First, waterborne bacteria in Pittsburgh Veterans Affairs hospitals led to at least five deaths from Legionnaires’ disease.
Then insulin pens reused on more than 700 patients in the Buffalo VA Center exposed them to hepatitis.
And last month, improper use of electronic medical records led to three deaths in the Memphis VA medical center’s emergency department.
In all, the deaths of at least 21 veterans nationwide appear linked to failures in VA medical care revealed during the past year in VA inspector general and news reports.
“The list keeps growing day by day,” Rep. Jeff Miller, R-Fla., chairman of the House Committee on Veterans Affairs, told the Tribune-Review. “Accountability remains the biggest problem across the board, regardless of whatever the issue is.”
VA spokesmen in Pittsburgh and Washington declined to comment.
On Wednesday, U.S. Attorney David Hickton said the government would not file criminal charges in connection with the Legionnaires’ outbreak. Hickton said his investigation, conducted with the FBI and the VA Office of Inspector General, found “no basis for charging any individual or any entity with a federal crime.”
Although the VA continues to examine responsibility for the outbreak, a growing chorus of critics says the medical nightmares need to stop. Some veterans advocates, congressional leaders and former employees say the nation’s health care system for veterans is broken.
“The veterans deserve better,” said Dorothy Stefanick of Delmont, a former registered nurse at the closed VA Highland Drive campus in East Liberty. “Nothing is getting done, and who’s getting stuck are the boys that are coming back. As far as I’m concerned, they deserve everything for what they’ve done, especially these boys coming back without arms and legs.
“It just tears my heart out to see these men going through this. If they don’t get the good care, then there’s something terribly wrong.”
Fixing health care problems in the nation’s 151 VA hospitals won’t be easy, experts say. The VA inspector general and Hickton’s office began investigating soon after the Legionnaires’ outbreak became public a year ago. The federal Centers for Disease Control and Prevention and the VA concluded the outbreak lasted from about February 2011 to November 2012 and likely caused at least 21 cases of Legionnaires’ disease.
A Tribune-Review investigation found VA Pittsburgh had water quality test results showing the presence of Legionella bacteria in its Oakland hospital five years before the outbreak.
The newspaper found that urine tests that could have identified Legionella bacteria in flu patients were not routinely performed; disclosure to state and local health authorities was delayed or did not occur; and problems arose with the copper-silver ionization system used to treat water at the University Drive campus in Oakland.
At congressional hearings, lawmakers called for accountability and transparency at the VA nationwide.
“No one wants to take responsibility for anything,” said William Cleveland, commander of the Pennsylvania American Legion, which has more than 800 posts. “Who’s in charge? You need accountability.”
VA facilities beyond Pennsylvania have experienced troubles:
• Inspectors examined three patients’ deaths in the emergency department of the Memphis VA Medical Center. One patient had a fatal reaction to medication despite a documented drug allergy. Another patient was found unresponsive after receiving multiple sedating medications. The third was not monitored despite critically high blood pressure and bleeding in the brain.
• An internal investigation at the VA hospital in Jackson, Miss., found nurse practitioners without proper federal certification wrote narcotics prescriptions. Some patients received drugs without being seen, according to a whistle-blower, Dr. Phyllis Hollenbeck, who described the situation at a September congressional hearing as “unethical, illegal, heartbreaking and life-threatening for the veterans.”
• Federal investigators said three mental health patients died from 2011 to 2012 in the Atlanta VA Medical Center, including one who was not properly monitored and killed himself in a hospital restroom.
• In the VA hospital in Columbia, S.C., veterans waited for months for procedures such as colonoscopies, delaying their diagnosis and treatment. At least six veterans are believed to have died as a result.
In Pittsburgh, problems extended to construction projects. In May, a contractor accidentally cut power for more than three hours to two operating rooms where surgeries were taking place.
The outage prompted surgeons to halt the liver transplant surgery of Gregory Bethony, a retired contractor from Framingham, Mass. His family said Bethony, who had liver disease, never fully recovered from the surgery. Bethony, 65, died two months after the transplant.
“Did something happen to Gregg’s liver while the power was out?” asked Judy Whittingham, Bethony’s girlfriend and a registered nurse. “What happened to the anesthesia? Did he lose oxygen to the brain?”
The lack of answers frustrates Bethony’s family and congressional leaders who view the incident as one more example of VA Pittsburgh’s questionable management.
“For the health and safety of our veterans, the VA has to make more than cosmetic changes,” said Rep. Tim Murphy, R-Upper St. Clair. “The problems we’ve witnessed here in Southwestern Pennsylvania are happening nationwide, so the steps toward fundamental reform must be bold.”
One solution Murphy favors is the proposed Infectious Disease Reporting Act, which calls for the VA to implement the same disease outbreak reporting requirements with state and local officials as private hospital and health clinics so that illness and outbreaks are quickly identified for immediate remedy.
The measure could merge with a similar bill in the Senate and win passage by December, according to legislative aides.
To regain the trust of veterans, employees and the public, everyone needs to know that when errors or mistakes happen, those responsible will be held accountable, Miller said.
“Unfortunately, what you see within the Department of Veterans Affairs is personnel being shifted from one facility to another, remaining in the same position — just at another hospital,” he said. “That’s not acceptable.”
Luis Fábregas is a Trib Total Media staff writer. Reach him at 412-320-7998 or firstname.lastname@example.org. Staff writer Adam Smeltz contributed to this report.