Tag: U.S. Deparment of Veterans Affairs

Clarksburg Veterans’ Murders Focal Point of Senate Hearing

Members of the U.S. Senate Committee on Veterans’ Affairs heard from VA officials about how the department is improving its quality of care after investigations into multiple high-profile scandals.

The murder of patients at a veteran’s hospital in West Virginia were a focus of discussion in the U.S. Senate Wednesday.

Members of the U.S. Senate Committee on Veterans’ Affairs heard from VA officials about how the department is improving its quality of care after investigations into multiple high-profile scandals at VA facilities in recent years, including the murder of seven veterans at VAMC Clarksburg by a nurse assistant.

Sen. Joe Manchin, D-West Virginia, joined his colleagues in calling for greater accountability of leadership to avoid future tragedies.

“How do we hold the VA leaders responsible in instance like the murders at Clarksburg?” Manchin said. “ How do they stay in the system? How are they able to retire with a benefit, with such disrespect and such neglect and malfeasance of doing their job?”

VA officials stressed that incidents like the one at Clarksburg are rare, and insisted the organization has integrated the findings from the ensuing investigations.

“The lessons learned from Clarksburg and from Fayetteville were discussed widely and continue to be,” said VA Assistant Under Secretary Carolyn M. Clancy. “When we have big leadership meetings, we start with a patient safety story.”

Clancy is referring to a former pathologist at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas, who was charged with three counts of manslaughter in 2019.

A Manchin-sponsored bill granting subpoena power to the VA’s Office of Inspector General passed the Senate last month, and is due to be taken up by the House of Representatives next week.

Second Lawsuit Filed In West Virginia VA Hospital Deaths

 A woman is suing the federal government over the 2018 death of her husband from a wrongful insulin injection at a West Virginia veterans hospital.

Norma Shaw’s lawsuit is the second one filed against Veteran Affairs Secretary Robert Wilkie in the past month involving the Louis A. Johnson VA Medical Center in Clarksburg. Both suits allege a “widespread system of failures” at the hospital.

Shaw filed the federal lawsuit Monday in the death of her husband, George Nelson Shaw Sr., an 81-year-old retired member of the Air Force.

Federal prosecutors have said they are probing the deaths of up to 11 patients at the hospital.

Norma Shaw’s lawsuit said her husband was admitted to the hospital on March 22, 2018, for lower extremity swelling, fatigue, weakness and shortness of breath. He died on April 10, 2018. A physician determined the cause of death was heart disease and advanced dementia but did not make a mandatory referral to a state medical examiner for an autopsy.

Nine months later, his body was disinterred. An autopsy performed at an air base in Dover, Delaware, found four insulin injection sites on both arms and one leg. His death was ruled a homicide, the lawsuit said.

It said no physician order was issued for the injections and that the hospital failed to securely store insulin and prevent its access by unauthorized personnel. It alleges an employee who administered the injection was not qualified to be a nursing assistant and that hospital staff failed to take appropriate action to stop the employee from giving the shots.

It also said similar sudden deaths occurred on at least seven other occasions from July 2017 to June 2018.

Hospital and Veterans Affairs leadership failed to investigate and document the factors that led to the other deaths and failed to notify patients and families about the unexplained pattern of events that could have prevented future deaths, including Shaw’s, the lawsuit said.

The lawsuit, first reported by the Charleston Gazette-Mail, seeks unspecified damages. A hospital spokesman did not immediately respond to a request for comment Wednesday.

The lawsuit was filed by Charleston attorney Tony O’Dell, who also filed a notice of a pending lawsuit in October with the Department of Veterans Affairs in the 2018 death of John William Hallman. The notice said the 87-year-old Navy veteran died at the Clarksburg hospital in 2018 from an insulin shot he did not need and caused his blood sugar to spike.

The first lawsuit involving the insulin shots was filed last month by Melanie Proctor in the death of her 82-year-old father, former Army Sgt. Felix Kirk McDermott. That death also has been ruled a homicide.

U.S. Sen. Joe Manchin of West Virginia has said the VA inspector general told his office about the opening of a medical and criminal investigation of the hospital in July 2018, after at least nine patients were diagnosed with unexplained low blood sugar.

The Democrat said VA officials had told him a “person of interest” was no longer in contact with any veterans at the facility.

The VA is the government’s second-largest department, responsible for 9 million military veterans.

Manchin, Capito Introduce Bill Calling For Transparency in Veterans Healthcare

West Virginia’s two U.S. Senators have introduced a bill Tuesday calling for more transparency in regard to patient safety and quality of care for veterans. The proposal comes as federal officials investigate suspicious deaths at a Veterans Affairs hospital in Clarksburg. 

Democrat Joe Manchin and Republican Shelley Moore Capito announced they have introduced The Improving Safety and Security for Veterans Act of 2019.  

In a news release, Manchin and Capito say the measure seeks to ensure that Congress, veterans and their families are fully informed about the policies and procedures in place nationally across the VA. 

The bill also would require the VA to submit a detailed report and timeline of events surrounding reported suspicious deaths at the Louis A. Johnson Medical Center in Clarksburg.

Federal officials are investigating at least 11 suspicious deaths at the facility. Autopsies show that some of those deaths were a result of a hypoglycemic event from unneeded insulin injections

“Victims’ families have waited long enough and deserve answers. I can’t imagine having a loved one murdered at a VA Medical Center and after a year and a half, still not knowing how it happened. I want to make sure this never happens to another Veteran at any VA facility ever again,” said Manchin. “Due to the lack of information being made available to the public, Veterans across our state are having a crisis of confidence in the safety, security, and quality of their VA healthcare.”

Capito echoed Manchin’s sentiments on the matter and said she too has been engaged in trying to find answers for the victims’ families.

“Our veterans should always feel safe and cared for at our VA hospitals. No questions asked,” Senator Capito said. “It’s for this reason that I’ve stayed on top of this issue since day one when the news first broke. Since that day, I have remained in close contact with those involved in this investigation, such as VA Secretary Wilkie, U.S. Attorney Bill Powell, Clarksburg VA Director Glenn Snider, and VA Inspector General Michael Missal, as well as checking in with staff on the progress of the investigation. It’s important that we get more information for the families, the veterans, and the community.”

Officials say they are focused on an unnamed person of interest, but prosecutors have not yet brought charges in the matter.

Officials: VA Hospital Intentionally Skewed Patient Data

Officials say a West Virginia Veterans Affairs medical center intentionally skewed patient data to reduce both the reported wait times and the volume of patients.

  The U.S. Office of Special Counsel said in a news release last week that a whistleblower prompted the investigation of the Louis A. Johnson VA Medical Center in Clarksburg. Officials say that over the last seven years, a manager at the facility urged nursing staff to place emergency patients into two unofficial clinics rather than record the encounter. The decision, among other things, caused an inaccurate analysis of staff workload.

Officials say the VA also improperly coded patient encounters for medical purposes and charged 602 veterans an incorrect copayment.

The medical center’s spokesman, Wesley Walls, says the skewing only affected the Clarksburg facility.

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