WASHINGTON — Last month,  Marine Corps veteran Robert Stahlnecker stood before a District Judge in Plains Township, Pa., and waived his right to a preliminary hearing on charges of harassing female employees at the VA regional office in Philadelphia. That harassment allegedly included threats of violence and references to rape made during dozens of phone calls and e-mails during the course of several months in 2009 and 2010.

Currently out on bail, Stahlnecker has been quoted in the press as saying his aggression and threats were a result of frustrations with the VA system.  

While Stahlnecker claims he never intended his tone to be threatening, that case is a disquieting reminder that the VA system, with its hundreds of facilities and sometimes troubled patients, is highly vulnerable to violence or threats of violence — sexual or otherwise — to staff, patients and visitors.

Despite that situation, according to a recent Government Accountability Office (GAO) report, VA has a disjointed and often ineffective way of tracking and responding to sexual assault incidents within its facilities.

 The GAO report contends that most sexual assault incidents reported to VA police are not reported to VA leadership or the VA Office of Inspector General (OIG), as is required by VA regulations. This leaves the agency’s leadership unaware of the extent of sexual assaults in their facilities or of how effective VA is in responding and following up on them.

VA Police trainees on the firing range. A recent report questions whether all sexual assault cases investigated by VA police were properly reported up-the-line.

Unreported Cases

When an incident, such as an alleged sexual assault, occurs at a VA facility, there are two tracks for reporting the incident — the first along law enforcement lines and the other along management lines. The management stream is intended to help ensure incidents are identified and documented for leadership’s attention. The law enforcement stream is so the incidents can be properly investigated.

The law enforcement stream begins with VA police — a separate security force employed to protect department facilities. If there is evidence of wrongdoing, VA police reports it to local law enforcement. Whether this is local police, state police  or another law enforcement agency can vary state-by-state. VA police are then required to notify not only facility leadership, but also VA’s Office of Security and Law Enforcement (OSLE) at the national level and the Office of the Inspector General (OIG).

On the management side, facility leadership is required to report all serious incidents to leaders at the Veterans Integrated Service Network (VISN) level, who then are required to pass that information on to VA Central Office. 

Whether through the law enforcement or administrative stream, reports of serious incidents should eventually end up at VA’s Central Office. That apparently had not been happening, according to the report.

GAO investigators found that 284 sexual assault incidents were reported to VA police from January 2007 through July 2010, including alleged incidents involving rape, inappropriate touching, forceful medical examinations, forced or inappropriate oral sex and other types of sexual assault incidents.  Of these, 89 were patient-on-patient sexual assault, 85 were patient-on-employee, 46 were employee-on-patient, 28 were unknown affiliation-on-patient, and 15 were employee-on-employee.

GAO spoke with leaders at four VISNs and compared VA police reports with the issue briefs received through the management reporting stream. They found that VISN officials in those four networks were not informed of most of the sexual assault incidents that occurred in their network’s medical facilities. The investigators also found that one VISN did not report any of the cases they received to VA’s Central Office.

Investigators reviewed 67 rape allegations reported to VA police during that time period and compared those cases with all investigation documentation provided to OIG. GAO found no evidence that about two-thirds of those rape allegations had ever been reported to OIG.

GAO provided OIG with summaries of the 42 rape allegations that never made it from VA police to their office. Several OIG senior-level investigators reviewed those summaries and reported that they would have expected about one-third of the 42 cases to have been reported to them. For about 12%, there was not enough information in the incident summary to make a determination. Page 2