Berrocal pointed out that the number of colonoscopies performed at the Miami VAMC has increased by 20% since 2009 — an indicator that the hospital is running smoothly and has re-earned veterans’ trust.

“I think we have put the necessary oversight systems in place to ensure that we are not placing our veterans at risk,” Berrocal said.

Berrocal had few answers to explain the recent escape and subsequent suicide of Catawabe Howard, a 32-year old woman who had spent eight years in the Army and Air Force Reserves. Howard was involuntarily admitted to Jackson Memorial after threatening to commit suicide. When it was discovered she was a veteran, Jackson Memorial transferred her to the Miami VAMC.

Less than 24 hours after being admitted, Howard walked out of the hospital. She located a gun and, in an incident early the next morning, opened fire on police officers and was shot and killed.

“This veteran escaped and committed suicide by cop just one day after she had been admitted to a system that should have protected her in her clearly fragile state of mind,” Miller said.

According to Berrocal, the hospital was still investigating the incident but admitted that mistakes were made. The paperwork from Jackson Memorial listed Howard as an involuntary admission, which would have required a much higher level of security than was provided.

 Berrocal said a conflicting telephone call from Jackson Memorial personnel telling VA staff that Howard was being voluntarily admitted created confusion between Jackson and VA about whether the veteran’s admission was voluntary or involuntary.

According to Nevin Weaver, director of Veterans Integrated Service Network (VISN) 8, his office was informed immediately about the incident.

“Mistakes were made,” Weaver told legislators. “The response by staff was not appropriate. We looked at individuals who were responsible and held them accountable.”

Asked if any staff members had lost their jobs due to the incident, Berrocal said during the hearing that, while some employees have been removed from the position they held at the time, no one has been discharged because the investigation by the hospital is still under way.

“I find it troubling that you say the Miami VAMC is moving in the right direction,” Miller told hospital officials.

 Drawing attention to data from a customer and staff survey of the facility, Miller pointed out that, in recent years, senior management satisfaction, psychological safety, customer service and overall satisfaction all have trended down.

“That is not the direction that any of us want to see in our medical centers,” he said.

Failures at Miami VAMC: Window to a National Problem

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