VA OIG Opens Investigation Into Legionnaire’s Cases In Pittsburgh

by U.S. Medicine

January 29, 2013

The VA Office of the Inspector General (OIG) is opening an investigation into the VA Pittsburgh Healthcare System and whether a recent outbreak of Legionnaire’s disease could have been prevented. The outbreak resulted in 29 cases of Legionnaire’s between January 2011 and November 2012 at the University Drive VA Medical Center in the Oakland area of Pittsburgh.

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It also allegedly resulted to at least one death—87-year old William Nicklas, who died November 23 from pneumonia complicated by Legionnaire’s. Nicklas had been a patient at the University Drive VAMC for two days in October of last year. After returning home, he began experiencing symptoms of Legionnaire’s, but was not diagnosed with the disease until November 21.  Nicklas’ family has filed a civil claim against VA, maintaining that his death was preventable and the fault of failures at VA to maintain its water systems.

The goal of the OIG investigation is to determine just that—whether VA could have foreseen the problem and avoided it through adequate water supply maintenance. World-renowned Legionnaire’s researchers and former Pittsburgh VA employees Janet Stout, MD and Victor Yu, MD, have suggested that if the water filtration systems at the hospital had been maintained properly the outbreak could have been avoided.

The OIG investigation comes after reviews by the CDC and an internal examination of the water system by the VA in Pittsburgh. It also comes after calls for action by Pennsylvania legislators.

“It is critical that VA be held accountable and that reforms are instituted so this never happens again in Pittsburgh or any other VA facility,” said Sen. Bob Casey, D-PA, following the announcement of an OIG investigation.

A similar call to action was made to Congress. Rep. Mike Doyle, D-PA, wrote to the leadership of the House VA Committee in December saying, “I believe that your Committee should utilize all tools available, including subpoena power, to assist with determining the cause of this deadly outbreak to protect against future failures.”

The House VA Committee has scheduled a hearing on the outbreak and VA’s actions to prevent it for February 5.


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