined that the full-time physician requested, and received approval for, authorized absences involving:

• Thirteen instances related to illness without being charged for sick leave.
• Two instances when he was absent for more than 4 hours without being charged for annual leave.

Medical center officials discussed tardiness with the full-time physician on two separate occasions.

• The first instance occurred on September 21, 2004, when the physician notified the timekeeper he would be late because “…he was feeling lazy.”
In addition to the 15 instances when the full-time physician did not request sick or annual leave, he had repeated instances of tardiness, extended lunches, and early departures.

We were unable to evaluate the full-time physician’s time and attendance practices from January 11, 2004, through August 15, 2004, because medical center officials did not document authorized absences during this period. The physician resigned from VA on September 21, 2005….


Durham, NC VA

Durham, North Carolina VA falsifies CCU documentation for defibrillators, fails to have an adequate number of defibrillators and has chipped pain, broken plaster and  malodorous  bathrooms.

VA policy requires that defibrillators be checked each shift in order to make sure that they are working, but at this VA they “gun decked” the paperwork and did not check the equipment that is used to save lives. Even the VA admits that it is “malodorous.”

Muscogee, OK VA

Veteran wanders off from the Muskogee Oklahoma Veterans Administration hospital and is found dead at a nearby construction site.

unfortunately, this patient went out for smoke break and just never came back.  Read the VA’s statement to Congress about how this veteran tragically died, because the staff didn’t notice that he was missing.

Muskogee VA, Patient Wanders Off and Dies at Construction Site

Cleveland, OH VA


VA Fails To Diagnosis Cancer In Cleveland

   Butler, PA VA

Probe in to Deaths At Butler PA VA Hospital Ends

While the Center for Disease control was examining deaths at the Butler, VA, its annual report stated:

From the Butler, PA VA’s 2005 Annual Report

Lebanon, PA VA

Philadelphia, PA VA


Philadelphia VAMC Fails to Monitor Post Anesthesia Patients, Medical Records Deficiencies & Dentists Who Don’t Change Gowns Between Patients

Due to lack of supplies, dentists at the Philadelphia VA failed to comply with the VA’s own requirements that they change surgical gowns between patients. The VA’s own inspectors found mistakes in 50% of the anesthesia records that they examined .

Pittsburgh, PA VA



Navy Veterans Widow Sues United States For Wrongful Death Due To Medical Malpractice At Pittsburgh VA

VA Doctor Suffocates Veteran When A Lung Tube Was Inserted.



Memphis, TN VA

Malpractice Suit Draws Scrutiny to VA HospitalUNDER THE MICROSCOPE: The local VA Medical Center is being sued by two sisters who  claim their 60-year-old brother – who died in 2004 – suffered from complications of a botched surgical procedure. The center must respond to the lawsuit within 60 days.

Shortly before 60-year-old James Carmon died in his home in the small town of Luxora in northwest Arkansas, a medical injury had made it so difficult for him to sit in his wheelchair he would have to lie down on his couch or bed after just half an hour to relieve the pain.

Back and forth he went, receiving in-home nursing care, shifting from the wheelchair to his couch and bed. Carmon – a construction worker who had served as an intelligence specialist in the Army during the 1960s – also was a diabetic. Records suggest that being confined to the wheelchair caused his feet to swell and develop sores.

At the time of his death in December 2004, he also had a large hole in his lower back where a surgical device allegedly had left burn marks…. i

…Carmon, born in 1944 in the town of Tomato, Ark., was a sheetrock hanger who was admitted to the Memphis VA in late 2002 for “routine, elective, lifestyle-enhancing” surgery, according to the suit. The procedure was supposed to clear the arteries in his legs, which had become compromised as a result of peripheral vascular disease.

Instead, Carmon was accidentally shocked during the surgery, and a surgical balloon was left lodged in his leg, according to court documents.

“It was this electrical shock that messed up his nerves, left him paralyzed and left a hole in his body down to the bone,”…


Austin, Texas VA Psychologist Pleads Guilty to Sexually Assaulting His Patients at Austin VA Outpatient Clinic

VA Physician Convicted of Sexually Assaulting Patients at Austin VAMC

John McDermott, Special Agent in Charge, Department of Veterans Affairs, Office of Inspector General (VA OIG), announced today that in the 299th Judicial District Court of Travis County, TX, Dr. Gregory S. Vagshenian was convicted of assaulting three of his patients. Vagshenian was found guilty of nine counts of simple assault and was acquitted of the greater charges of sexual assault by a mental health services provider. Judge Jon Wisser announced the guilty verdict and will sentence Vagshenian on March 22, 2004.


2006 Austin, Texas VA hires a surgeon that it considers to be a” risky” candidate and then fails to supervise him in accordance his term of probation 90% of the time. Less than three months after being hired, the surgeon is recommended in a chief of a surgical service.


“judged that these suits did not represent significant ongoing quality of care or liability concerns.” However, in an August 2003 e-mail, a PSB member addressing the facility’s chief of staff makes the following statement: “I presented him back to the PSB last Thursday which I chaired for you and everyone was in agreement that the candidate was risky. . . .”


…However, when endorsing the initial appointment, the VISN did request that special attention be given to assessing the surgeon’s skills during the proctoring period established by the PSB. Operative reports for the first 3 months of his appointment (October–December 2003) do not support consistent proctoring of the physician. Of the 41 surgeries the physician performed during his first 3 months of employment, only four were proctored as required by the provision of his appointment. Ten cases were assisted by a surgeon of the same specialty who had been appointed on the same date and also required proctoring. The remaining cases had either physician assistants and/or residents assisting the surgeries, with no other physicians recorded as present.


On November 2003, a memorandum submitted by a senior physician to the Chief of Staff indicates both physicians under the proctoring provision were now able to work independently. He also recommends the physician in question be made service chief of his specialty.

McDermott stated the conviction resulted from a joint investigation conducted by VA OIG Special Agents and Healthcare Inspectors; the VA Temple Police; and other State and Local Law Enforcement Officers. VA Psychiatrists also assisted in the investigation and noted Forensic Psychiatrist Dr. Thomas Gutheil provided expert testimony at the trial.

From April 1993 to May 2001, Dr. Vagshenian was employed as a Psychiatrist at the VA Austin Outpatient Clinic, located in Austin. The victims testified Vagshenian performed unwanted sexual acts on them under the guise of a routine physical exam. A OIG February 19, 2004


6 Austin, Texas VA hires a surgeon that it considers to be a” risky” candidate and then fails to supervise him in accordance his term of probation 90% of the time. Less than three months after being hired, the surgeon is recommended in a chief of a surgical service.

“judged that these suits did not represent significant ongoing quality of care or liability concerns.” However, in an August 2003 e-mail, a PSB member addressing the facility’s chief of staff makes the following statement: “I presented him back to the PSB last Thursday which I chaired for you and everyone was in agreement that the candidate was risky. . . .”

…However, when endorsing the initial appointment, the VISN did request that special attention be given to assessing the surgeon’s skills during the proctoring period established by the PSB. Operative reports for the first 3 months of his appointment (October–December 2003) do not support consistent proctoring of the physician. Of the 41 surgeries the physician performed during his first 3 months of employment, only four were proctored as required by the provision of his appointment. Ten cases were assisted by a surgeon of the same specialty who had been appointed on the same date and also required proctoring. The remaining cases had either physician assistants and/or residents assisting the surgeries, with no other physicians recorded as present.

On November 2003, a memorandum submitted by a senior physician to the Chief of Staff indicates both physicians under the proctoring provision were now able to work independently. He also recommends the physician in question be made service chief of his specialty.



San Antonio, TX VA

San Antonio Texas hires surgeon that it considers to be a “risky” candidate, doesn’t subject the surgeon to the required peer review or supervision, and then promotes the surgeon.

Healthcare Inspection

Credentialing and Privileging Irregularities at the

South Texas Veterans Health Care System

San Antonio, Texas

Report No. 06-00703-147 May 22, 2006 VA Office of Inspector General Washington, DC 20420


The OIG Hotline Division received the above allegations from a former patient who wishes to remain anonymous. The complainant underwent surgery by the named physician in the private sector in 2001.

The complainant alleged the physician in question provided negligent medical care in the private sector prior to his employment with the Department of Veterans Affairs, resulting in over 300 malpractice claims against him. The complainant further alleged the physician had a poor bedside manner when he cared for the complainant. Finally, the complainant questioned how the VA could hire a physician with this malpractice history, indirectly alleging C&P irregularities. While we cannot address the allegations resulting from events which occurred in the private sector, this report does evaluate both the physician’s quality of care and bedside manner since his employment with the VA. We conducted a review of the physician’s malpractice claim history and application of VA’s C&P process to this physician hire.

Issue 1: Alleged Malpractice Claim History and Credentialing and Privileging Irregularities

We could not substantiate the allegation of 300 malpractice claims in the private sector, but did substantiate certain C&P irregularities related to determining the physician’s malpractice claims history. The complainant alleged the physician in question had over 300 malpractice claims filed against him prior to his appointment with the VA. The physician’s C&P file contained evidence of a total of eleven malpractice claims, three of which were reported to the NPDB. Of the remaining eight claims, five were dismissed and three were pending at the time of this review. Two of the three pending claims were filed after the physician received an initial appointment to the facility, but prior to the reappointment of the physician in August 2005. Our inspection revealed an additional claim filed in May 2005, during the term of the physician’s VA employment, against a mid-level provider as an agent of the physician in question. Therefore, we found evidence of a total of 12 malpractice claims.

The NPDB, a database containing malpractice actions resulting in a settlement or judgment against a practitioner, is “intended to augment, not replace, traditional forms of credentials review.”1 VHA Handbook 1100.19, the handbook describing VA’s policies pertaining to C&P, requires primary source verification of information contained within the NPDB. VHA Handbook 1100.19 requires that the C&P file contain (1) a statement by the practitioner explaining any malpractice claims, (2) evidence that the facility evaluated the facts regarding resolution of the malpractice case(s), and (3) a “statement of adjudication by an insurance company, court of jurisdiction or statement of claim status from the attorney.”2

Practitioner Explanatory Statements

The C&P file contains explanatory statements from the physician regarding the eight malpractice claims filed prior to his initial C&P application. We found no deficiencies in the submission of explanatory statements by the practitioner during the initial C&P process.

Two years after the physician’s employment with the VA began, he submitted an application for renewal of privileges (reappointment) as required by VHA Handbook

1 National Practioner Databank, “About the Databanks”

2 VHA Handbook 1100.19, 5.k.(3).

VA Office of Inspector General 3

Facility and VISN Evaluation of Malpractice Cases

The C&P file contains evidence that the Professional Standards Board (PSB) reviewed the malpractice claims identified through NPDB and sought the opinion of a regional risk management official and VA Central Office (VACO). The VACO C&P Director recommended consultation with the VISN Director. A July 2003 memorandum from the facility Chief of Staff to the VISN Chief Medical Officer presented a brief synopsis of the three cases found in NPDB, adding that the facility reviewing personnel “judged that these suits did not represent significant ongoing quality of care or liability concerns.” However, in an August 2003 e-mail, a PSB member addressing the facility’s chief of staff makes the following statement: “I presented him back to the PSB last Thursday which I chaired for you and everyone was in agreement that the candidate was risky. . .

…However, when endorsing the initial appointment, the VISN did request that special attention be given to assessing the surgeon’s skills during the proctoring period established by the PSB. Operative reports for the first 3 months of his appointment (October–December 2003) do not support consistent proctoring of the physician. Of the 41 surgeries the physician performed during his first 3 months of employment, only four were proctored as required by the provision of his appointment. Ten cases were assisted by a surgeon of the same specialty who had been appointed on the same date and also required proctoring. The remaining cases had either physician assistants and/or residents assisting the surgeries, with no other physicians recorded as present.

On November 2003, a memorandum submitted by a senior physician to the Chief of Staff indicates both physicians under the proctoring provision were now able to work independently. He also recommends the physician in question be made service chief of his specialty…



VA’s computerized pharmacy records do not stop medication errors. Study shows 1 in 4 VA patients still subject to serious medication errors.

Despite having the best technology available, the VA still manages to make a serious medication error for 1 out of every 4 hospitalized patients.937 patients admitted to the Salt Lake City, VA hospital during a 20-week period in 2000. They found 483 significant adverse drug events; 25 percent of the patients hospitalized had at least one.



Puget Sound Washington VA thoracic surgeons failed to supervise residents and VA management policy does not follow VA national policy or notifying patients of the right to file claims.

While the VA claims that the VA’s policy is to disclose medical malpractice and advise individuals of their rights to file malpractice claims, this is another example of a VA simply ignoring the VA’s own policies on malpractice claims.


Seattle VA Nurse Pleads Guilty to Stealing Drugs from the VA

James N. Konzek, 35, of Kent, WA, was sentenced in U.S. District Court to 4 years of probation, $4169 in restitution, and a $25 court assessment fee. Konzek had previously pled guilty to possession of a controlled substance.

Carver stated that the charge stemmed from an investigation conducted by his Seattle Resident Agency. The investigation disclosed that Konzek, a former VA Licensed Practical Nurse (LPN) employed at the VA Puget Sound Health Care System in Seattle, WA, had repeatedly removed controlled substances, including Oxycodone, from the hospital’s supply for personal use. VA OIG October 20, 2003 

VA Psychologist Convicted Of Perjury For Covering Up Sexual Relationship With VA Patient

Medication errors persist in computer age
Utah study: Hospital problems include proper ordering, dosage and monitoring
By Carey Hamilton
In rare cases, patients prescribed narcotics without laxatives have been rushed to operating
rooms or even died from complications – because one side effect of certain painkillers is
Such bad reactions to medications are called adverse drug events, and computerizing the
prescription process is seen as key to helping prevent them.
But a new study by doctors at the Veterans Administration Healthcare System in Salt Lake
City shows a high rate of medical error in drug ordering, dosage and monitoring can persist
after computerization.
Published this week in the journal Archives of Internal Medicine, the study says
researchers found no errors related to transcription, such as the misinterpretation of a
handwritten prescription. But they discovered medical errors contributed to 27 percent of the
adverse drug events suffered by patients over a 20-week period in 2000.
“People on the one hand expect computers to solve all problems,” said lead researcher
and VA Hospital physician Jonathan Nebecker. “They eliminated transcription problems, but
the program was not designed to detect problems with drug choice and dosing.”
Previous studies have shown that unintended injuries from drugs account for up to 41
percent of all hospital admissions and more than $2 billion a year in inpatient costs.
Nebecker and colleagues reviewed electronic records from 937 patients admitted to the VA
hospital during a 20-week period in 2000. They found 483 significant adverse drug events;
25 percent of the hospitalizations had at least one.
Patients at VA hospitals are 90 percent male and tend to be older, sicker and poorer than
patients at other facilities. While the number of adverse drug events discovered was higher
than other studies have shown, researchers don’t believe the patients’ actual rate was
higher. Instead, they credit the clarity of computerized records.
“It’s not that there were more events, the measurements are better,” Nebecker said. “We
found that three-quarters of adverse drug effects were recognized by the computerized
The researchers found errors occurred at the following stages of care: 61 percent at the
ordering of prescriptions, 25 percent during monitoring, 13 percent while drugs were given to
patients and 1 percent at dispensing.
Some of the most common drugs patients encountered problems with were for pain, the
heart and kidneys.
VA hospitals are recognized for their use of technology, including computerized patient
“Instead of having to run to the bedside to check paper charts, we now can look up
patients’ records on a computer from anywhere in the hospital,” said John Hurdle, one of the
study’s authors.
One error that used to occur rather frequently involved the moving of patients to different
rooms. Nurses would then give the new patient the medication intended for the previous
To avoid that potential catastrophe, VA hospitals have come up with bar-coded wrist bands
to identify patients and their medications.
The VA’s computers also raise a red flag when patients have allergies to medications,
which has led to a significant reduction of reactions in that area.
Even so, IVebecker and Hurdle acknowledge more computer-sophisticated programming is

needed to help eradicate prescription complications. Hospitals that want to reduce adverse
drug events should seek programs that offer automated advice for choosing drugs, setting
dosages and monitoring, their study said.
“Preventing harm is our focus,” Hurdle said. “But prescription drugs are always inherently
The study was supported by grants from the Veterans Administration Health Service
Research and Development Service in Washington, D.C.; the Geriatric Research, Education
and Clinical Center; the VA Cooperative Studies Program in Albuquerque, N.M.; and the Salt
Lake Lake Informatics, Decision Enhancement and Surveillance Center.
Where the errors occurred:
61 percent
25 percent
13 percent
1 percent
Computerized prescriptions don’t eliminate errors
Records from 937 patients admitted to the Veterans Administration hospital in Salt Lake
City over a 20-week period in 2000.
448 Adverse reactions to drugs
35 Overdoses or underdoses.
Toll for patients:
438 were moderate
45 were serious, including 6 deaths.
Medication errors contributed to 27 percent.

Primary care clinics at VA hospitals not recognizing PTSD Medical Study News, 511 6/05

Primary care clinics at Veterans Affairs hospitals are not recognizing posttraumatic stress
disorder in a significant number of cases, according to a Medical University of South
Carolina study of 746 patients.
The study, conducted Dr. Kathryn M. Magruder and colleagues, showed that the clinics
examined recognized less than half (46.5 percent) the PTSD cases identified by the
The study, which appears in the June issue of General Hospital Psychiatry, shows an overall
11.5 percent prevalence of PTSD among the patients of four southern Veterans Affairs
hospitals, a figure consistent with other recent studies. According to the study, veterans with
PTSD have higher rates of major depressive disorders as well as other co-morbid psychiatric
illnesses such as substance use, severe social and occupational disability and poor quality
of life.
PTSD “undoubtedly is costing society much more than presently estimated” said Magruder,
adding that the condition also “exacerbates other health problems that often afflict PTSD
sufferers.” PTSD is a psychiatric disorder that can occur following the experience or
witnessing of life-threatening events such as military combat, natural disasters, terrorist
incidents, serious accidents, or violent personal assaults, and it has been identified as one of
the most costly psychiatric conditions in the U.S. health care system.
PTSD symptoms include nightmares and flashbacks, difficulty in sleeping, and feelings of
detachment and estrangement, and can be so severe and long lasting as to significantly
impair a person’s daily life.
Investigators analyzed findings from a survey of patients seen at two Alabama and two
South Carolina facilities. The patients underwent psychiatric interviews using standard
diagnostic tests and were subject to 12-month retrospective chart reviews. “What the
research really shows is the need for a more structured approach to identifying veterans
suffering from PTSD and a better understanding of both patient and provider reasons for not
recognizing and addressing PTSD,” Magruder says. “Without additional resources, primary
care clinics simply cannot be expected to do the job that should be done.”
Dr. Charles C. Engel, an Army colonel and psychiatrist, and an associate professor at the
Uniformed Service University of the Health Sciences in Bethesda, Md., says that the study
shows a “substantial room for improvement in both screening for PTSD and the delivery of
care needed by PTSD sufferers.” The study is funded by the U.S. Department of Veterans

Daily News Summary KWCH 12 Eyewitness News (Wichita, KS), 5/2/05
VA Hospitals
By Liz Collin
They pledge their lives to this country but what level of care do local veteran’s and their
loved ones have a right to expect when they check into the Wichita VA? Some patients tell
us they were ignored four former employees say the hospital is fraught with problems.
As part of six month FactFinder 12 investigation, intensive care experts told us the situation is downright scary. Former VA patients say the hospital can and must do better. The director declined at least a dozen requests for an interview on our findings. In written responses VA officials say “It takes pride in the care it gives to our nations veterans.”
Their wars are long over but their battles are not. The fight now is for better healthcare at the Wichita VA. More than a year later the Rolph family is still coming to grips with the sudden death of its father and husband, Neil.
Shawn Rolph talks about his dad. Shawn says, “He was a good guy. He loved to hunt, loved
his grand kids. I honestly don’t think he thought he was going to die going to die when he.
went in there.” At 62, Neil learned he had colon cancer. After a successful operation at the VA Neil was told he could leave in a few days.
Kona Rarig is Neil’s daughter. She says, “We had to walk him to and from the bathroom, we
had to get him up to walk ourselves, we were basically there taking care of him.” Neil’s wife,
Janice says only doctors checked on Neil, not nurses. That’s why Janice Rolph was hesitant to leave her husband’s side during his hospital stay
She says otherwise, the staff ignored his needs. The Rolph’s aren’t the only one’s who’ve
complained about the care inside this hospital.
At the age of 48 Shawn O’Callahan suffered a major heart attack. While recovering Shawn
got in the habit of buzzing for more medication to kill his pain.
One time more than an hour passed and no one ever came. That’s when Shawn unplugged
himself and went looking for help. When he got into the hallway he overheard a nurse talking  about his request. Shawn says, “He said, well Mr. O’Callahan is just going to have to wait like everyone else.” Another half hour went by before his medicine finally came.
After seven days in the hospital with her husband Janice left him alone one night. A cousin
went to pick Neil up the next morning to bring him home but when they got there Neil was
already dead. Kona says, “They didn’t cover him, they didn’t shut the door. They could have sat down and had a conversation with him not realizing he wasn’t there.”
Neil’s death certificate shows he died at 9:47 that morning Kona remembers calling to check on her dad sometime after 11 in the morning and Kona says a VA nurse bluntly told her that her father was dead.
The VA says Neil died of a blood clot. The next day Janice got a call from the doctor who did Neil’s surgery. He told her Neil shouldn’t have died. The doctor said he quit his job because of what happened and that he’d never again work at a veteran’s hospital.

FactFinder 12 wanted to find out why patients and their families say they were ignored. Weasked to see a track record of response times in the ICU.
A memo shows a 24-hour test in 2001 of code red alarms in the ICU. It showed red alarms
sounding for as many as seven hours. That doesn’t mean the staff is ignoring the patients,
an alarm could be nothing more than a patient sitting up in bed. What it does mean is if
something serious happens while the first alarm continues to go off, nurses might not even
know it.
Terry Grey worked at the Wichita VA as a biomedical engineer for 20 years. Grey says
alarms constantly went off in the ICU and because of it he saw nurses put gauze pads over
the speakers to muffle the noise and that wasn’t all. Grey says, “They started unplugging
them, especially at the night because they said it bothered the patients from sleeping.” When Grey brought his concerns to the hospital director he was told to mind his own business.The VA says there’s no proof of alarms being unplugged or covered. Grey’s complaints were checked out by the Office of Inspector General, the agency that oversees care at the VA hospital. It says the hospital passed muster and that’s what families like the Rolph’s can’t understand.
After that 2001 study ICU workers changed the settings on the monitors. That means red
alarms won’t sound so easily cutting back on non-life threatening alarms. In 2003 another
study found an alarm sounding for 16 minutes and in 2004 an alarm was on for 4 minutes. In that case the record says a nurse was in the room.


VA neglects patients in Dallas, VA neglects patients in Dallas -Vet Forced to Call 911 from VA Hospital Room

It really says something when a veteran who is already hospitalized at a VA hospital, has to call 911 to get medical attention from the VA medical staff.

Alabama VA Management Fails to Discipline Health Care Providers Involved in Confirmed Patient Abuse Patient

….We substantiated an allegation that an East Campus patient was physically abused, and no one was disciplined.  We received other allegations of patient abuse at both the East and West Campuses, which we did not substantiate. Allegation 1:      A patient was physically abused at the East Campus, and no one was disciplined. We substantiated this allegation.  On the August 18, 1995 evening tour of duty, a registered nurse found an East Campus Nursing Home Care Unit patient in his wheelchair.  The wheelchair was tied to a side rail in the dayroom.  His body was restrained, and he was soiled with feces and urine.  The nurse also noted that the right side of the  patient’s face and his right eye had an estimated 2 to 3 day-old laceration and bruise.  The nurse wrote a memorandum to the nurse manager, but did not record her findings in the patient’s medical record. The CAVHCS Director convened an Administrative Board of Investigation on August 23, 1995.  The board sustained the allegation that physical abuse occurred. Board members could not, with certainty, identify the abuser(s), but they strongly suspected that two particular nursing employees were responsible, because they had been assigned to the  patient on August 16, and these two employees were the first ones to notice the bruises, but did not report them. The CAVHCS Director wrote a memorandum to the Regional Director regarding this case, stating his intent to discipline a nursing assistant, two registered nurses, a licensed practical nurse, and a medical doctor because: ?   The two employees did not report the bruises that they noted. ?   A Nurse Supervisor and Manager did not fulfill their supervisory roles. ?   A physician told the nurse not to report the abuse.
As of November 13, 1997, only one nursing assistant had received a disciplinary action. The other employees were not disciplined as planned.  According to a human resources specialist, Nursing Service managers did not want to discipline the registered nurses if the physician was not also disciplined.  The Chief of Staff did not discipline the physician.  We did not find any evidence that the Director followed up on these disciplinary issues.  Therefore, the facility failed to act appropriately on a confirmed allegation of patient abuse.

VA OIG September 29, 2003

Eastern Kansas VA Fails to Report Doctors to NPDB March 25, 2005

Quality Management – Controls Needed Strengthening Condition Needing Improvement. QM controls needed strengthening to ensure: • Physicians involved in tort claim settlements were reported to the National Practitioner Data Bank.1 • Resuscitation data was collected and evaluated. • Patient complaints were reported to the Performance Improvement Leadership Council for recommendations and actions. Tort Claim Settlements. The Credentialing and Privileging Coordinator did not have access to the National Practitioner Data Bank to ensure the health care system was in compliance with national reporting requirements. In March 2004, the coordinator contacted VISN 15 requesting access to the data bank, but as of July 2004 she still did not have access. As a result, health care system managers did not report three physicians who were involved in tort claim settlements. Resuscitation Events. The Intensive Care Unit (ICU) Advisory Committee did not analyze resuscitation events. Joint Commission on Accreditation of Health Care Organization standards require medical facility managers to collect data and evaluate the effectiveness of resuscitation events to identify opportunities to improve patient care. The ICU Advisory Committee met quarterly and received a brief summary of resuscitation events but did not analyze the data to identify trends by location, time, provider, and problem. Patient Complaints. The patient representative did not report patient complaints to the Performance Improvement Leadership Council. The representative did collect and trend patient complaints but made no recommendations and took no actions to improve performance and services related to patient complaints. Recommended Improvement Action 1. We recommended that the VISN Director ensure that the Health Care System Director: (a) obtains the required access to the National Practitioner Data Bank for the Credentialing and Privileging Coordinator; (b) requires the ICU Advisory Committee to collect and evaluate resuscitation events by location, time, provider, and problem; and (c) provides patient complaints to the Performance Improvement Leadership Council for appropriate actions. 1 The National Practitioner Data Bank is primarily an alert or flagging system intended to facilitate a comprehensive review of health care practitioners’ professional credentials. VA Office of Inspector General 4 Combined Assessment Program Review of the VA Eastern Kansas Health Care System The VISN and Health Care System Directors agreed with the findings and recommendations. The health care system assigned the QM and Performance Improvement Coordinator to coordinate tort claim management in July 2004. In October 2004, the coordinator applied for and received entity registration verification from the National Practitioner Data Bank. All resuscitative events are evaluated for quality assurance and opportunities to improve patient care. The results of the analysis, which include locations, time, provider and problems, are forwarded to the ICU Committee for review and recommendations.

Uncredentialed Physicians Treat Veterans at South Bend Indiana VA

Allegation No. 2:  That two particular HMO clinicians were not credentialed and  privileged by the NIHCS.
The allegation was substantiated.  We reviewed CBOC documentation for patient encounters for a physician and a nurse practitioner (NP) for the period from January 1999  to June 2000.  We also reviewed credentialing and privileging information for both  individuals.  Neither practitioner had been granted privileges to treat VA patients, even  though they had been treating veterans during the 18-month period.        When asked why the physician had been allowed to treat veterans even though the NIHCS had not granted privileges to do so, HMO employees stated that the physician had been granted a waiver. They presented an undated, unsigned document as evidence of a meeting that had occurred at the HMO at which this issue was discussed.  The document was entitled ?VA Project Update? and stated that the physician ?had been granted a waiver by VA and will be allowed to treat veterans; credentialing should be done by the end of next week.?  Content suggested that the document was generated prior to the point that the physician began treating VA patients.      No one from the NIHCS or the HMO could recall who might have awarded this waiver.  The NIHCS Chief of Staff and the Chief of Patient Care Support Services stated that they were unaware that uncredentialed providers were seeing patients until approximately 6 weeks prior to this review in August 2000.  However, we had discussed this issue with top managers during the March 2000 CAP review and in the May 2000 report of that review.  NIHCS staff finally completed the physicians credentialing and privileging processing on August 3, 2000.  Thus, we are not making a recommendation, although we note that it took approximately five months to correct a relatively simple problem.

Battle Creek, MI VA Ignores VA’s Requirement to Report Substandard Medical Practice to NPDB

Combined Assessment Program Review of the VA Medical Center Battle Creek, Michigan  events and close calls, and RCA documentation needed to reflect the extent that recommendations were implemented and monitored for effectiveness. Reporting.  VHA policies require that adverse actions affecting clinicians? clinical privileges (reductions, suspensions, or revocations) be reported to the NPDB and to appropriate state licensing boards.  Credentialing and privileging records showed that a contract physician was allowed to resign in January 2004 in lieu of contract termination for substandard clinical  performance.  The physician’s VA clinical supervisor stated that a review of the physician’s  performance had not been conducted to determine if he met criteria for reporting to the NPDB  and to appropriate state licensing boards.  This occurred because the clinical supervisor was unaware of VHA’s reporting requirements.  Medical center managers needed to conduct a review of the physician’s performance to determine if the physician should be reported to the NPDB and to appropriate state licensing boards.  In addition, medical center managers needed to educate clinical supervisors about VHA reporting requirements.  RCA Reviews.  VHA policies require that root causes underlying variations in clinical performance associated with adverse patient events or close calls be identified through an RCA process.  From January through December 2003, 3 individual RCAs and 4 quarterly aggregated RCAs were conducted.  None of the three individual RCAs identified appropriate root causes  for the events being investigated.  None of the four quarterly aggregated RCAs adequately identified root causes, defined improvement actions, or established measurable outcomes.  In  addition, RCA documentation was not sufficient to show that recommended improvements were implemented and monitored for effectiveness. VA OIG July 30, 2004

Patient Abuse Ignored and Inappropriate Patient Care at Alabama VA

We substantiated this allegation. On the August 18, 1995 evening tour of duty, a registered nurse found an East Campus Nursing Home Care Unit patient in his wheelchair. The wheelchair was tied to a side rail in the dayroom. His body was restrained, and he was soiled with feces and urine. The nurse also noted that the right side of the patient’s face and his right eye had an estimated 2 to 3 day-old laceration and bruise. The nurse wrote a memorandum to the nurse manager, but did not record her findings in the patient’s medical record. The CAVHCS Director convened an Administrative Board of Investigation on August 23, 1995. The board sustained the allegation that physical abuse occurred. Board members could not, with certainty, identify the abuser(s), but they strongly suspected that two particular nursing employees were responsible, because they had been assigned to the patient on August 16, and these two employees were the first ones to notice the bruises, but did not report them. The CAVHCS Director wrote a memorandum to the Regional Director regarding this case, stating his intent to discipline a nursing assistant, two registered nurses, a licensed practical nurse, and a medical doctor because: The two employees did not report the bruises that they noted. A Nurse Supervisor and Manager did not fulfill their supervisory roles. A physician told the nurse not to report the abuse. As of November 13, 1997, only one nursing assistant had received a disciplinary action. The other employees were not disciplined as planned. According to a human resources specialist, Nursing Service managers did not want to discipline the registered nurses if the physician was not also disciplined. The Chief of Staff did not discipline the physician. We did not find any evidence that the Director followed up on these disciplinary issues. Therefore, the facility failed to act appropriately on a confirmed allegation of patient abuse…..

….We received allegations, which we substantiated, involving eight instances of inappropriate patient care at the East and West Campuses. We found that, in three cases, clinicians should have admitted West Campus patients for care sooner. We found that quality managers at both campuses had appropriately identified and reviewed most cases brought to OHI’s attention, when the cases met the criteria for VHA’s occurrence screening program. The occurrence screening process was generally well done except that clinical managers did not always aggressively follow findings related to issues of inappropriate physician performance.VA OIG Report September 29, 1998 medical malpractice information for the veterans administrationVeterans administration medical malpractice, medical malpractice at the VA, Veterans administration medical malpractice claims, Veterans administration medical malpractice doctor,,Veterans administration medical malpractice surgeon, Veterans administration medical malpractice physician, W. Robb Graham, Esq. VA medical negligence attorney, standard form 95, claim for medical malpractice against the VA, lawyer for malpractice claim against the veterans administration, medical malpractice at the New Jersey VA, medical malpractice at the East Orange NJ VAMC, medical malpractice at the Lyons, NJ VA, medical malpractice at the Lyons New Jersey Veterans Administration, Philadelphia VAMC Medical Malpractice Claims, W. Robb Graham attorney for veterans administration medical malpractice cases in New Jersey & Pennsylvania .

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.



17 thoughts on “Medical Malpractice at the VA

    • Hi,

      Regarding denial of service and medical malpractice complaints against Bay Pines and Gainesville VAMC’s, I need to contact Mr. Robert E. Bauman, who wrote one of your articles above. Do you have contact info?


  1. Veterans hospital emergency room malpractice, June 15, 2011, Veterans Hospital Patient and Patient Caregiver Medical Malpractice June 15, 2011 at Veterans Health Care System of the Ozarks 1100 North College Avenue Fayetteville, AR 72703 TELEPHONE 479-443-4301
    Why can’t these people meet face to face, or, by U.S. Mail. My husband has very little faith and TRUST in politicians anymore. We are constituents to each of you gentlemen. we pay each of you for your help. We supported and voted for Womack, Pryor, and Boozman. That was good for them, but Gods sake don’t ask them for their help in a Government matter.
    We once drove to Bentnville, AR to a political rally of some sort and we politely confronted Congressman Steve Womack with this issue face to face. Congressman Womack assured us the issue would be taken care of and he introduced me to his USELESS Military and Veterans Advisor Mr. Lewis Kaslow who assured us he would call us back and gave us his card containing his telephone 479-464-0446 and fax number 479-464-0063 Mr. Lewis Kaslow said he would be in touch with us on the following Monday. He failed to get back in touch with us so We called his office on the next Tuesday afternoon and Mr. Kaslow stated that to much time had passed by to investigate the abuse and suggested we forget the matter ever took place. (it had only been one year and the law states two years from the date of the abuse.) I think it was April or May of 2013 we filed for and was granted a tort claim which proved to be useless.
    Senator Mark Pryor PHONE 202-224-2353,
    Congressman Steve Womack PHONE 202-225-4301, and Senator John Boozman, each of Arkansas, we have not received written information concerning the formal investigation we ask of you concerning our request into U.S. Veterans Hospital Patient, and Patient Caregiver Abuse and medical malpractice at the Veterans Health Care System of the Ozarks U.S. Veterans Hospital, Fayetteville, Arkansas, June 15, 2011, John R. Henley M.D. and Mark A. Elderle M.D. Fayetteville Arkansas U.S. Veterans Hospital Administrators DEPARTMENT OF VETERANS AFFAIRS Fayetteville Arkansas 72703-6995.
    Congressman Womack, Senator Boozman, and Senator Pryor in our frustration we were in contact with each of you regarding the U.S. Veterans hospital shortly after June 15, 2011. To this date, we have received NO formal apology or reply regarding this issue from the office of President of the United States, President Obama and eventualy (several months ago we contacted Senator who wrote us back through US mail to contact Congressman Womack.)
    Mark A. Elderle M.D. and John R. Henley M.D. Fayetteville Arkansas U.S. Veterans Hospital Administrators DEPARTMENT OF VETERANS AFFAIRS Fayetteville Arkansas 72703-6995
    When we pulled up to the Emergency Room, I pulled into the drive-thru, and a male EMPLOYEE Came out and RUDELY told me I could NOT park here because it was the ambulance entrance that I would have to move my car down the hill and go in through the emergency room check in. I got back in the car, and pulled down the hill and went up the stairs and went to the check in desk. When I told the employee at the desk what was going on, he told me to pull my car BACK up the hill to where I just was because they would have to get my husband out of the car and into a wheelchair. I walked back to the car, backed up the hill to the door and they came out and put my husband in a wheel chair and wheeled him back to the check in desk. In a few minutes they came and got us and a nurse checked us in and asked us all kinds of questions about what was going on. After she was finished, they took my husband back to a room in the ER where we were for the next 5 hours. Five hours in which my husband lay in pain and his own URINE, FECES, and STENCH. When we were leaving the VA hospital, when I went to go out the door we came in, I was trying to push/force it open and the HIPPIE looking guy behind the desk (the same one who made me pull down the hill in the first place) RUDELY YELLED “Don’t do that, you’ll break the door”, “we have to push the button”, and I said to him “Then open the damn door!” So he pushed the button, the door opened, and I went and got the car and came back for my husband. I was the one who was mad, not my husband. My husband was incapacitated DUE TO THE STROKE he was having and not at all mad or upset. He was barely conscious … We then drove to Fort Smith AR (because of MY decision, not his) to Sparks Regional Medical Center where my husband, was hospitalized, and treated with human dignity. But because of the critical time lost (wasted) at the VA hospital – there was not much medically they could do by the time we got there except to make sure he was stable. This was time lost in a possible life/death situation.
    The average person living on a strict budget get very little help from Politicians, however, if a person is wealthy, or a lobbyist, the politicians suck up to them. It seems to be all about MONEY.
    Not one US Veteran, a US Veterans caregiver, or a US Veteran family member deserves humiliation and malpractice at any United States Government facility.
    Why did you, our United States Government not offer to help a fellow US Veteran? Why did you NOT (along with other washington politicians) help my husband and I to receive the help we needed, as we pleaded with you for over two years? Do you respect and want our vote? Are each of you favoring lobbyist and the rich as other politicians appear to be doing? What kind of United States Government are you, besides claiming to be as broke as our family? Sirs, we have been let down, and my husband feels he has been lied to, and totally abused by the United States Government to which he swore to defend and give his life for.
    Our tort claim maybe expired by now, but my husband insist on getting this message to the media and the public, hoping the public and other veterans are aware there are severe problems in the US Veterans system, as well as the US Political system.
    Mr. and Mrs, Lynn E. Carter
    I have to this day 10-28-2013 received the formal investigation and I think my tort claim has expired. I obtained The Tampella Eberspacher Law Firm and they could not help me. I am amazed that my elected officials did not investigate and Congressman Steve Womack of Arkansas refused (after telling me to my face) this issue would be taken care of, then Mr. Womacks VA Rep told me to forget it ever happened, and to much time had gone by to investigate the issue, that was back in the spring of 2012. I never once ask for money, never. I only want to let the public know how US Veterans and their spouse/caregivers are being treated and neglected by our elected officials. Our Government officials are paid by we the people who got them elected. About a month ago I contacted Congressman Tom Cotton (via telephone) because he is running in my district (district 3) and his secretary got rude with me, telling me Tom Cotton is district 4 , HELLO! he is now running against Senator Mark Pryor, in my district 3. So sorry I signed up for US Military duty during the Vietnam Era. My wife and I are honest, taxes etc paid as we get them, law abiding citizens, who now feel like second class, low class lying citizens.
    Lynn E. Carter
    Fort Smith, Arkansas

  2. I don’t know anything anymore. I won a FTCA for Medical Malpractice in 2008 but continue to lose my 1151 claim because someone keeps copying and pasting the wrong information about what happened to me I have been denied twice for surgeries I never had I am about give up mode. How can you win a FTCA for MEd Mal and keep losing an 1151 claim decided by someone who is not a doctor. This has destroyed my life and caused me years of excruciating pain.

  3. The way the VA outpatient clinic treated my daddy was appalling. The totally ignored his repeated attempts at this ongoing issue but concentrated only on what was a “routine” exam. They would completely disregard my insistence to be in the same room while they were questioning him, ask him question that he did not know the answer or what the doctor was talking about, then allow me in the room and stated that they(the doctor) and daddy talked when in fact daddy knew nothing about what they doctor said but daddy would only say OK to everything since he was hard of hearing and the doctor would then ask daddy questions about me, like was I married, did I have a boyfriend, where did I live, did I date, etc which were clearly none of this doctor’s business. Daddy was then diagnosed with an chest X-ray that was irregular back in 2009 but the VA doctor completely ignored it. The doctor wold not recognize PTSD but would call it daddy’s “nerves” This doctor and facility was completely incompetent to be doing any kind of medical work on any veteran. These are men who served our country to protect me and my family and they deserve nothing but the best in healthcare. Our federal government, VA treats these men as second class citizens and mistreats and misdiagnosis’s these men and ignores their medical issues. What the VA does is appalling and there should be some kind of court remedies to prevent this from continuing to keep happening. If the VA had properly diagnosed and treated my daddy he would be alive today. I am a grown woman and grandma but the disgust of the VA treatment facilities grows deep inside me.

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  5. I was awarded a service-connected disability based on the Gardner decision in 1996. That fact establishes the VA malpractice in my case. Here are the facts of that case: I was overdosed with Synthroid ( a thyroid medication) for almost an entire year. The endocrine department refused to believe the numerous blood tests that verified that. That overdose exacerbated the myasthenia gravis I have but the VA failed to diagnose. They have misdiagnosed squamous cell cancer as a scalp condition. They refused to believe I had a history of hypoglycemia for more than 10 years. That only changed when a doctor did a finger stick and found I was indeed hypoglycemic. When I filed a federal Tort claim the VA challenged the diagnosis even though several board certified specialists all confirmed it. The VA hired an independent expert to resolve the “controversy”. When he agreed with me and the other civilian doctors they ignored his findings. I filed a complaint the OIG. They sent a letter of inquiry to Haley. The former Director there, Mr. Silver, replied that I had been fabricating the diagnosis and that my last admission was for “ingestion of gasoline”. Mr. Silver either never read the ER notes or he read them and deliberately lied to the OIG. When I reported this to the OIG they refused to pursue it. My disability award only goes back to 2008, but I am fighting for the original date in 1996. The VA has used numerous dirty tricks to continue to deny my claim. They “misplaced” evidence; misstated my claim; ignored supporting evidence; rejected my Primary Care doctors assessment because “they could not read his signature”. They have violated numerous VA rules and regulations and case law. But they remain unaccountable. Something needs to be done about this Kangaroo court.

  6. you put your love one in a place for veterans for strength and well being, its full of lies and nothing good, just death. the va hospital is no better, doctor want use you for practice by the students, and have no time to talk with you fill you with plent of lies, you have got to know and think for your self.

  7. My dad have been going to VA since 2001, Had prostate cancer in 2010, had treatments got past that, he was 74 yrs old, smoked and had arthritis and yes he had the first signs of COPD, but as time past going to all his appointments, his pain got worse,so for the next 2 or 3 years doctors kept telling him the same thing so around 2012 starting losing weight pain still bad like a number 8 sometime 10, coughing got worse jaw starting hurting chest pains, joint pains, but still copd and arthritis april of 2014 went to doctor appointment told doctor he couldn’t swallow having problems eating,( doctor said eat 5 to 6 cough drop and get aspercreme for joint pain) no test, not evening trying to find so other causes, we finally got him to a paid doctor in june 2014, Had throat cancer, bone cancer and lung.He died sept.30 2014, If they would have just look or care at all they could have found it could have took treatments and been here longer.

  8. I have filed a sp95 and was told its past the 2 years but I was not totally sure it was a malpractice issues tell over a year and a half after the fact. It was not supported tell the new VA Doctor said it was caused by the other VA doctor a year and a half ago. We are still waiting for reply from claim. I need to file this 1151 claim asap and get things moving need help please. Its hard to stay focused with the pain and PTSD I now have and states having in my medical records.

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  10. holy crap buying private insurrance with all the horror stories so frightening

    got 3 hpv guardasil vaccine shots at the VA starting around june 2013 Horrible pain for two years had to wear braces on my back both ankles wrists and elbows and had severe alergic reactions and diarhea the whole time. Severe for 6 months the let off for a month or two then another 6 month severe everything back in the splints suffereing three times so I was able to predict the start lenght and end of the last third severe 6 month long pain in braces and alergic reactions and diarehea. numb tinglin in legs arms and around trunk feels like something is moving on me but there is nothing. blood clots bruises under the skin extremely painful ingrown hairs that itch stab and bruise big. Hair loss with scalp painful itchy staby sores all over scalp everyghing for two years now. VA didn’t say there was any risk when people had already died from the vaccine no diagnosis at all over the last two years a number of VA doctors saw me suffering for years wrapped in braces from head to toe having severe alergic reactions and diehrea for two years nothing no diagnosis. phychosematic and food alergies they said. all labs normal inline with guillian barre they never even told me that a spinal tap to see excess protein in spinal fluid is a way to diagnos guillian barre they didn’t even tell me that let alone offer me one. Kept pushing the 2nd and third hpv vaccine guardasil shots even while I was suffering and covered in braces while they had no answer they were trying to kill me. I need a va mapractice laweyr too. had an dmg they said my nerves were fine when I was in the most severe amount of pain in the wrist and arm at that point it just doesn’t make sense. still in the back brace still left foot cannot find a shoe size or brand that doesn’t hurt my foot gone to shoe store 4 times over the last 2 years desperatly trying to find releif with none yet and all hope lost. Still have hair loss and scalp sores itching burning searing pain, still have severe alergic ractions and whole days of severe alergic reactions sophocated with flem and ear wax the slightest flem or ear wax or temperture change and my bunrt out nerves all scream for me to commic suicide bout every 2-3 days still. recent labs normal. I feel like the gov knew the risk and said it was ok to kill people like me and ruin their lives so merk can make more money and payoff the cdc. and the VA just covers everything up and leaves me to die from the vaccine they gave me. People had died from this years before they gave it to me. They were trying to kill me and all evidence that said its their fault malpractice and they knew guardasil was dangerous even life threatening. They still disrespect me and say there’s no way it could happen while I’m still in a back brace for two years and they have no explanation for that or even care to try or about my foot or the intense alergic reactions and diahrea I’ve had for two years running. I just want to die. Can you help?

    I can’t ever go back to the VA for them to kill me I can never have a serious operation or get anesthesia or what was ordered for me a gastro operation put me under send tube down my throat might of helped diagnose or save my life but I’m sure the VA would kill me with their mal practice I can never go back there. the google reviews of the brand new facility are all the lowest rating available. Everyone knows the VA is a murdering suicide factory but they still send me in there to die among the wolves. They didn’t know or share the dangers of the hpv vaccine ignorant or knowledgeable liars gave it to me while severly physically ill braces all over my body twice and continued to avoid or find the truth and continued to try to kill me when I was already at risk of death. I kept trying to trust them and gave up and deciding to to get and find a lawyer is hard and a big step not being able to trust multiple docs at the va is not normal having to find a lawyer to sue the va for medical malpractice is not normal.

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  14. I fell 10 feet on to concrete. Working on a cable TV line.For my sons .i got up took 2 ibuprofen and sat down. My daughter in law who is a trauma nurse. Told me to go to the hospital. My son took me to the VA hospital. They took me immediately to a room. And said they would give me an x-ray. I told the doctor could I fly to Quantico Virginia in 8 days. He said will see what your x-ray says.I was really hurting but I thought I hade cracked ribs hopefully. About 1hour later he said i had to small cracked ribs not separated. I asked can i fly in 8 days. He said yes you can do anything you want. He gave me a lot of pain medication. I said thank you and my son took me home. Now to make a long story short. I flew to Quantico. My daughter was graduating boot camp and making 2nd LEUTANIT. I was just putting her rank on i thought I was dying. Didn’t tell her called 911 they took to the hospital the doctor told me I was dying. I had about 2 hours left I was ready to die. I felt so bad for my daughter they said they would not let that happen. I had 8 to 10 severely broken separated ribs Nemo and hemo thorax 3000cc of blood in my lung was getting Tampa nada .Sent me to another hospital did thoracic surgery on me. Before that they cut me open without anything to kill the pain.came to 2 days later l efr 7 days later that was November 16th 2014 i am still hurting really bad not for the ribs but the operation thoracic surgery thats all for now

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