VA Care Delays Implicated in Veteran Fatalities; Lawmakers Express Anger

By Sandra Basu

Barry Coates, Army veteran

Barry Coates, Army veteran

WASHINGTON Veterans have died from delayed or never delivered medical care at VA facilities, according to lawmakers who accused the agency of not addressing the problems in a transparent way.

“When errors do occur, and they seem to be occurring with alarming frequency, what VA owes our veterans and our taxpayers, in that order, is a timely, transparent, accurate and honest account about what mistakes happened, how they are being fixed, and what concrete actions are being taken to ensure accountability,” House Committee on Veterans Affairs Chairman Rep. Jeff Miller (R-FL) said at a House hearing.

Miller made his comments at a hearing last month on delays in VA medical care and preventable deaths of veterans. Only two days before the hearing, Miller said, the VA provided evidence of 23 veterans who died, primarily of gastrointestinal issues, due to delays in care at VA medical facilities.


pencil_white.jpgOpinion poll:
Are care delays at VA facilities creating additional morbidity and mortality for veterans?

Please click here to participate in this month’s U.S. Medicine readership poll.


Outside of VA’s review, Miller said his committee has reviewed at least 18 preventable deaths that occurred because of mismanagement, improper infection-control practices and other problems.

“There is no excuse for these incidents to have occurred,” Miller said.

Meanwhile, the Phoenix VA Health Care System also was under fire after allegations that at least 40 patients may have died waiting for care there and that the facility had a secret list of patients who were waiting for appointments.

“The moment we heard about the allegations around these 40 individuals who had died in Phoenix, I immediately ordered the Secretary of Veterans Affairs, Gen. Shinseki, to investigate,” President Obama said about the allegations at the end of April.

Within a week, Shinseki said that  “in view of the gravity of the allegations and in the interest of the Inspector General’s ability to conduct a thorough and timely review,” he had directed that Phoenix VA Health Care System Director Sharon Helman, Associate Director Lance Robinson, and a third PVAHCS employee be placed on administrative leave until further notice.

VHA Undersecretary for Health Robert Petzel, MD, told the Senate Committee on Veterans’ Affairs late last month that, in addition to the Inspector General’s investigation, VA also sent a team to Phoenix to review appointment scheduling procedures at that facility and to look into any delays in care.

He said that to date they had “found no evidence of a secret list and we have found no patients who have died because they have been on a wait list.”

“We think it is very important that the Inspector General be allowed to finish their investigation before we rush to judgment as to what has actually happened in Phoenix,” Petzel said.

Severe Abdominal Pain

During the House of Representatives hearing, 44-year-old Barry Coates, an Army veteran, told lawmakers that he is terminally ill “due to the inadequate and lack of follow-up care” through the VA system.

Coates said he had severe abdominal pain in November 2010 and, after he sought treatment at the Carolina Pines Regional Medical Center in Hartsville SC, a colonoscopy was recommended. After seeing various VA physicians and taking medications they prescribed, however, the colonoscopy was not performed until December 2011, more than a year later.By that time, the colonoscopy found a 4.4mm nodule and he was diagnosed with Stage 4 colorectal cancer, according to Coates, who said he was told that a proper rectal exam would have easily found the growth and allowed for earlier treatment. The cancer now has spread, with lesions in his liver and both lungs.

In written testimony, he said he was totally and permanently impotent as well as incontinent and that extensive chemotherapy has resulted in permanent neuropathy in both his hands and feet, causing constant discomfort and pain.

“Something needs to be done; somebody needs to be held accountable for it,” Coates told lawmakers.

Lawmakers were appalled by Coates’ story. “Have you had any formal apology from the VA?” Rep. Julia Brownley (D-CA) asked Coates.

Coates said he had not.

Thomas Lynch, MD, VHA Assistant Deputy Undersecretary for Health for Clinical Operations, called Coates’ testimony “a compelling story.”

“What we have heard is a sad story. Before I walked up here, I apologized to Mr. Coates,” he testified before the committee.

Lynch further said that VA officials would look into what happened “so that we can understand, and he can get a better explanation and the explanation he deserves.” He added that the agency needs to learn from these situations and “do better.”

VA Is ‘Learning Organization’

Still, he said the VA strives to be transparent in disclosing errors in care.

“As a system, we have taken a lead in being transparent, we have taken a lead in clinical disclosure. We are not perfect, sir. We are a learning organization. When errors occur we do try to express apologies to the involved patients and their families,” he said.

Overall, Lynch told lawmakers the VA is making improvements to the consult system to address delays. He said there have been flaws in how the system had been used that resulted in delays in patient care.

“We observed that there were flaws in our consult process that allowed consults to remain open or unresolved. That put noise in our system and prevented us from trying to identify those facilities where there was a need for alternatives, such as fee-basis care,” he testified.

Lynch said changes are being made to the process to track trends in delays and ask “critical questions about whether those facilities have the resources to address those delays.”

Meanwhile, lawmakers wanted to know whether anyone had lost their jobs due to patient delays. Lynch said he did not have that information.

Lawmakers said that they would also look into the allegations about the Phoenix VAMC.  The chairman of the Senate Committee on Veterans’ Affairs Sen. Bernie Sanders (VT-I) vowed that his committee would hold a hearing after the VA IG finished its independent investigation.

At a Senate hearing held at the end of April Sen. Richard Burr (R-NC) said that “this is not the first issue on quality of care that faces the department.”

“One veteran death related to delays in care is one too many,” he said.

Share Your Thoughts

Please answer the following math problem to prove you are a human! *