Five Veterans’ Deaths Linked to VA Medical Center

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Poor hiring practices may have led to deaths of 5 veterans at an Illinois VA medical center, according to a recent investigation. Still more veterans were exposed to risks from poor training and documentation of facility doctors.

“OIG received complaints in October and December 2011, and in January and February 2012, about the clinical care provided by two physicians at the facility.”

From December 2011 – March 2012, eight cases were reported for review; this included five deaths of disabled veterans at the VA medical center in Marion, IL.

The investigation, spearheaded by the Department of Veterans Affairs Office of Inspector General (OIG), confirmed recent veterans’ complaints submitted by Senator Richard Durbin of Illinois.

Two of the four malpractice style allegations against doctors at the Marion VA medical center were deemed legitimate. Most allegations focused on unnamed “Physician A.”

According to the report, the Veterans Administration hired “Physician A” despite having not practiced medicine for “many years.” The Veterans Affairs OIG did not stipulate just how many years the doctor had been out of practice. However, the OIG report did state that the VA medical center failed to ensure proper oversight of the doctor.

The oversight may have prevented the deaths of the disabled veterans in question. Unfortunately, these veterans died at the hands of a physician who was poorly equipped to practice medicine. Further, “Physician A” may be responsible for the deaths and poor treatment of many disabled veterans beyond the five listed within the report. Three more investigations in the Marion facility are pending.

The OIG further found that the Veterans Administration also failed to ensure proper documentation and training of medical doctors using ventilators in the Intensive Care Unit (ICU). Ventilators are used to replace spontaneous breathing when a patient is unable to breath independently.

The Veterans Affairs OIG summary, listed on the main page, omits any mention of the deaths related to the malpractice of “Physician A.” However, the full report linked from the summary page outlines a sad story of gross negligence of management within the VA medical center in question.

See this link for the full report: http://www.va.gov/oig/pubs/VAOIG-12-00496-191.pdf

Marion, Illinois VA Medical Center Background

“The facility provides services to approximately 43,000 veterans residing in southern Illinois, southwestern Indiana, and northwestern Kentucky. It is a general medical and surgical facility providing a full range of patient care services. Comprehensive healthcare is provided through primary care, specialty care, and long-term care, with services in medicine, surgery, psychiatry, physical medicine and rehabilitation, neurology, oncology, dentistry, geriatrics, and extended care. Additional specialty care is available by referral to other VA facilities or to contracted facilities. Part of Veterans Integrated Service Network (VISN) 15, the facility has 30 active acute care beds, an 8 bed intensive care unit (ICU), and a community living center (CLC) with 60 beds.

The facility ICU is categorized as Level 4,indicating that dedicated ICU attending staff are not required and any physician may provide ICU care without specialty consultation.

Complex airway management, including the use of ventilators, is one component of services provided in all ICUs, and the facility routinely has patients on ventilators. In fiscal year 2011, there were 233 ventilator days for 39 patients.”