OSC: Shortcomings in VA Response to Problems at Manchester VA Hospital

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Manchester VA Hospital

UPDATE: News releases from Rep. Annie Kuster, D-NH, and Rep. Carol Shea-Porter, D-NH.: Congresswoman Annie Kuster (NH-02), the Ranking Member of the Oversight & Investigations Subcommittee of the House Veterans’ Affairs Committee, is calling for a Congressional oversight hearing to investigate the Department of Veterans Affairs’ review practices. (See both releases at end of story.)

WASHINGTON, D.C./Jan. 25, 2018 – The Office of Special Cousel on Thursday notified President Trump of shortcomings in the Department of Veterans Affairs’ (VA) response to disclosures of wrongdoing at the VA Medical Center of Manchester, New Hampshire.

Whistleblower disclosures included concerns that a large number of patients at the Manchester facility developed serious spinal cord disease as a result of clinical neglect. OSC found the VA’s response largely sluggish until the media covered the problems. Even after that coverage, the agency chose not to review certain serious allegations.

“The VA did not initiate substantive changes to resolve identified issues until over seven months had elapsed, and only did so after widespread public attention focused on these matters,” Special Counsel Henry J. Kerner wrote to the President. “It is critical that whistleblowers be able to have confidence that the VA will address public health and safety issues immediately, regardless of what news coverage an issue receives.” Kerner wrote that OSC referred the allegations to the VA for investigation in early January 2017, but the VA did not take any action to remove responsible management officials or initiate a comprehensive review of the facility until after the Boston Globe published an article in July.

“This sends an unacceptable message to VA whistleblowers that only the glaring spotlight of public scrutiny will move the agency to action, not disclosures made through statutorily established channels,” Kerner wrote. The four whistleblowers, all medical doctors, brought forward concerns of a higher presence of a serious spinal cord condition known as myelopathy among Manchester VA patients, despite a significant decline in this condition in the general U.S. population. They alleged that transfers to another facility were not performed in a timely manner, against agency policy.

They described substandard surgical procedures, leading to one patient who developed a spinal infection and possibly died from complications and another patient who developed a spinal infection after surgery but survived. The whistleblowers alleged that the prior chief of the Spinal Cord Unit inappropriately copied and pasted chart notes for patients between 2002 and 2012, contributing to the high incidence of myelopathy in the Manchester VA patient population. The whistleblowers also described a longstanding fly infestation in an operating room. OSC referred the matters to the VA, which conducted an investigation and sent a report to OSC on June 20, 2017.

The report contained internally inconsistent conclusions at odds with the information adduced in the investigation. OSC requested two supplemental reports to address many of these issues and provide updates on external chart reviews. Ultimately, Kerner found that the VA’s findings were not reasonable. Kerner wrote that the agency appears to have chosen not to review allegations concerning dirty and potentially contaminated surgical instruments because they did not appear in OSC’s original referral letter.

“This position is at odds with the conduct and disposition of prior investigations of allegations referred by OSC,” Kerner wrote. “It further demonstrates a myopic approach that could potentially cause harm by ignoring allegations of substantial and specific dangers to public health and safety.”

Kerner described the VA’s initial sluggish response to the allegations, such as recommending additional medical chart reviews, compared to the agency’s immediate and comprehensive response to the Boston Globe article, which included making major personnel changes pending the outcome of a “top to bottom” review of the facility and a pledge to spend an additional $30 million at the Manchester VA to improve patient care.

Given that potentially lengthy chart reviews of patients involved in these matters are ongoing, OSC will request updates on the progress of this analysis as well as findings when the reviews are completed. OSC will request an update in writing every six months regarding the disposition of these reviews and the expected timeline for completion. OSC will also request a summary of the findings upon completion. OSC sent a copy of the letter to the President, unredacted versions of the?agency reports, and the whistleblowers’?comments to the Chairmen and Ranking Members of the Senate and House Committees on Veterans’ Affairs.

Sen. Jeanne Shaheen, D-NH, said in a news release: “This report is alarming and highlights the importance of having the Office of Special Counsel involved in investigating these serious claims,” said Senator Shaheen. “These findings validate many of the concerns raised by the whistleblowers.  It’s disturbing that the VA did not properly respond or investigate these matters. The VA must take this report seriously and take immediate action. I hope ongoing investigations and studies related to care at the Manchester VA will shed more light. Our veterans deserve nothing less than high quality, convenient, accessible healthcare, and I will not accept anything less.”

According to Shaheen’s news release, she alerted the Office of Special Counsel (OSC), detailing allegations provided by whistleblowers, in 2016, which prompted this investigation. Shaheen also contacted then-Manchester VAMC Director Danielle Ocker and then-VA Under Secretary for Health David Shulkin about the claims when they were brought to her attention, and has continued to meet with the whistleblowers, Manchester VA representatives, Secretary Shulkin and members of the VA New Hampshire VISION 2025 Task Force to ensure there is accountability and that Granite State veterans have access to the full range of care services they deserve.”

 OSC ?also filed?the letter to the President, the whistleblowers’ comments, and redacted?copies of the agency reports in its public file at www.osc.gov.? *** The U.S. Office of Special Counsel (OSC) is an independent federal investigative and prosecutorial agency. Our basic authorities come from four federal statutes: the Civil Service Reform Act, the Whistleblower Protection Act, the Hatch Act, and the Uniformed Services Employment & Reemployment Rights Act (USERRA). OSC’s primary mission is to safeguard the merit system by protecting federal employees and applicants from prohibited personnel practices, especially reprisal for whistleblowing, and to serve as a safe channel for allegations of wrongdoing. For more information, please visit our website at www.osc.gov.

UPDATE: News release from Rep. Annie Kuster, D-NH: Congresswoman Annie Kuster (NH-02), the Ranking Member of the Oversight & Investigations Subcommittee of the House Veterans’ Affairs Committee, is calling for a Congressional oversight hearing to investigate the Department of Veterans Affairs’ review practices. Kuster is sending a letter to the Subcommittee Chairman Jack Bergman (R-MI) requesting the hearing following a scathing review of VA’s investigation into challenges at the Manchester VA Medical Center. Additionally, she is calling for investigations by the Department of Veterans Affairs (VA) Office of Inspector General (OIG) and the U.S. Government Accountability Office (GAO) to identify what led to insufficient care for veterans at the Manchester VAMC.

“The review released today by the Office of Special Counsel is damning in its assessment of the Department of Veterans Affairs investigation into the failure to properly care for veterans at the Manchester VAMC,” said Kuster.“The VA has proven itself unable to perform a fair internal investigation of the mishandling of veterans’ care in Manchester. It’s clear that a more independent investigation is necessary to identify what went wrong at the Manchester VAMC. Furthermore, any investigation, in addition to looking at the specific accusations of the Manchester whistleblowers, must also examine the larger circumstances within the whole VA, including VISN 1, that allowed care to erode at Manchester.”

“The failure of OMI to perform a satisfactory investigation into the serious allegations at Manchester VAMC is deeply concerning and raises questions about the information provided by VA as it regards to care for veterans nationwide,” Kuster continued. “I am requesting that the Oversight & Investigations Subcommittee examine the VA’s review process and that VA immediately provide the Committee with all the documents concerning the investigations of the Office of Medical Inspector and related actions with the Manchester facility. Our veterans deserve much better than this, and I’m committed to working to improve care for veterans in Manchester and across the state.”

Kuster’s call follows the determination by the Office of Special Counsel (OSC) that the findings in an investigation conducted by the VA Office of Medical Inspector (OMI), “do not appear to be reasonable,” and that, “The agency reports received by the Office of Special Counsel (OSC) were not fully responsive and were frequently evasive in their reluctance to acknowledge wrongdoing.”

 Congresswoman Carol Shea-Porter’s comments on the Special Counsel report:

WASHINGTON, DC— Congresswoman Carol Shea-Porter today released the following statement after the Office of Special Counsel issued its report on the Manchester VA Medical Center.

“The Office of Special Counsel’s report is deeply troubling. It should not take a media expose for the VA to conduct the investigation these issues clearly required. This report shows that the VA must review its process for investigating whistleblower complaints and do more to include third-party reviewers. The VA should act quickly to address the very serious issues described in the Special Counsel’s report. Veterans deserve the highest quality of care, and I will continue to push for major capital investments at the Manchester facility so that all our veterans can receive the care they need in our state. I am closely monitoring efforts to rapidly improve both access and quality of care for veterans in New Hampshire, and I am eagerly awaiting the completion of the investigative reports. VA leadership, both at the local and national level, must be held accountable for their long-delayed response to the concerns raised by the Manchester whistleblowers.”

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