Legion Seeks VA Accountability – Preventable Death

American Legion National Commander Daniel M. Dellinger told Congress at an April 9 hearing that Department of Veterans Affairs (VA) leadership must be held accountable for mistakes that result in preventable deaths at its medical facilities.

"Patient deaths are tragic – preventable deaths are unacceptable," Dellinger testified to the House Committee on Veterans' Affairs. "But failure to disclose safety information – or worse – to cover up mistakes, is unforgivable, and The American Legion will not sit quietly by while some VA employees cover up the truth – and the VA shouldn't, either."

During his testimony, Dellinger recalled the deaths of six patients from an outbreak of Legionella bacteria at the Pittsburgh VA Medical Center. When a team from the Legion's System Worth Saving (SWS) Task Force visited the facility last November, administrators claimed the outbreak was caused by equipment failure.

A March 12 CBS news report, citing emails and internal memos from Pittsburgh VA administrators, proved they were aware that the deadly Legionella outbreak was caused by human error – a fact that had not been shared with the Legion's visiting SWS team.

Last January, Dellinger told the committee that another American Legion SWS team visited the G.V. Sonny Montgomery VA Medical Center in Jackson, Miss., "where a veteran died when all of the blood was drained from his body because he wasn't properly monitored during a medical procedure."

The SWS team asked the facility's director, Joe Battle, for a copy of the action plan being used to address such critical problems, but he refused to provide it.

At the Atlanta VA Medical Center, Dellinger testified, "two veterans died of an overdose, and one committed suicide, that was attributed to mismanagement and an inability to get the mental health care they needed in a timely manner. Veteran suicides continue to plague our nation at 22 per day, with no clear strategy from VA on addressing suicides proactively."

Repeating the phrase, "While we wait," Dellinger listed more persistent problems that reflect a lack of VA accountability and/or effectiveness:

• Veterans with traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD) are being overprescribed with medications, and VA is demonstrating "a reluctance toward looking at complementary and alternative medicine because giving out pills is faster than providing veterans the therapy sessions they need."Servicemembers returning to civilian life "are falling through the cracks due to (Department of Defense) and VA's inability to create a single, interoperable medical record."
• VA may have reduced its disability claims backlog by 44 percent in the past year, but "hundreds of thousands of veterans are waiting for their initial disability claim, or appeal, which prevents them from receiving their VA health care."
• Because of a lengthy review process for press releases issued by its medical centers, "officials in VA's Central Office (VACO) are preventing hospitals from being transparent" during crises that affect patients and enrollees.

"We all need to continue to ask the hard questions," Dellinger told the committee. "What is VA doing to fix these problems, and are they concerned about keeping me informed? How is VA holding their leaders accountable for these errors?

"The American Legion will not stop asking the hard questions, and we hope you won't, either."

After his testimony, Dellinger fielded several questions from committee members. Rep. Paul Cook, R-Calif., asked about VA's culture and whether it was lacking when it came to the way in which patients were treated. Dellinger said as he travels across the country visiting VA facilities, "you can tell the ones who are caring. Others are there for a paycheck.... I see some great chiefs of staff and other ones that are just biding their time."

VA, Dellinger told Cook, needs to be held accountable from the top down. Military leaders who make serious mistakes can be court-martialed, while many VA senior executives, "are allowed to resign, and then there's nothing."

In The American Legion's written testimony, Rep. Gus Bilirakis, R-Fla., noted that VA's medical center in Jackson, Miss., has kept the Legion waiting five months for a report it had requested. He asked if such delays were common.

"We do see lengthy delays," Dellinger said. "They try to do everything out of Washington." Responses could be sped up if VACO allowed its regional offices and medical centers "to address things in a timely manner."

Rep. Corrine Brown, D-Fla., said that some observers think the VA system is broken, while others believe it can still be fixed. She asked Dellinger how he rates VA's system on a scale of 1 to 10. "Let me break it down into two aspects," he said. "For medical care and community-based outreach, I think that is an 8 to a 9." But VA's system of oversight is not as good, and he would "rate that at about 5."

Dellinger told Brown that many of VA's problems reside at its central office in Washington. One such problem created by VACO is its insistence on reviewing press releases and other public communications drafted by staff at medical centers; these reviews take weeks if not months. For example, Dellinger said the Pittsburgh VA facility had prepared a public statement explaining the recent outbreak of Legionella virus and steps being taken to contain it. "Their statement was ready to go out and VACO held it up," he said. Review of the statement took so long that it was never released.

Ed Lilley, the Legion's senior field service representative, added that VA needs to address crises when they happen. When medical centers remain mum about a potentially life-threatening situation, "veterans are scared. They're nervous because they just don't know what steps VA is taking."

Testifying with Dellinger at the hearing was Army veteran Barry Coates, who was diagnosed with Stage IV cancer. He told the committee that, due to inadequate VA care, "I stand here before you, terminally ill today." He described his long, painful journey in trying to get proper medical treatment. His colonoscopy had been delayed many months; when he was finally examined, his cancer was found to be terminal. "Something needs to be done," he said. "Someone needs to be held accountable for it."

Coates, who turns 45 next month, said he had never been advised by VA that he might qualify for fee-based treatment in the private sector. VA had never offered him any recourse for his long-delayed treatment. When asked whether VA had offered any kind of apology for his condition, his one-word reply was "none."

In an especially emotional comment, Rep. Jackie Walorski, R-Ind., apologized to Coates "on behalf of a bureaucratic system that is broken.... This is an American disaster. If I could change your circumstance, I would do it in a heartbeat." Crying, she predicted the VA officials at the hearing "will give us long, dramatic answers and nothing is going to change" unless Congress "stands up to the negligence."

Addressing Dellinger, Walorski said, "To The American Legion, sir, you guys come in here faithfully" and stand by veterans, "and I just want to commend you" for consistently trying to improve the VA system. "Together, let's change the system."

In his opening remarks, Chairman Jeff Miller, R-Fla., said that a briefing held April 7 by VA, and its testimony prepared for the hearing, provided "very few details about what, if any, specific actions have been taken to ensure accountability for 23 veterans who lost their lives, and the many more who were harmed because they did not get the care they needed in a timely fashion."

Calling testimony provided by VA for the hearing "ridiculous," Miller said, "It answers no questions, it provides no new information, and I'm tired of begging the Department of Veterans Affairs to answer this committee's questions."

Click here to read Dellinger's written testimony submitted for the HVAC hearing.

Reports issued by the Legion's System Worth Saving Task Force on VA medical centers nationwide are available online here.