VA handling of health research ripped

VA handling of health research ripped.

The U.S. Department of Veterans Affairs suppressed information that shows links between health problems and the dangers veterans were exposed to in Iraq, Afghanistan and the Gulf War, according to a whistle-blower who testified to a House panel last week.

Steven Coughlin described an “epidemic of serious ethical problems” in the VA’s Office of Public Health, where, until December 2012, he worked as a senior epidemiologist for 4 1/2 years.

“If the studies produce results that do not support Office of Public Health’s unwritten policy, they do not release them,” Coughlin told a Committee on Veterans Affairssubcommittee.

“This applies to data regarding adverse health consequences of environmental exposures, such as burn pits in Iraq and Afghanistan, and toxic exposures in the Gulf War. On the rare occasions when embarrassing study results are released, data are manipulated to make them unintelligible,” he said.

Veterans activists have long complained that the VA has been loathe to acknowledge connections between veterans’ health and the situations they faced in theaters of war. Agent Orange during Vietnam and Gulf War illness are two examples.

The connection can make a huge difference for veterans’ federal benefits.

In a prepared statement the VA said: “The Department of Veterans Affairs has a decades-long history of conducting world-class research studies that meet accepted and rigorous scientific standards. … All allegations of malfeasance are taken seriously and are investigated fully. … The VA agrees with Gulf War veterans that there are health issues associated with service (there).”

Coughlin was not the only witness venting frustration with the VA’s health research and treatment.

It doesn’t have effective treatments for Gulf War illness, said Anthony Hardie, a Gulf War veteran who suffers with chronic health issues. “A cabal of federal bureaucrats and contractors work at every step to delay, defer and deny, and even so far as to obfuscate and refuse to implement laws, policies and expert recommendations,” said Hardie, who sits on the congressionally chartered Research Advisory Committee on Gulf War Veterans’ Illnesses, known as RAC.

Lea Steele, an epidemiologist at Baylor University who studies the health of Gulf War veterans, said the VA continues to ignore science and to minimize the seriousness of the Gulf War illness impact. A large study this year of Gulf War veterans, for instance, doesn’t even ask about symptoms related to the illness. “This is a wasteful and inexcusable missed opportunity at best, and something akin to scientific malpractice at worst,” Steele said.

Victoria J. Davey, chief officer of public health for the VA Health Administration, said the department is committed to care for all veterans.

In his testimony, Coughlin, now an adjunct professor of epidemiology at Emory University, claimed:

- His supervisor told him not to look at data on hospitalizations and doctors’ visits for veterans of Iraq and Afghanistan when studying the relationship of their health problems to exposure to burn pits and other inhalation hazards.

- VA officials at first refused to set up a system to offer intervention for veterans who told surveyors that they had suicidal feelings. Coughlin was threatened with disciplinary action by his bosses during the process. Eventually, mental health professionals were able to follow up with the troubled veterans.

- When Coughlin tried to make changes recommended by experts to a study of Gulf War veterans, his supervisors killed the idea by falsely claiming it would cost $1 million to do so, he said.

Coughlin said some of the research costs tens of millions of dollars but doesn’t serve the veterans.

He called on Congress to force change. “In view of the pervasive pattern where these officials fail to tell the truth, even to VA leadership, the VA cannot be expected to reform itself.”

Connecticut Veterans Affairs Commissioner Linda Schwartz said the U.S. Department of Veterans Affairs has long had a problem of conflict of interest in its health studies.

“There is much more effort put into disproving this stuff than dealing with these issues up front,” said Schwartz, who studied Agent Orange and has a doctorate in public health from Yale University. “It does a disservice to the veterans and our country.”

VA’s research should be done by academic institutions, she said.

The hearing was called to look at the care for Gulf War veterans. Gulf War illness is a chronic illness with multiple symptoms, including muscle pain, fatigue, cognitive problems and rashes. It affects veterans of the 1991 Gulf War.

Although it was initially dismissed as psychosomatic, scientists have linked it to a drug given to troops to combat nerve gas and to toxic pesticides.

A $10 million study that Coughlin worked on called the National Health Study of a New Generation of U.S. Veterans looked at the exposures faced by veterans who served in Iraq and Afghanistan.

More than a fifth of those veterans also served in the Gulf War, but the VA has not released the treasure trove of data that could shed light on their health effects from the earlier war. “Anything that supports the position that Gulf War illness is a neurological condition is unlikely to ever be published,” Coughlin said.

Rep. Mike Coffman, R-Colorado, and the top Democrat on the committee, Rep. Ann Kirkpatrick, D-Arizona, pressed Davey and other officials on why they are taking so long to develop better training for doctors and information for vets about the illness.

“I find the conduct of the VA embarrassing,” Coffman said, before asking the panel of VA officials if any of them were veterans. If they were, “I don’t think we’d be here today” he said, with an emphatic bang of his gavel.

$75,000 settlement in Manhattan VA medical malpractice case Sylvester Johnson v. United States of America; 2011 Jury Verdicts LEXIS 211679


Sylvester Johnson v. United States of America;


December 13, 2011

Headline: Patient And United States Reach $ 75,000 Settlement In New York Federal Court Medical Malpractice Action Related To Spinal Stenosis Surgery

Party Names
Johnson, Mr. Sylvester

United States of America

Method of Resolution: Settlement

All Dates: 2007 Plaintiff’s Surgery Performed
07/06/2009 Complaint Filed
12/13/2011 Stipulation and Order of Settlement Filed and Action Dismissed

State: New York

Court: US District Court for the Southern District of New York

Judge: Henry B. Pitman

Case Summary 

Sylvester Johnson had surgery performed in 2007 at the United States Department of Veterans Affairs Medical Center, Manhattan Campus. The surgery was to alleviate his spinal stenosis. Johnson alleged that the surgery was negligently done and caused numerous problems including urinary retention, fecal incontinence and erectile dysfunction.

On July 6, 2009, Johnson filed a medical malpractice complaint in the U.S. District Court for the Southern District of New York against United States of America pursuant to the Federal Tort Claims Act, 28 U.S.C.S. Section 2671, et seq. The United States answered, asserting that its doctors had acted within the standard of care.

On Dec. 13, 2011, the parties filed a stipulation of settlement which provided for the United States to pay Johnson $ 75,000 in exchange fora release of all claims. Magistrate Judge Henry B. Pitman entered the order of settlement and dismissed the action on the same date.

$7,800 settlement for the death of a veteran who was misplaced at the Buffalo VA—Vanessa A. Quinn, As Executrix of the Estate of William Hunt, Jr., Deceased, v. United States of America; 2012 Jury Verdicts LEXIS 13756

Vanessa A. Quinn, As Executrix of the Estate of William Hunt, Jr., Deceased, v. United States of America; 2012 Jury Verdicts LEXIS 13756.

All Dates: 01/26/2009 Decedent Misplaced at Hospital
03/15/2009 Decedent Died
03/26/2010 Complaint Filed
01/13/2012 Motion for Settlement Filed
01/17/2012 Revised Petition for Settlement Filed
01/25/2012 Decision and Order Approving Settlement Entered

State: New York

Court: US District Court for the Western District of New York

Plaintiff Counsel
Michele A Braun
Firm Name: Lipsitz, Green, Scime & Cambria Llp

Defendant Counsel
Mary K Roach
Firm Name: U.S. Attorney’s Office – Buffalo

Judge: William M. Skretny

Case Summary 

On Jan. 26, 2009, William Hunt, Jr. was at the Veterans Affairs Medical Center (VAMC) in Buffalo, New York for tests related to his pulmonary and cardiac disorders. He was taken by wheelchair into radiology and apparently left there for several hours, without food, water, or medications. He allegedly suffered complications as a result. On March 15, 2009, Hunt died.

On March 26, 2010, Vanessa A. Quinn, As Executrix of the Estate of William Hunt, Jr., Deceased, filed a complaint against the United States of America in the U.S. District Court for the Western District of New York pursuant to the Federal Tort Claims Act, 28 U.S.C.S. Section 2671, et seq. alleging medical malpractice.

On Jan. 13, 2012, Quinn filed a motion for settlement. On Jan. 17, 2012, she filed a revised petition for settlement. The settlement provided for a settlement of $ 7,800, with $ 808.90 towards a VAMC lien and for $ 3,817.50 to plaintiff’s counsel for disbursements. Chief Judge William M. Skretny entered a decision and order approving the settlement on Jan. 25, 2012.

Award: $ 7,800

$ 255,701.20 verdict for Plaintiff after 10 day trial for death of veteran as result of medical malpractice at Miami VA MARIA JOSE PEREZ, Individually and as Personal Representative of the Estate of FRANCISCO PEREZ, vs. UNITED STATES OF AMERICA (United States District Court for the Southern District of Florida); 2012 FL Jury Verdicts Rptr. LEXIS 373

MARIA JOSE PEREZ, Individually and as Personal Representative of the Estate of FRANCISCO PEREZ, vs. UNITED STATES OF AMERICA (United States District Court for the Southern District of Florida); 2012 FL Jury Verdicts Rptr. LEXIS 373.

Cause Of Injury: Decedent Francisco Perez was a 55-year-old veteran with a history of psychiatric problems. He had been a patient for a number of years at the Department of Veterans Affairs Medical Center in Miami, Florida, and the satellite clinic in Oakland Park. He was seen by Gregory Manov, M.D., Psychiatrist, at the Oakland Park VA Clinic on April 3, 2008. Mr. Perez’ psychiatric diagnosis on April 3, 2008, was delusional disorder. Dr. Manov’s office note for that date stated that Mr. Perez was still quite delusional, was having inappropriate affect, had little insight and was not taking his medications. It further stated that Mr. Perez was still convinced of his delusion that a gang was after him. On April 10, 2008, Mr. Perez was seen by Brenda Heitman, ARNP at the Oakland Park VA. Again, Mr. Perez was noted to be non-compliant with his medications and continued to be delusional. No admission was ordered and no referral to the care of the mental health intensive team was ordered. On April 19, 2008, Mr. Perez was found dead due to a self-inflicted gunshot wound at his home.

In a complaint filed on Jan. 21, 2010, plaintiff Maria Jose Perez, the decedent’s daughter, claimed that defendant United States of America, by and through its employees, agents, and servants at the Miami VA and the Oakland Park VA, negligently failed to adequately monitor, treat and admit Mr. Perez to the psychiatric ward due to his worsening condition, which led to his death. The action proceeded to a 10-day bench trial

$ 2,000,000 malpractice settlement Janet Richardson on behalf of Darryl Richardson, an incompetent adult, and U.R., a minor, and J.R., a minor v. United States of America; 2012 Jury Verdicts LEXIS 19058

Janet Richardson on behalf of Darryl Richardson, an incompetent adult, and U.R., a minor, and J.R., a minor v. United States of America; 2012 Jury Verdicts LEXIS 19058.

Janet Richardson on behalf of Darryl Richardson, an incompetent adult, and U.R., a minor, and J.R., a minor v. United States of America; 2012 Jury Verdicts LEXIS 19058


December 05, 2012



Topic: Medical Malpractice – Failure to Monitor – Medical Malpractice – Delayed Treatment


Judge: Fred Biery

Case Summary

On Jan. 26, 2010, plaintiff Darryl Richardson, 47, a security guard, was admitted to the Audie L. Murphy Veterans Affairs hospital in San Antonio and diagnosed with congestive heart failure. On Feb. 4, he experienced a cardiac arrest while using a bathroom down the hall from his room. He was resuscitated but sustained brain damage.

Richardson’s wife, on behalf of her husband and their two minor children, sued the federal government for medical malpractice. Plaintiff’s counsel argued that the bathroom floor in Richardson’s room was covered in urine, causing him to leave for the hall bathroom.

Plaintiffs’ counsel argued that Richardson’s sister, who was visiting with other family members, saw the emergency help light flashing over the bathroom door and called for help, but that it took approximately 25 minutes to locate a key to open the door and assist Richards, and another 10 minutes passed before epinephrine was administered.

The plaintiffs’ medical experts gave the opinion that the delay was the cause of Richardson’s brain damage. Plaintiffs’ counsel argued that the hospital breached the standard of care by failing to provide Richardson with a clean restroom in his room; failing to properly monitor his condition; failing to provide him with portable oxygen for ambulation; and failing to have a readily accessible bathroom key. All of these factors contributed to Richardson’s cardiac arrest and subsequent injuries, his family claimed.

Injury Text:

Plaintiffs’ counsel argued that Richardson sustained severe permanent brain damage, resulting in serious cognitive, memory and motor control impairment. Richardson can only intermittently communicate or recognize family members. He requires assistance with basic tasks and will require 24-hour care for the remainder of his life. His family sought $4 million for future medical care and an unspecified amount for past and future pain and suffering, physical impairment and lost income.

The defense economics expert disputed the lost-wage claims. The defense life care planning expert maintained that the plaintiffs’ claims for Richardson’s future medical needs and lifespan were excessive, arguing $2 million was a more reasonable estimate of future medical costs.


Award Details: The parties settled prior to trial for $2 million.


Portland VA Medical Center supply tech gets three-year term for collecting child porn

Portland VA Medical Center supply tech gets three-year term for collecting child porn

Three-year term for collecting child porn.

A former police officer, politician and Gulf War veteran blamed battlefield exposure to toxic chemicals as one factor that led him to amass thousands of graphic videos depicting sexual abuse of girls.

Colby Michael McCormick, 46, was sentenced Friday in Clackamas County Circuit Court after pleading guilty to eight counts of second-degree encouraging child sexual abuse.

McCormick, a supply technician at the Portland Veterans Affairs Medical Center, was arrested in June 2012 when investigators discovered his online activities. He was released from the Clackamas County Jail on his own recognizance and immediately resumed such activities, then was arrested again Sept. 11.

Altogether, McCormick amassed about 3,000 hard-core videos of girls engaged in sexual behavior, many with adult male relatives.

Circuit Judge Eve Miller sentenced McCormick to three years and four months in prison. Prosecutor Bryan Brock had sought a sentence of more than seven years.

McCormick, a former Marine, said he suffered from Gulf War syndrome related to his deployment in Iraq in the early 1990s. Exposure to toxic substances has been linked to fatigue, depression and other maladies suffered by military personnel.

McCormick, who lived near Clackamas Town Center, claimed he turned to child pornography when he was depressed.

Robert Stanulis, a psychologist, testified that Gulf War syndrome could be a factor in McCormick’s behavior. He testified there is scientific evidence to substantiate the connection.

McCormick may be one of the first defendants in Oregon to invoke a new state law that allows a person’s military service to be used as a mitigating factor at sentencing. Senate Bill 124, which took effect June 6, is retroactive and applies to criminal cases that have not been resolved.

McCormick offered a tearful apology for his crimes, and family members spoke in support, asking that he receive sex offender treatment. Former Jefferson Mayor Mike Myers also spoke on McCormick’s behalf, praising his public service.

McCormick was a Jefferson city councilman, a city police force member and a former Jefferson Rural Fire Protection District battalion chief.

In 2000 he ran as a Democrat for what was then House District 30 but was defeated in the general election.

“They portrayed him as a veteran and a public servant who should be treated differently, and argued he get some kind of discounted sentence because of it,” Brock said. “I wanted the court to judge him by his current behavior, not on what he did in the past.”

Laurels & Lances

Laurels & Lances.

Lance: To Dr. Robert Petzel. The Department of Veterans Affairs’ top health official, appearing at The National Press Club in Washington to tout planned tech upgrades, claimed he had a meeting, then stared straight ahead and refused to acknowledge a Trib reporter’s questions about the Pittsburgh VA Healthcare System’s deadly 2011-12 Legionnaires’ disease outbreak. The doctor’s reprehensible stonewalling speaks volumes about the VA’s arrogance, self-interest, dereliction of its sacred duty to America’s veterans and disregard for public accountability.


VA hospital failures bring senator home | Opinion | Columbus Ledger Enquirer

VA hospital failures bring senator home | Opinion | Columbus Ledger Enquirer.

Under other circumstances Sen. Johnny Isakson might have been showboating for the voters. He is, after all, a politician, even if he isn’t up for reelection until 2016.

But Isakson’s attention to abuses at Atlanta’s VA hospital, ever since those abuses were revealed in a federal report and highlighted in an Atlanta television investigative series, have borne little resemblance to showboating. Neither did his decision to set up a Senate “field hearing,” a rare event that took place Wednesday at Georgia State University.

It all has the ring of genuine outrage. And it’s outrage every Georgian — every American — should share.

Some of the specifics have been outlined in news stories and commentaries, in this newspaper and elsewhere. The short version of a long, ugly story is that mismanagement, neglect and sheer incompetence have led to the deaths of at least three mental health patients at Atlanta VA Medical Center. One committed suicide in the hospital and wasn’t discovered for more than 24 hours. Others simply got lost in the bureaucratic maze. For a time, the report revealed, one out of every five veterans who showed up seeking mental health care never got it.

Among those being asked some tough questions Wednesday were high-ranking officials of the Department of Veterans Affairs and hospital administrators. Isakson pressed Dr. Robert Petzel, VA undersecretary for health, on changes that have been and will be made.

The VA official said there had been “both corrective and administrative actions taken,” and that two people “involved in this process have resigned from, retired from the VA.”

How much responsibility those two unnamed ex-employees bear, and how effective the operational changes will be, are questions impossible to answer, at least for now.

The facility’s new director, Leslie B. Wiggins, who took over leadership of the embattled facility in May, outlined some substantial changes the hospital has made in oversight and patient access. When a TV reporter asked Isakson if he was satisfied, the senator answered, “So far. It’s not finished yet.”

It shouldn’t be. Atlanta VA Medical Center might be today’s Ground Zero for abuse and neglect of American veterans, but there have been too many others in the past and, sadly, there will be more in the future. If there’s anything that gets more lip service and less actual service than our debt to veterans, it would be hard to name.

One vet at the hearing, retired 1st Sgt. Vondell Brown with the Wounded Warrior Project, was quoted in Bloomberg News: “The bottom line is we sit here and talk about policies and procedures and talk about what’s right and what’s wrong, but I think for simple veterans like myself, we really don’t care how much you know until we know how much you care.”


Read more here:

Murphy seeks reversal of bonus given to Pittsburgh VA leaders during Legionnaires’ outbreak – Pittsburgh Post-Gazette

got bonus? Our effort to recognize VA executives who have alredy recognized themselves with a cash bonus while providing substandard service to veterans! More on VAmalpractice.infoMurphy seeks reversal of bonus given to Pittsburgh VA leaders during Legionnaires’ outbreak – Pittsburgh Post-Gazette.

U.S. Rep. Tim Murphy sent a letter to U.S. Veterans Affairs Secretary Eric Shinseki today asking him to rescind recent bonuses given to leaders of the regional and Pittsburgh VA offices given the ongoing revelations about a Legionnaires’ outbreak.

The letter was in response to a letter sent last month to Mr. Murphy, an Upper St. Clair Republican, that upset Mr. Murphy because Mr. Shinseki defended regional VA director Michael Moreland saying Mr. Moreland “is an outstanding professional who continuously demonstrates strength, commitment, integrity, and a relentless commitment to public service.”

Mr. Murphy and Rep. Keith Rothfus, R-Sewickley, wrote to Mr. Shinseki earlier asking why Mr. Moreland and others received bonuses even as the Legionnaires’ outbreak was ongoing.

“In your reply,” Mr. Murphy wrote Mr. Shinseki today, referring to the July letter, “you stated the VA ‘can and will do more to prevent future incidences.’ While preventing the spread of infectious diseases should be a top priority for VA leadership, the department must also hold responsible those in a position of authority who did not adhere to the VA’s own directives and standards of care. And at the very least, the taxpayers should not be giving them bonuses.”

In the final report on the outbreak at the Pittsburgh VA, the federal Centers for Disease Control and Prevention found that in 2011 and 2012 at least 16 veterans were possibly or definitely infected with the disease during stays at the Pittsburgh VA and five more veterans died.

The Pittsburgh Post-Gazette reported two weeks ago that a sixth veteran may also have died after contracting Legionnaires’ at the VA.

Mr. Murphy included a list of all six men’s names in his letter to Mr. Shinseki, writing: “It is in the memory of these veterans that I am writing to you today.”

In addition to asking Mr. Shinseki to rescind bonuses to the leadership at the Pittsburgh VA, Mr. Murphy asked that Mr. Shinseki tell him within 10 business days “whether there have been any suspensions, sanctions or firings of individuals who contributed to the failures that led to the November 2012 outbreak. The review is not over; our congressional investigations continue.



Read more:

Jeff Miller Chairman of the HVAC …Vets deserve better than VA’s practice of rewarding failure | House Committee on Veterans’ Affairs

Vets deserve better than VA’s practice of rewarding failure | House Committee on Veterans’ Affairs.


The Department of Veterans Affairs has received a lot of negative attention lately for failing to adequately deliver the care and benefits America promised our veterans.

In addition to the department’s massive disability-benefits backlog, a disturbing pattern of preventable veteran deaths and other patient-safety issues has emerged at VA hospitals around the country.

Sadly, the department’s widespread and systemic lack of accountability may be encouraging more veteran suffering instead of preventing it.

Examples of the department’s lack of accountability are numerous. But almost as plentiful — and even more shameful — are the many cases where VA employees and executives are being rewarded rather than punished for their incompetence.

Officials with the VA Pittsburgh Healthcare System have botched the handling of a deadly Legionnaires’ disease outbreak at nearly every turn. Five veterans are now dead from the pneumonialike disease. But instead of giving those who failed to prevent the outbreak pink slips, VA gave them glowing performance reviews and huge bonuses.

According to the Centers for Disease Control and Prevention, up to 21 veterans were sickened between February 2011 and November 2012, but that didn’t stop VA Pittsburgh Director Terry Gerigk Wolf from receiving the highest possible score on a VA performance review covering the bulk of the outbreak period.

Shockingly, Wolf’s review makes no mention of the outbreak, and instead praises her for leading a “groundbreaking Civility Initiative” and helping improve her employees’ resume-writing skills.

Memories of the outbreak seem to have eluded VA officials again when they nominated Wolf’s boss, VA regional director Michael Moreland, for the Presidential Rank Award, America’s highest civil-service accolade. For Moreland, the honor included a whopping $62,895 bonus, which he formally accepted just three days after VA’s inspector general reported VA Pittsburgh’s response to the outbreak was plagued by persistent mismanagement.

Most people would find VA’s celebration of Wolf and Moreland in the aftermath of a deadly outbreak they were too incompetent to stop hard to believe. Yet the situation is routine at the department, where failing executives have been collecting massive bonuses for years. Recent examples include the following:

A VA executive in charge of the nearly 60 offices that process disability benefits compensation claims collected almost $60,000 in bonuses while overseeing a near seven-fold increase in backlogged claims.

A VA health official in New York pocketed nearly $26,000 in bonuses while presiding over chronic misuse of insulin pens that potentially exposed hundreds of veterans to blood-borne illnesses.

Two April VA inspector-general reports identified serious instances of mismanagement at the Atlanta VA Medical Center that led to the drug-overdose deaths of two patients and the suicide of another. True to form, VA doled out nearly $65,000 in performance bonuses to the medical-center director who presided over the negligence.

In early May, I spent the day at the Atlanta VAMC, along with several members of Georgia’s congressional delegation. Hospital officials told us that although they had identified specific employees whose actions had contributed to patient deaths, no one had been fired.

When I asked a roomful of Atlanta VAMC leaders if there were any other serious patient-care incidents Congress needed to know about, they said no, failing to reveal a previously unreported suicide the media would expose just four days later.

This alarming pattern of complacency has cast a dark shadow over VA medical centers around the country. For months, Congress has tried in vain to compel VA leaders to take meaningful steps to prevent deaths and adverse incidents. Unfortunately, department officials seem more intent on protecting and rewarding VA’s worst-performing employees than sending a powerful message that substandard care for veterans will not be tolerated.

Our veterans deserve better. For VA’s quality of care to improve, department officials must be willing to hold accountable anyone responsible for letting patients fall through the cracks. Rewarding failure will not help VA better serve those who served our country. It will only lead to more delays and more dead American heroes.

U.S. Rep. Jeff Miller, a Republican from Chumuckla, Fla., is the chairman of the House Committee on Veterans’ Affairs.