Defense Department Isn’t Reviewing Doctors, Putting Patients in Danger, Watchdog Says

Danyelle Luckey had been on the aircraft carrier Ronald Reagan barely a week before she began vomiting and feeling ill. After reporting her symptoms to doctors, she was given a flu vaccine, despite them not being recommended for sick patients, and sent on her way.

Days later, not feeling any better, she returned and was tested for flu and strep. She was prescribed fluids, Motrin and bedrest. When she failed to improve, her shipmates carried her back to the clinic, where, after five days, she was admitted and given a blood test, which showed her kidneys and liver were failing. As officers prepared to evacuate her off the ship, she died from sepsis, according to her father, Derrick Luckey.

Retired Army PFC Dez Del Barba was at basic training, Fort Benning, Georgia, when he contracted an infection. He went to sick call six times before a physician at a civilian emergency room ordered a blood test. He had streptococcus A, which developed into necrotizing fasciitis, a flesh-eating bacteria. 

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More than 100 days later, he lost his left leg, most of the flesh in his right leg and required skin grafts over 55% of his body.

As far as he knows, his case was never investigated.

“It's been 1,143 days, and I still have no clear answers on the status of any quality assurance investigation that may or may not have been initiated promptly,” Del Barba told members of the House Armed Services personnel subcommittee on Wednesday. “What happened to me did not have to happen. This was preventable.”

While the Defense Department has procedures for ensuring quality of care and patient safety, facilities often fail to adhere to them, harming patients or potentially placing them in danger, the Government Accountability Office, an independent taxpayer-funded watchdog, found as part of an investigation into the military medical system’s quality management procedures.

According to a preliminary report released by the GAO on Wednesday, a review of four medical facilities in the military health system found that administrators failed to verify medical licenses of about a sixth of the centers’ doctors before they were allowed to practice, failed to document assessment requirements when evaluating concerns about treatment and did not adhere to patient safety review procedures in cases that would qualify for a compensation claim.

The report did not name the four, and GAO Health Care Team Director Sharon Silas said that they would remain anonymous as part of the investigation agreement with the Defense Department.

During the hearing, Silas said the oversights put patients at risk.

“[In one case] at the beginning of the review, facilities are supposed to consider taking adverse privileging action against a provider if the safety events were particularly egregious, and we found there was no documentation that any consideration was ever taken,” Silas said.

In 2016, the military health system recorded 108,000 occurrences in health facilities that threatened patients’ health or lives, according to a 2018 report from the GAO. At the time, the agency recommended that DoD improve tracking of such events, which it said would improve overall care.

Congress passed the Sgt. First Class Richard Stayskal Military Medical Accountability Act in 2019 as part of the defense budget process to give service members a way to file medical malpractice claims against the Department of Defense.

DoD published guidance on that process in mid-2021 but to date, the bill’s namesake, a former Army Special Operations soldier whose lung cancer was missed by military physicians and diagnosed at a significantly later stage by civilian doctors, has not received any compensation, according to his attorney, Natalie Khawam.

The delay, as well as DoD’s seeming inability to hold accountable providers who fail to meet standards of care, raise concerns about the agency’s commitment to adequately treat troops and their families, said Rep. Jackie Speier, D-Calif., subcommittee chairwoman.

“It is incomprehensible and shameful that we cannot ensure [that service members] have quality medical care,” Speier said. “My efforts to allow service members to file claims against the military for instances of medical malpractice aren't only a matter of justice – they are about accountability.  I am frustrated to say the least that DoD has been so slow to implement the Stayskal Act.”

According to Rep. Mike Gallagher of Wisconsin, the subcommittee’s ranking Republican, roughly 400,000 hospitalized persons in the U.S. experience an adverse event that was preventable, costing $20 billion each year.

While a 2014 review found that the military health system is largely comparable to civilian care, there appears to be variability, with some metrics falling below national standards, said Gallagher, a former Marine and Iraq war veteran.

“The bottom line is, the military health system is not where it needs to be,” Gallagher said.

Defense Health Agency Director Lt. Gen. Ronald Place said during testimony that DHA oversees accreditation for its hospitals and clinics and belongs to several accreditation organizations to ensure that facilities are certified and providers are accredited.

DHA, he said, has seen patient safety improvements in the past four years “that measures against peers.”

But he added, when patient events occur, the malpractice claims process exists and DHA does review cases. And to Derrick Luckey and Del Barba, he apologized.

“Your testimony today was compelling and heartbreaking …  I apologize for [your] losses. I’m deeply committed to ensuring we learn from your losses so we can better our system so we have fewer losses,” Place said.

GAO’s findings on the four health facilities were preliminary, with a complete report due out in mid-2022, according to Silas.

Speier asked for assurances from Place that when the full report is published, DHA will follow the recommendations to ensure that the military health system performs at its highest levels.

“I think we are all interested in the same thing,” Speier said. “We don’t want practitioners out there providing services to our service members who need more training, or have forgotten their training, or just are not good physicians or health-care professionals.”

Correction: This story was updated April 1 to reflect Del Barba's training status and correct who diagnosed him with strep and necrotizing fascitis.

– Patricia Kime can be reached at Patricia.Kime@Military.com. Follow her on Twitter @patriciakime

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