Mane Was Resident of Facility Leasing VAMC Space
Click To Enlarge: Bedford VA Hospital Campus
BEDFORD, MA—On June 12, 2020, a badly decomposed body was found in the emergency exit stairwell of the Bedford Veterans Quarters (BVQ), a privately operated, independent living facility on the campuses of VA’s Edith Nourse Rogers Memorial Veterans Hospital. The body was discovered to be that of Tim White, 62, who had been a resident of the BVQ and had been reported missing on May 13.
White was an Army veteran struggling with homelessness, and his room at the facility had been just down the hall from the stairwell. He was found in the same clothes he was last seen wearing, suggesting that his body had lain in that stairwell, undiscovered, for nearly a month. Due to the extensive decomposition of the body, cause of death is undetermined.
As for how White’s body could go undiscovered for so long, a recent VA Office of the Inspector General report pointed the finger at negligence by hospital staff, VA police, and Caritas Communities Inc., the company that manages the facility. The report also highlighted the need for more clarity on just what VA’s responsibilities are to veterans like White, who are technically not patients but rather are classified as “residents.”
White was reported missing on May 13 by the BVQ house manager. Superiors at Caritas were emailed by management, who informed them that White had not been seen since May 8 and was not in his room. Caritas informed the Bedford VA’s chief of social work, and the house manager was instructed to contact the Bedford police to file a missing person’s report.
A Bedford police officer arrived at BVQ to take the report, and White was entered into the national missing person database. VA police were informed of the missing person report shortly after.
According to the OIG investigation, the VA police’s response was very limited. An email was sent to officers, White’s picture was posted on bulletin boards, and one VA police officer conducted a search in the wooded area behind the BVQ. But VA police never conducted a search of the building leased by BVQ—Building 5.
White was eventually found by another BVQ resident. An autopsy found no evidence of trauma or suspected foul play, but an exact cause of death could not be determined.
The discovery of White’s body resulted in a storm of publicity for the Bedford VA. Several members of Congress requested an OIG investigation, which began shortly after the discovery of the body. However, it was delayed until the local district attorney’s office closed its criminal investigation in December 2020.
The OIG report released last month found that the lack of response from VA police was “heavily influenced by their view that [White] was considered to be a resident and not a patient of the medical center.” VHA directives instruct VA police and clinical staff to first conduct a preliminary search and then a comprehensive search of buildings when a patient is missing. There is not a similar directive for individuals who are not considered patients.
Even a preliminary search would have included emergency stairwells, resulting in the discovery of White’s body almost immediately, OIG investigators stated.
In interviews with OIG investigators, the Bedford VAMC director testified that, “We have a policy for missing patients and what needs to be done, [while the Caritas residents] can come and go as they please.”
According to the director of VA’s Office of Security and Law Enforcement, VA police would have “no authority or responsibility to look for that person at all.”
The OIG report noted that, while there is no VA directive specific to nonpatient residents of VA buildings, there is one requiring VA to “provide for the … protection of person and property on VA property within VA’s jurisdiction.”
“Mr. White resided at a facility on VA property and was last seen there prior to being reported missing,” the report declares. “He was entitled to basic protection in the form of VA police involvement and a search.”
The report includes recommendations to the VA Undersecretary for Health that VA update its directors and VA handbook, clarifying VA police responsibilities for missing persons on VA property, regardless of their patient status. After White’s body was discovered, the Bedford VA police drafted a new standard operating procedure for missing people, regardless of whether they are a. The procedure includes a search checklist and requires a preliminary search of nearby buildings.
OIG investigators also discovered that a poor understanding of Caritas’ lease by VA police and by hospital staff prevented White’s body from being discovered earlier.
Several months prior to White’s disappearance, Caritas management requested that VA police no longer conduct regular patrols of the building unless specifically requested. The Bedford VA police chief at the time—Shawn Kelley—agreed to the request and ordered his officers to cease regular patrols. This violated VA policy as well as the terms of VA’s lease with Caritas. According to the lease, parts of the building were still considered unleased VA property, including the emergency exit stairwells, which had previously been a regular part of VA officer’s patrols.
“Police did not discover Mr. White’s remains in the stairwell during the month after he was reported missing because they were no longer patrolling [the building],” the report states. “The VA police chief exceeded his authority in issuing this order.”
Kelley resigned while the OIG investigation was underway.
Confusion About Lease Terms
This misunderstanding of the terms of Caritas’ lease extended beyond VA police. Confusion among medical centers staff resulted in the emergency exit stairwells in the building not being cleaned as part of regular VA cleaning and maintenance.
The hospital’s chief of Environmental Management Service (EMS) testified that he was informed by his predecessor when he took over the position in 2014 not to bother with Building 5, since that was leased to Caritas. He was unaware that the lease did not extend to the emergency stairwells. The EMS chief testified that he physically checked emergency stairwells in nonleased VA spaces several times a week.
VA leadership, including the executive director of the Office of Security and Law Enforcement, concurred with OIG’s findings and recommendations. OSLE is drafting new standard operating procedures for VA police nationwide, ensuring that searches will be conducted for anyone reported missing on VA property, regardless of their patient status.