Legionella outbreak caused by human error

A series of emails obtained by CBS News shows that top executives at the Department of Veterans Affairs (VA) medical center in Pittsburgh knew that a deadly outbreak of Legionella bacteria was caused by human error – more than a year before action was taken to warn patients.

During a Feb. 5, 2013, congressional hearing, VA officials from the Pittsburgh facility testified that the hospital’s water system was responsible for the spread of Legionella that took the lives of five patients and made 16 more seriously ill.

Daniel M. Dellinger, national commander of The American Legion, said, "Now that we know human error – not a faulty water system – caused the deaths of five patients that could have been prevented, The American Legion expects VA to act immediately to correct such horrendous accountability. This cannot continue – VA must improve its accountability to ensure that veterans are not at risk when seeking treatment."

VA executives have consistently attributed the cause of the Legionella outbreak to failures in the medical center’s copper-silver ionization water system. Dr. Robert Jesse, VA’s deputy under secretary for health, told the House Committee on Veterans’ Affairs that "The performance of this system, its maintenance and monitoring, is complex and may have failed to consistently prevent Legionella growth."

The emails tell a different story. One of them, dated Sept. 30, 2011, shows that VA Pittsburgh staff had received lab tests indicating the hospital’s water system tested positive for the deadly bacteria that causes Legionnaires’ disease. One month later, Legionella took the life of nursing home resident John Ciarolla.

It took until November 2012 for the Pittsburgh facility to acknowledge publicly that Legionella had infected its water supply and that patients were at risk.

"The fact that VA staff knew about the outbreak more than a year before they decided to warn their patients about the risk is unbelievably negligent," Dellinger said. "If the Pittsburgh VA had acted immediately, in September of 2011, what are the chances those five patients who died might still be alive today?"

The American Legion’s System Worth Saving Task Force visited the Pittsburgh VA hospital in September 2013 to evaluate its health-care quality and learn what responses were taken to eliminate the Legionella outbreak. Over a period of two days, the Legion team interviewed several key members of the facility’s staff, including director Terry Gerigk Wolf.

Wolf and others on her staff discussed several corrective measures taken, including the formation of a Water Safety Committee in January 2013 to oversee all policies and operations that control Legionella, and maintain a safe water supply. Human error was not mentioned by any of the staff as a possible contributor to the outbreak.

The Legion’s subsequent report on VA Pittsburgh cited confusion among the hospital’s staff in overseeing the water system before creation of the Water Safety Committee.

Last June, The American Legion sent a letter of support to Rep. Mike Coffman, R-Colo., for a bill he introduced, the Infectious Disease Reporting Act (H.R. 1792). The legislation would direct the VA Secretary to report each case of infectious disease (as required by state law) that occurs at a VA medical facility to appropriate state entities and accrediting organizations.

In part, the Legion’s letter stated, "As the tragic events resulting in the deaths of at least five veterans in western Pennsylvania have made clear, timely reporting of outbreaks of diseases such as Legionella can help prevent needless suffering.

"While we cannot bring back the five veterans who tragically perished due to this deadly disease in Pennsylvania, through diligent reporting we can hopefully prevent future loss of life."