VA Cites Several Errors in Patient’s Scalding Death

Poor supervision and a malfunctioning hot water system led to the scalding death of a brain-damaged man at the West Los Angeles Veterans Administration Medical Center, VA officials said Wednesday.

Thomas O’Neil, 45, who had been under care at the hospital for 24 years, was burned while being bathed at the hospital on Feb. 7 in water as hot as 160 degrees, VA officials said in documents released at a news conference.

O’Neil’s mother has filed a $250,000 wrongful-death claim against the VA alleging negligence on the part of nurses at the hospital.

The VA, after the hospital conducted an internal investigation, said a nursing assistant responsible for O’Neil left him unattended for about five minutes. The hospital report said that because of his head injuries, O’Neil had an “inability to recognize pain.”

The attendant, before leaving the patient, had bathed him and drained the tub, the VA said. But when the attendant returned, officials said, the shower was running and O’Neil was in the tub.

James Fox, a Sherman Oaks attorney representing O’Neil’s mother, Gertrude, said the patient was immersed in the hot water, which apparently came straight out of the boiler. Normally wheelchair-bound, O’Neil could not get in or out of the tub without assistance, Fox said.

“The nurses were under strict orders with this patient to watch him in the bathtub,” Fox said.

Although his skin was red and peeling, the attendants did not immediately realize that the burns warranted an emergency response, which delayed treatment, officials said.

Faulty repairs to the hospital’s plumbing system were said to be responsible for the scalding water reaching the man’s bath.

The nursing assistant and his supervisor have been relieved of direct patient-care responsibilities pending further review of the case, the VA said.

Although a Los Angeles County coroner’s report said O’Neil suffered second- and third-degree burns over 80% of his body, he was not transferred to the burn ward at County-USC Medical Center for several hours. He died two days after he was transferred to the burn center.

The man’s case also has been taken up by a patients rights group, which is questioning how the mishap could have occurred given O’Neil’s limited mobility.

The VA said in a statement dated May 4, but released Wednesday, that the case had been forwarded to the FBI for investigation. The coroner’s office initially ruled the death an accident.

Dr. Kenneth W. Kizer, VA undersecretary for health, said in a statement released by his Washington office that he has ordered a second review of the case. It is to be conducted, he said, by officials who do not work in the West Los Angeles facility, to determine “the quality of care provided to Mr. O’Neil after he sustained his burn injuries.”