VA inquiry stops short of linking deaths to delays in care in Phoenix


On the same day President Obama pledged to regain veterans’ trust, Department of Veterans Affairs investigators reported that they had been unable to prove that delays in medical care caused any deaths at the VA medical center in Phoenix, epicenter of a national scandal over mismanagement in the veterans healthcare system.

In a report released Tuesday, however, the VA’s Office of Inspector General criticized the Phoenix VA for “troubling lapses in follow-up, coordination, quality and continuity of care.”

Investigators said they had examined the electronic health records and other information of 3,409 veteran patients and identified 40 who died while waiting for appointments from April 2013 to April 2014. But the review stopped short of linking their deaths to delays in care.


“We were unable to assert that the absence of timely quality care caused the deaths of these veterans,” the report says.

Meanwhile, the White House announced new initiatives for veterans, and Obama told the annual American Legion conference in Charlotte, N.C., that he was working to “regain the trust” of veterans.

“We are going to get to the bottom of these problems. We’re going to fix what is wrong,” he said. “We’re going to do right by you and we are going to do right by your families, and that is a solemn pledge and commitment that I’m making to you here.”

The president called the long wait times and “secret lists” for appointments exposed by whistle-blowers at clinics across the country “outrageous and inexcusable.” He called the new chief of the VA, Robert McDonald — a former chief executive of Procter & Gamble and a graduate of West Point — a no-nonsense reformer. The previous VA chief, retired Gen. Eric K. Shinseki, resigned in the face of the scandal.

The VA inspector general’s report found that, in addition to 1,400 veterans waiting for appointments at the Phoenix VA, at least 3,500 more were on unofficial wait lists and at risk of never getting their requested or necessary appointments.

“These investigations, while most are still ongoing, have confirmed that wait-time manipulations are prevalent throughout VHA,” the report says.


A systemic underreporting of wait times stemmed in part from the lack of available staff and appointments, increased patient demand for services and an antiquated scheduling system, it says.

“This report cannot capture the personal disappointment, frustration and loss of faith of individual veterans and their family members with a healthcare system that often could not timely respond to their mental and physical health needs,” the report says.

William Audet, an attorney for Sally Barnes-Breen, whose father-in-law died while waiting for a follow-up appointment at the Phoenix VA, called the report disappointing.

Thomas Breen, 71, had a history of bladder cancer and had discovered blood in his urine last fall. The Navy veteran had to wait two months for a follow-up appointment at the Phoenix VA. His family finally took him to a private hospital, where he was told he had terminal bladder cancer. He died Nov. 30.

Audet said VA investigators did not interview Barnes-Breen or her family.

“I think for Sally … it’s a continuing disappointment,” Audet said. “It’s another letdown by the government.”

The White House on Tuesday also announced 19 policy changes and public-private partnerships aimed at easing service members’ transition to civilian life, including improved coordination between the departments of Defense and Veterans Affairs on mental health services, better veteran access to psychiatric medications and greater awareness of and training on suicide prevention.


The Pentagon and the National Institutes of Health have launched a study on early detection of suicide risk, post-traumatic stress disorder and traumatic brain disorder, and the VA will invest $34.4 million in a national clinical trial on suicide prevention involving 1,800 veterans at 29 hospitals, the White House said.

“We have to end this tragedy of suicide among our troops and veterans,” Obama said in his speech. “As a country, we can’t stand idly by.”

The president gave Congress credit for passing a $16.3-billion measure to reform the VA, which he signed into law. It includes roughly $6 billion to expand VA programs, personnel and facilities. It also permits veterans who have waited more than a month for an appointment or who live more than 40 miles from a VA facility to see a private doctor at government expense.

The Republican head of the House committee overseeing veterans issues criticized Obama’s efforts Tuesday.

“President Obama’s actions today fall far short of what’s needed to regain the trust of America’s veterans,” said Rep. Jeff Miller of Florida, chairman of the House Veterans Affairs Committee. “What we need from the president right now is more follow-through and less flash when it comes to helping veterans.”


Carcamo reported from Tucson, Hennessey from Washington.