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The Final Phoenix VA Report Is Out – No Deaths Linked To Delays?

Posted  August 28, 2014

By Marlene Koury

The VA Office of the Inspector General (“OIG”) released its final report this week on the alleged patient deaths, wait times and scheduling issues at the Phoenix VA.  Despite the allegations of several whistleblowers, the investigators found that there was no conclusive evidence that delays in care were linked to veterans’ deaths. But the report cautioned that, even so, the Phoenix VA has significant and serious problems with wait times and poor quality of care.

The OIG investigated a number of allegations, including gross mismanagement of VA resources, criminal misconduct by VA senior hospital leadership, systemic patient safety issues, and possible wrongful deaths. The investigators reviewed health records for thousands of veterans and found that 3,500 veterans were on “unofficial wait lists” waiting to be scheduled for a primary care appointment.

In addition, the report identified and examined more closely 45 cases that had “unacceptable and troubling lapses in follow-up, coordination, quality and continuity of care.” In 28 of those 45 cases, the OIG found clinically significant delays in care associated with access to care or patient scheduling. 6 of the 28 patients died. In addition, the OIG found 17 care deficiencies that were unrelated to access or scheduling. 14 of the 17 patients died. The OIG found, however, that while these cases “document poor quality of care, we are unable to conclusively assert that the absence of timely quality care caused the deaths of these veterans.”

Acting Inspector General Richard J. Griffen acknowledged the severity of the issues at the Phoenix VA, saying “[t]his report cannot capture the personal disappointment, frustration, and loss of faith of individual veterans and their family members with a health care system that often could not respond to their mental and physical health needs in a timely manner. Immediate and substantive changes are needed.”

The report recommended that the Veterans Health Administration review the 45 cases examined in the report to determine the appropriate response to possible patient injury and allegations of poor quality of care. It also recommended that the VA establish a process that requires facility directors to report when their facility cannot meet access or quality of care standards. And it recommended that all existing wait lists at the Phoenix VA be reviewed to identify veterans who may be at risk because of a delay in the delivery of health care and provide the appropriate medical care.

One of the whistleblowers, VA medical director Dr. Katherine Mitchell, was disappointed by the findings, saying “my general view is that the VA should never have been trusted to interview itself or investigate itself….It hasn’t done a good job in all the OIG investigations it’s done thus far, and there’s no reason to believe it’d be different in this particular case.”