VA accountability the focus in Pittsburgh

Announcing that he was not in Pittsburgh “for a witch hunt,” but to make sure veterans get the benefits they’ve earned, Rep. Jeff Miller, R-Fla., opened a field hearing by the House Committee on Veterans’ Affairs at the Allegheny County Courthouse.

Following a series of preventable deaths and outbreaks of infectious diseases at several Department of Veterans Affairs (VA) medical centers across the country, Chairman Miller decided to hold a hearing on VA accountability in Pittsburgh – where an outbreak of the Legionella bacteria (Legionnaires’ Disease) at the local VA hospital caused the deaths of five veterans and made another 16 seriously ill.

The committee heard dramatic testimony from seven individuals, five of whom lost loved ones at VA facilities that have been cited for mismanagement by VA’s own Officer of Inspector General.

Brandie Petit, whose brother shot himself at the VA medical center in Atlanta, said that his body wasn’t discovered until the following day. Petit said her brother had been taking 20 pills a day, prescribed by VA doctors who said the agonizing pain he felt in his knees was “all in his head.”

“Veterans fight for our freedoms,” Petit told the committee. “I do believe they should be treated with respect…. We need to make sure that compassion is not forgotten.”  She said the hearing was being held 10 months to the day when her brother’s corpse was found. “This could have been avoided.”

Gerald Rakiecki, a veteran and VA police officer, described a situation at the VA medical center in Buffalo, N.Y., in which nothing was done to save 240 boxes of veteran’s medical records that had become wet and moldy. He testified that four VA “whistle-blowers” who tried to have the problem corrected received “clear, written threats” from their managers.

Rakiecki said that VA employees should be pillars of integrity and ethics, but this was “not the case” in Buffalo, where the management demonstrated a “total disregard for veterans health.”

Three panelists who testified lost loved ones to the recent Legionella outbreak at the Pittsburgh VA hospital. Robert and Judy Nicklas told the committee how Robert’s father was admitted to the VA facility on Nov. 1, 2012, and died 22 days later from the Legionella infection. He had been allowed to drink water from the hospital’s system that the Centers for Disease Control and Prevention were already investigating.

The daughter of another veteran who died from the Legionella outbreak, Maureen Ciarolla, told the committee d she wanted “no more stonewalling” from VA on their accountability for such tragedies.

When asked by the committee if they knew of any VA employees who were being held accountable for patient deaths, each panelist answered “No.”

Dr. Robert Petzel, VA’s under secretary for benefits, said he was “saddened by these stories of loss, I’m saddened by the incredible journey that these people have had to go through as a result of what has happened in several of our medical centers, and I offer my absolutely sincerest condolences and sympathy, and empathy, to all of you.”

Petzel said that VA has been responding to the management and patient-safety problems at several of its facilities, and that recommendations made by VA’s Office of Inspector General were being followed.

“The lessons learned from Pittsburgh, and they are extensive, are now being used to ensure water safety at all of our VA medical centers throughout the nation, and we continue to work with federal, state and local officials, and partners, to keep all informed about this situation,” Petzel said.

The patient-care issues raised by the committee “are serious," Petzel said, "but they are not systemic. VA has a long-established record of providing safe health care. While no health-care system can be made entirely free from inherent risks, when adverse incidents do occur, VA studies them to fully understand what has happened, how it happened, how the system allowed it to happen, and how the system can be changed to prevent it (from) happening again.”

The American Legion was the only veterans service organization to submit written testimony to the hearing. The Legion noted that it had been 338 days since the Pennsylvania Bureau of Laboratories contacted the Centers for Disease Control and Prevention regarding a possible outbreak of Legionnaires’ disease at the VA medical center. “It has been 338 days for the veterans of Pittsburgh and two things are certain: five veterans are still dead, and the public has not seen any consequences for the leadership failures that led to those deaths.”

Recounting the failures in management and patient-safety at several VA facilities in its testimony, the Legion said that its System Worth Saving (SWS) Task Force “will be addressing all of these locations in follow-up visits in the coming year, and looks forward to sharing the results of our independent research with the committee and with the public. For the time being, the close scrutiny of the veterans’ community must be on VA to evaluate their reaction and response to addressing these terrible lapses.”

Ron Conley, past national commander of The American Legion and architect of the Legion’s SWS program, attended the hearing. “There has to be some accountability," he said. "It doesn’t seem like the VA is structured to make people accountable for errors and mistakes. VA health care is the best health care in the nation. But when you run into problems, you have to take immediate action to straighten those problems out and – if necessary – give out appropriate punishment to the people involved.”