Investigators completing probe into VA Medical Center in North Las Vegas | Las Vegas Review-Journal

WASHINGTON — The inspector general for the Department of Veterans Affairs is finalizing an investigation into how the VA Medical Center in North Las Vegas handled treatment of Sandi Niccum, a 78-year old blind veteran who waited six hours in pain for emergency care in October, Congress was told Wednesday.

A report “should be publishable in three weeks or so,” John Daigh Jr., assistant inspector general for healthcare inspections, told members of the House Committee on Veterans Affairs. The report is expected to include recommendations and a response by the medical center on suggested improvements.

The VA hospital was facing allegations that it mishandled Niccum’s treatment after she arrived for a scan and X-ray for stomach pain that left her weak and in tears. The long wait was compounded by problems with incomplete radiology orders and reported uncaring treatment of the veteran who was 100 percent service-disabled.

Niccum, a longtime community volunteer and former officer in the Disabled American Veterans organization, died on Nov. 15 in a Las Vegas hospice. Her Oct. 22 ordeal at the VA hospital was documented in notes and records released with her permission by a friend after her death, triggering investigations locally and in Washington, prodded by the House committee.

Rep. Dina Titus, D-Nev., asked Daigh for an update on the Niccum investigation during a hearing into VA delays in treating patients that may have played a role in 23 deaths and compromised the health of dozens of other veterans.

“I want to see what the recommendations are and then we’ll stay on top of the hospital to implement those recommendations,” Titus said after the Niccum report was given.

Hospital surveillance video sought by the House panel for the inspector general’s investigation had been deleted, a development that still concerned lawmakers Wednesday.

At one point in the hearing, committee Chairman Rep. Jeff Miller, R-Fla., inquired about the deleted videotape. “How did that occur?” he asked Dr. Thomas Lynch, VA assistant deputy undersecretary for health.

As VA officials said when the deletions were discovered, Lynch told Miller the tapes are automatically recorded over after 30 days.

“We don’t have that information,” the VA official said. “From our standpoint it’s unfortunate. We would like to have seen what happened as well.”

Contact Stephens Washington Bureau Chief Steve Tetreault at or 202-783-1760. Find him on Twitter: @STetreaultDC

via Investigators completing probe into VA Medical Center in North Las Vegas | Las Vegas Review-Journal.

Delay in care caused two deaths at Hampton VA –

Two patients at the Hampton Veterans Administration Medical Center died and five became sicker because of delayed gastrointestinal care, according to a report released Monday by the National Veterans Administration.

The report said the Hampton medical center was the third-worst out of 1,700 VA facilities across the country in terms of problems caused by delayed gastrointestinal care.

A veterans medical center in Columbia, S.C., was the worst in the country, with six deaths and 20 patients who were “harmed during care.” The medical center in Augusta, Ga., was second, with three deaths and seven patients made sicker.

Mike Dunfee, medical director of the Hampton medical center, said that while he couldn’t give specific dates for the Hampton incidents, they “spanned the entire length of the study.”

He emphasized that many factors contributed to the incidents.

“There was a lot going on behind the scenes,” Dunfee said. “There were significant enough issues that we thought we should be transparent about our processes. An error happened but it’s not necessarily the case that it led to the patient’s death.”

In response to the release of the report, the Hampton medical center issued a formal statement regarding the more than 45,000 veterans it serves in Hampton Roads:

“Any adverse incident involving a Veteran who is receiving our care is one too many. When an incident occurs in our system we aggressively identify, correct and work to prevent additional risks. We conduct a thorough review to understand what happened, prevent similar incidents in the future, and share lessons learned across the system.”

Dunfee was not able to give the length of the delays that led to the deaths in Hampton, but said they were a result of processing requests for diagnostic procedures and not for treatment.

“It’s not cut and dried,” he said. “It’s not as simple as a consult was ordered and not acted on for a lengthy period of time.”

The medical center sees some patients for colonoscopies within the VA system and sends others to see gastroenterologists in the community.

via Delay in care caused two deaths at Hampton VA –

U.S. GAO – VA Health Care: Ongoing and Past Work Identified Access Problems That May Delay Needed Medical Care for Veterans

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. W. Robb Graham, Esq. can be  reached  at  attorney who handles claims for veterans who have claims for malpractice against the VA, New Jersey VA Medical Malpractice lawyer, NJ Veterans Affairs Medical Malpractice attorney, NJ Veterans Administration Medical Malpractice Attorney, Philadelphia VA medical malpractice lawyer, Attorney for standard form 95 for claims for injury or wrongful death involving medical malpractice for veterans at the Philadelphia Department of Veterans Affairs Medical Center W. Robb Graham, Esq. ,  Federal Tort Claims Act attorney for veterans with medical malpractice claims from the Philadelphia Veterans Affairs Medical Center , Coatesville Veterans Affairs Medical Center, Lebanon Veterans Affairs Medical Center, Butler Veterans Affairs Medical Center , Erie Veterans Affairs Medical Center,  Wilkes Barre Veterans Affairs Medical Center, Pittsburgh Veterans Affairs Medical Center, Ft. Dix VA Clinic, Camden N.J. VA Clinic  W. Robb Graham, Esq. can be contacted through

GAO study reveals huge delays in the VA’s referral of veterans to specialists.

Ongoing and past work identified access problems that may delay needed medical care for veterans662395

GAO’s ongoing work examining VHA’s management of outpatient specialty care consults identified examples of delays in veterans receiving outpatient specialty care, as well as limitations in the Department of Veterans Affairs’ (VA), Veterans Health Administration’s (VHA) implementation of new consult business rules designed to standardize aspects of the clinical consult process. For example, for 4 of the 10 physical therapy consults GAO reviewed for one VAMC, between 108 and 152 days elapsed with no apparent actions taken to schedule an appointment for the veteran. For 1 of these consults, several months passed before the veteran was referred for care to a non-VA health care facility. VA medical center (VAMC) officials cited increased demand for services, and patient no-shows and cancelled appointments among the factors that lead to delays and hinder their ability to meet VHA’s guideline of completing consults within 90 days of being requested. GAO’s ongoing work also identified variation in how the five VAMCs reviewed have implemented key aspects of VHA’s business rules, such as strategies for managing future care consults—requests for specialty care appointments that are not clinically needed for more than 90 days. Such variation may limit the usefulness of VHA’s data in monitoring and overseeing consults systemwide. Furthermore, oversight of the implementation of the business rules has been limited and did not include independent verification of VAMC actions. Because this work is ongoing, we are not making recommendations on VHA’s consult process at this time.

In December 2012, GAO reported that VHA’s outpatient medical appointment wait times were unreliable. The reliability of reported wait time performance measures was dependent in part on the consistency with which schedulers recorded desired date—defined as the date on which the patient or health care provider wants the patient to be seen—in the scheduling system. However, VHA’s scheduling policy and training documents were unclear and did not ensure consistent use of the desired date. GAO also reported that inconsistent implementation of VHA’s scheduling policy may have resulted in increased wait times or delays in scheduling timely medical appointments. For example, GAO identified clinics that did not use the electronic wait list to track new patients in need of medical appointments as required by VHA policy, putting these patients at risk for not receiving timely care. VA concurred with the four recommendations included in the report and, in April 2014, reported continued actions to address them. For example, in response to GAO’s recommendation for VA to take actions to improve the reliability of its medical appointment wait time measures, officials stated the department has implemented new patient wait time measures that no longer rely on desired date recorded by a scheduler. VHA officials stated that the department also is continuing to address GAO’s three additional recommendations. Although VA has initiated actions to address GAO’s recommendations, continued work is needed to ensure these actions are fully implemented in a timely fashion. Ultimately, VHA’s ability to ensure and accurately monitor access to timely medical appointments is critical to ensuring quality health care to veterans, who may have medical conditions that worsen if access is delayed

via U.S. GAO – VA Health Care: Ongoing and Past Work Identified Access Problems That May Delay Needed Medical Care for Veterans.

Lawmakers eye ways to curb preventable deaths at VA hospitals – News – Stripes

Joseph Petit went to the VA hospital for knee pain and depression and came out on a litany of powerful drugs that he said made him hallucinate.

He repeatedly asked doctors for help with the side effects, but he said they gave him more antipsychotics, antidepressants and anxiety drugs that made him feel worse.

Petit told his sister that he heard voices and felt bugs crawling under his skin. To keep from harming his family, he would chain himself up in his room at night, according to Brandie Petit.

“I understand matters of the brain are extremely delicate,” she told Stars and Stripes last month. “But my brother was not crazy before that medicine.”

via Lawmakers eye ways to curb preventable deaths at VA hospitals – News – Stripes.

Boehner: VA Needs More Power to Fire Bad Managers |

Legislation advances to deal with the effects of the VA's self perpetuating bureaucracy. More at  attorney for veterans medical malpractice cases W. Robb Graham,

Legislation advances to deal with the effects of the VA’s self perpetuating Legislation advances to deal with the effects of the VA’s self perpetuating bureaucracy.

House Speaker John Boehner, R-Ohio, is throwing his support behind legislation that would give the head of the Department of Veterans Affairs the authority to fire underperforming executives.

But Boehner was clear during a question and answer period following a Thursday morning press conference on the bill that he does not believe VA Secretary Eric Shinseki should resign or be fired.

“I think the secretary needs to have more authority to manage his own department. It’s as simple as that,” Boehner said. “That’s what this bill would do.

Boehner was joined by the bill’s author, Rep. Jeff Miller, R-Fla., and Sen. Marco Rubio, R-Fla., who is introducing identical legislation in the Senate, as well as representatives from AMVETS, The American Legion, Iraq and Afghanistan Veterans of America, and Concerned Veterans for America.

“By any measure the VA is failing [veterans] and their families,” said Boehner said, citing problems with the disabilities claims backlog and preventable hospital deaths. “If you’re presiding over a bureaucracy that’s failing our veterans, you shouldn’t be receiving bonuses. You should be gone.

The press conference with Boehner followed a House Veterans Affairs Committee hearing where lawmakers pressed Deputy VA Secretary Sloan D. Gibson for details on several issues they have been tracking.

These include the VA’s rehiring of a former employee who was involved in a motor vehicle accident in which another employee died. A government review of the accident concluded the rehired employee had been intoxicated and driving a government truck when his colleague fell from it into traffic.

“Why isn’t drinking and driving a government vehicle on business a fireable offense?” Miller asked.

Committee members also asked Sloan to identify the VA hospitals where 10 veterans had died because of delays or oversights. The VA has so far only named two hospitals where nine vets had die – six in Columbia, S.C., and three in Augusta, Ga.

Sloan told the lawmakers he did not have the information but would get back them.

Miller has repeatedly slammed the VA for awarding bonuses to managers of VA medical centers linked to patient deaths, exposures of patients to HIV, and delayed medical consultations that led to serious injury or death for veteran patients.

With Thursday’s press conference Miller is hoping to crank up the heat on what he calls the VA’s lack of accountability. In recent months he has been chronicling on his House website requests for information that he has submitted to the VA that have gone unanswered.

More recently he has begun listing instances in which the VA has not responded to media requests for information.

Miller told after the press conference that he believes executives at all federal departments and agencies operate under the same policies as the VA’s. He also conceded that his proposed legislation could be seen as a threat to managers across government, including those in the Senior Executive Service.

“Again these are very high level individuals, very well paid individuals,” he said. “They should be afforded solid protections in the workplace, but the secretary should have the ability to fire them and not give them bonuses … It’s easier to get a bonus at the [VA] than it is to get fired.”

Rubio said all Americans expect government to be accountable and effective.

Peter Hegseth, chief executive officer of Concerned Veterans for America, said millions of veterans “feel like second class citizens” because of the way they’ve been treated by the VA. They file claims and wait unacceptably long times, ask for a mental health appointment and are told to wait months, or call hot lines only to be put on hold for an hour, he said.

“It’s unacceptable and we believe it’s time for transparency,” he said.

Louis Celli, legislative director for The American Legion, said his organization “is a partner with VA and has a vested interest in making sure it operates effectively and efficiently,” he said.

The Legion supports the bills filed by Miller and Rubio, he said, just as it supports the VA and Shinseki.

“The American Legion was here when the VA was created,” Celli said. “We’ve seen 23 veterans appointed as secretary and we’ll be here for the next 23.”

No Democrat lawmakers took part in the press conference, but Miller said he does have bipartisan support.

“We’re still talking with them about issues,” Miller said. “There are some concerns they have and were trying to work our way through it, because we really want to see this thing through, because our committee is probably the most bipartisan committee in the House.”

— Bryant Jordan can be reach at

via Boehner: VA Needs More Power to Fire Bad Managers |

VA Hospital Bars State Inspectors | Health News Florida

Florida Health Inspectors are banned by VA Officials, and they wonder why the quality of care for veterans does not improve? More at  attorney for veterans medical malpractice cases W. Robb Graham,

Florida Health Inspectors are banned by VA Officials, and they wonder why the quality of care for veterans does not improve?

Two surveyors from the Florida Agency for Health Care Administration were denied access to records and escorted out of the VA  Medical Center in Riviera Beach on Thursday when they tried to inspect it,  the Palm Beach Post reported.

AHCA, which inspects private and public hospitals in the state, added VA facilities to the list at the request of Gov. Rick Scott following media reports that veterans were encountering delays in access to diagnostic testing  that in some cases were fatal.

A spokeswoman for the VA said talks were going on with Scott’s office to work out an arrangement satisfactory to all parties.

via VA Hospital Bars State Inspectors | Health News Florida.

I-Team 8 looks into preventable deaths at VA clinics |

I-Team 8 looks into preventable deaths at VA clinics |

INDIANAPOLIS (WISH) – I-Team 8′s chief investigative reporter Karen Hensel has spent years uncovering the long wait times for benefits, the lack of care and deaths of veterans in Indiana VA hospitals. Congress is demanding change, forcing transparency and accountability from the VA.

The deaths include decorated Iraq war veterans who shot or hanged themselves after being turned away from mental help. Since 9/11, the Department of Veterans Affairs paid out $200 million to almost 1,000 families in wrongful death cases – that includes in Indianapolis.

At the Roudebush VA Medical Center, at least eight patients died from 2003 to 2011 in what the VA classified as a wrongful death.

The non-profit Center for Investigative Reporting found in 2003, one veteran’s case was classified as “Failure to treat, failure to diagnose -for example, concluding the patient has no disease or condition.” The family got $65,000 in that case.

Another veteran died after a “wrong procedure or treatment.”  The family given $120,000 for that death.

The highest payout from Roudebush of $200,000 came in 2009 in what was termed “failure to monitor.”  In all, the report found 13 preventable deaths in Indiana with the VA paying out $1.4 million to Hoosier families.

The revelation of the deaths comes at a time the VA is under intense scrutiny from congress. Rep. Jackie Walorski (IN-R) also sits on the House Veterans Affairs committee which is the oversight of the VA.

“The recent news at least 31 deaths at VA medical centers nationwide were completely preventable is only the tip of the iceberg of the complete mismanagement of this department,” she said.

I-Team 8 has repeatedly reported findings of bonuses handed to senior VA employees.

“It’s easier for those people to receive a bonus than it actually is for them to be fired,” House VA committee chairman Rep. Jeff Miller (R-FL) said.

I-Team 8 checked federal records and found the medical director of Roudebush in Indianapolis received bonuses totaling $1,700 during two of the years veterans died preventable deaths.

But in Pittsburgh, five-figure performance bonuses were handed out to hospital directors as a deadly outbreak of Legionnaires’ disease spread through the VA hospital. In Waco, Texas, it was a $53,000 bonus.

“If you’re presiding over a bureaucracy that is failing our veterans, you shouldn’t be receiving bonuses, you should be gone,” House Speakers John Boehner (R-OH) said.

At a budget hearing on March 13, 2014, Congress pressed for proof of VA staff disciplined after medical errors resulted in a veterans death.

“In 2012 we dismissed, involuntarily removed, over 3,000 employees. In 2013 we did the same thing. In those two years of the 6,000 fired, just six were senior managers,” VA Secretary Eric Shinseki explained.

At a press conference, the members of congress agreed the majority of VA employees are doing a thorough and careful job.  Congress is stepping in with a new VA accountability bill that would allow the secretary of Veterans Affairs to fire or demote the federally protected employees, the senior executives, for performance problems.  This is all about forcing transparency and accountability to the VA. The committee which is the watchdog of the VA says even they can’t get answers to questions they asked two years ago.

Meanwhile, I-Team 8′s calls to the medical director at Roudebush VA Medical Center were not returned.

I -Team 8 is breaking down hundreds of pages of documents to determine if the numbers of wrongful death cases are even higher in Indiana.

Feds settle lawsuits over Legionnaires cases at VA Pittsburgh hospitals | TribLIVE

Fortunately for all of us Legionella in the water was not a problem for Michael E. Moreland and the VISN 4 staff whose offices were no where near the infected  buildings as their offices where located in "Class A" office space conveniently located next to the ball field! More at W. Robb Graham attorney representing veterans with federaltort claims act claims agaiinst the Department of Veterans Affairs for medical malpractice

Fortunately for all of us Legionella in the water was not a problem for Michael E. Moreland and the VISN 4 staff whose offices were no where near the infected buildings as their offices where located in “Class A” office space conveniently located next to the ball field!

A settlement with the government is both a relief and a frustration for families of veterans who died in a Legionnaires’ disease outbreak in Veterans Affairs hospitals in Pittsburgh.

“This has been the longest funeral we’ve ever been through,” Maureen Ciarolla of Monroeville said on Friday, emotion straining her voice. She had hoped VA personnel would be held accountable for the death of her father, Navy veteran John Ciarolla, 83, of North Versailles during the outbreak.

“I’m relieved it’s over, but it’s not nearly what they deserved,” said Debbie Balawejder, also of Monroeville. Her father, Frank “Sonny” Calcagno, 85, died Nov. 22, 2011. Although he died in Forbes Hospital in Monroeville, he spent six weeks in VA Pittsburgh facilities on Highland Drive and in Oakland.

The Justice Department agreed on Thursday to settle their claims and two others during negotiations in a mediator’s office Downtown, according to attorney John Zervanos, who represented the Ciarolla and Calcagno families.

Families and their lawyers declined to talk about the details of the settlement, but it won’t include discipline for the VA executives who presided over the outbreak, which sickened at least 22, six of whom died from February 2011 to November 2012.

“To me, what they did was criminal,” Balawejder said. “They’re never going to pay the way they should for what they did.”

The VA referred questions to the Justice Department, which declined to comment.

In addition to the claims of Calcagno and Ciarolla, the government on Thursday agreed to settle the lawsuits brought by veterans George Christoff, 64, of Altoona, who served in Vietnam; and Gregory Darnell Jenkins, 54, of Edinboro in Erie County, who contracted the disease during stays in Pittsburgh VA facilities but recovered…

The government previously reached an agreement in a fifth case with the family of World War II veteran William E. Nicklas, 87, of Hampton, whose death on Nov. 23, 2012, was the outbreak’s last. Nicklas checked into VA Pittsburgh’s University Drive hospital in Oakland for medication problems — after the Centers for Disease Control and Prevention told hospital leaders that patients were being sickened by the same strain of Legionella detected in the VA’s water.

U.S. District Judge Arthur Schwab on March 26 and on Friday entered orders in the Nicklas and Ciarolla cases suspending the lawsuits based on mediators’ reports that the cases have been settled.

Harry S. Cohen, one of the lawyers for the Nicklas family, said they reached an agreement with the government last week and felt relieved but frustrated.

“It was with mixed feelings that they resolved the case. One hundred percent of their questions weren’t answered,” he said.

Cohen declined to discuss the settlement amount. A mediation did not resolve the case, but the family agreed to settle on the day that Greta Nicklas, Nicklas’ widow, was scheduled to be deposed, he said.

“The Nicklas family had an interest in not putting Mrs. Nicklas through the trauma of protracted litigation,” he said.

Schwab’s order keeps the families and the government from having to spend money on preparing for trial while they complete the settlements and file formal motions to dismiss the lawsuits. If the agreement falls through, the judge can reactivate the case and let it proceed to trial.

“These settlements have nothing to do with holding the individuals responsible for their deaths accountable,” said U.S. Rep. Keith Rothfus, R-Sewickley. Reps. Tom Murphy, R-Upper St. Clair, and Mike Doyle, D-Forest Hills, as well as U.S. Sens. Bob Casey Jr., D-Scranton, and Pat Toomey, R-Lehigh Valley, have been actively involved in the situation, Rothfus said, and “still have questions that the VA must answer.”

Chief among those questions is why VA executives in Pennsylvania, Georgia, South Carolina and Tennessee received bonuses and positive performance reviews instead of punishment for allowing such negligence, said House Veterans Affairs Chairman Jeff Miller, R-Fla. Former VA regional director Michael Moreland received approval for a $63,000 lifetime performance bonus shortly before the outbreak became public.

“What’s worse, department officials have repeatedly pointed to nondisciplinary actions such as employee retirements and transfers or bureaucratic slaps on the wrist, such as temporary written warnings, in a disingenuous attempt to create the appearance of accountability,” Miller said.

Until the department holds executives accountable, “it is simply illogical” to think the VA will fix the problems, he said.

Brian Bowling and Mike Wereschagin are staff writers for Trib Total Media. Reach Bowling at 412-325-4301 or Reach Wereschagin at 412-320-7900 or

via Feds settle lawsuits over Legionnaires cases at VA Pittsburgh hospitals | TribLIVE.

State association applauds Trib’s reporting on VA Legionnaires’ disease outbreak | TribLIVE

Great job Adam Smeltz, Luis Fábregas & Mike Wereschagin let’s hope that a Pulitzer is next!


Three Tribune-Review staffers won the Pennsylvania Associated Press Managing Editors public service award for their investigation of a fatal Legionnaires’ disease outbreak at the Pittsburgh VA Healthcare System.

The award, announced on Friday, was among 14 given to Trib Total Media staffers in the annual journalism competition sponsored by one of the state’s premiere journalism organizations.

Luis Fábregas, now the Trib’s medical editor, and reporters Mike Wereschagin and Adam Smeltz were honored for a series of stories examining the VA’s handling of the outbreak, which killed at least six veterans and sickened at least 16 others. Their investigation showed that the waterborne Legionella bacteria were found at one Pittsburgh VA hospital at least five years before the supposed beginning of the fatal outbreak, that Veterans Affairs officials in charge during the outbreak received thousands of dollars in performance bonuses and that the VA failed to follow federal guidelines for testing water and waited a year after the first diagnosis to warn the public.

Other Tribune-Review staffers receiving awards in the competition for newspapers with more than 75,000 circulation:

• Travis Sawchik, second place in sports feature reporting for “Shifting Gears,” about the Pirates’ approach to positioning fielders.

• Dejan Kovacevic, second place in sports/outdoors column for “Hey, baseball, can you hear us yet?”

• Guy Wathen, second place in feature photo for “She can still cut a rug” and second place in personality portrait for “Vatican astronomer.”

• Christopher Horner, second place in sports photo for “No avoiding the tag.”

• Andrew Russell, second place in spot news photo for “Three Brashear students shot.”

Staffers at the Valley News Dispatch in Tarentum, a Trib Total Media newspaper, were honored in competition among papers with 15,000 to 30,000 circulation:

• Eric Felack, first place in feature photo for “School days begin.”

• Liz Hayes, Braden Ashe and Brian Rittmeyer, second place in business writing for “Classes dismissed.”

• Rittmeyer and Hayes, second place in spot news reporting for “Tarentum, Kiski miners hurt.”

• Mary Ann Thomas, second place in feature writing for “Built on Bricks.”

Trib Total Media winners in competition among papers with less than 15,000 circulation:

• Rick Bruni Jr. of The Valley Independent in Monessen, second place in feature writing for “Valley soldier immortalized at Afghan base he never saw” and second place in spot news reporting for “Fire, explosions hit junkyard.”

• Evan Sanders, then of The Daily Courier in Connellsville, second place in photo story for “Dead is final.” Sanders now works in the Tribune-Review’s Greensburg newsroom.

via State association applauds Trib’s reporting on VA Legionnaires’ disease outbreak | TribLIVE.

VA releases findings on deaths, injuries from delayed tests


Report identifies medical malpractice in VISN 8. More at attorney for veterans medical malpractice cases W. Robb Graham,

Report identifies medical malpractice in VISN 8

VA releases findings on deaths, injuries from delayed tests.

Three veterans died and nine others were injured as the result of delays in treatment for gastrointestinal cancers in the VA’s Sunshine Healthcare Network serving Florida, southern Georgia, Puerto Rico and the Virgin Islands, according to a much-anticipated VA report released Monday. The report also laid out corrective measures being taken to prevent similar problems in the future.

None of the deaths was the result of actions at the James A. Haley Veterans’ Hospital in Tampa or the C.W. “Bill” Young VA Medical Center in Bay Pines, according to the National Consult Delay Review Fact Sheet report delivered to Congress. But there were two “institutional disclosures” at the Bay Pines facility and one in Tampa, according to the report. That means that patients or their representatives were notified that the veterans were harmed during their care. The report does not provide any specifics about the level of harm, nor does it list any patient names.

Two of the deaths resulted from delays at the North Florida/South Georgia VA Health System and one was from the West Palm Beach VA Medical Center, according to the VA. Another two patient deaths in the region were determined not be related to the delays, according to the VA.

The deaths and injuries in the Sunshine Healthcare Network were from 301,000 consultations made between 2010 and 2012, according to Joleen Clark, director of the Sunshine Healthcare Network, also known as VISN 8.

Nationwide, there were 17 other deaths and 44 other patient injuries found during a VA review initiated after deaths were discovered in Georgia and South Carolina.

There were seven deaths reported by VA facilities in South Carolina, three in Georgia, two in Virginia and one each in West Virginia, Ohio, Arizona, Colorado and Iowa, according to the report.

As a result of the findings, which included a review of 250 million consultations from 1,700 VA medical centers since 1999, the VA has a better understanding of the consultation process and improved how it authorizes and monitors health consultations, said Thomas Lynch, the VA’s assistant deputy undersecretary for health for clinical operations.

The majority of the deaths nationally happened as the result of delays in 2010 and 2011 said Lynch, who could not offer a specific figure or dates.

“For any veteran to die as the result of a medical error, or be harmed, is clearly a tragedy,” said Lynch. “I think an even greater tragedy is if we don’t learn from what happened and attempt to improve systems.”

The review was of seven “high interest” consults, including gastrointestinal endoscopy, said Lynch. A systemwide review is ongoing.

One of the changes, said Lynch, is enabling the VA to have a systemwide overview of consultations and react accordingly. If there is an increase in consultations requested, managers can react by either adding more staff in the case of sustained increases or jobbing out the work to local health care systems if the increase appears temporary.

In the Sunshine Healthcare Network, officials are now reviewing any consultation older than 60 days as well as instituting an automated tool to make sure that those with immediate needs are not waiting, said Clark.

Until Monday, VA officials had refused to list all the facilities involved in the deaths and injuries. The VA also denied a Freedom of Information Act request filed by The Tribune seeking the information, which was first reported by CNN.

The issue became fodder for politicians reacting to stories and an editorial in The Tampa Tribune. First, Sen. Bill Nelson, D-Fla., then Gov. Rick Scott weighed in on the issue, with Nelson writing a letter to VA Secretary Eric Shinseki and visiting Haley, while Scott ordered the state’s Agency for Health Care Administration to inspect VA hospitals. Those inspectors were turned away from the West Palm Beach VA center last week. The VA cited patient privacy as the reason.

Scott on Monday repeated his call for the VA to let the inspectors in.

“If the VA is interested in transparency and accountability, they will open their doors to state inspectors so we can get answers about the subpar treatment our veterans are receiving,” said John Tupps, a Scott spokesman.

“I’m glad to see the VA being open,” Nelson said in an emailed statement. “At the end of the day, it’s all about giving veterans the best care.”

U.S. Rep. Jeff Miller, R-Fla., chairman of the House Veterans Affairs Committee, agreed with Nelson that getting the information out to the public was a good step. His committee has been seeking the identity of where the delays occurred since last September.

“These heartbreaking findings are just the first step VA must take in rebuilding the trust of the veterans and family members affected by these tragic delays in care,” said Miller. “In addition to swiftly putting in place reforms to ensure this never happens again, it is incumbent upon VA to reveal precisely when these deaths and injuries occurred and whether any VA employees who may have allowed veterans to fall through the cracks have been held accountable. Unfortunately, we haven’t seen any evidence so far indicating that preventable deaths at VA facilities result in serious discipline for the employees responsible.“

Before the VA could begin any disciplinary action, it first had to determine the problem and find a solution, said Carolyn Clancy, the VA’s assistant deputy undersecretary for health, patient safety, quality, and value.

“Now we can review whether any disciplinary action is warranted,” Clancy said.

Miller seemed skeptical.

“If you look at recent VA preventable deaths linked to mismanagement – in Pittsburgh, Atlanta, Columbia, S.C., Augusta, Ga., and Memphis, Tenn. – VA executives who presided over negligence are more likely to have received a bonus or glowing performance review than any sort of punishment,” he said. “What’s worse, department officials have repeatedly pointed to nondisciplinary actions such as employee retirements and transfers or bureaucratic slaps on the wrist, such as temporary written warnings, in a disingenuous attempt to create the appearance of accountability. Such semantic sleights of hand are insulting to the families of those who died, veterans seeking care at VA as well as the taxpayers who fund the department’s operations. Until department leaders take steps to ensure VA employees and executives are adequately punished rather than rewarded for mistakes, it is simply illogical to think the many problems plaguing VA will subside.”

Miller’s committee will hold a hearing on the matter Wednesday.

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