Investigation Into Three Memphis VA Medical Center Deaths

(Memphis) The Office of the Inspector General looked into allegations of inadequate care for three Mid-South veterans who died in the Memphis VA Medical Center’s Emergency Department.

In April 2012, a patient with back and neck pain was given medication he was allergic to, and went into cardiac arrest. He was taken off life support eight days later.

In August, a veteran, who also had back pain, was given four different medications.

Forty-five minutes later, he was unresponsive. He went into a coma, and died 13 days later.

The last victim, a vet with a history of medical issues, was admitted with shortness of breath and eye pain. He also had extremely high blood pressure.

He died a day later, because, according to the report, his blood pressure was not “managed aggressively.”

Just last month, the OIG filed another report that uncovered half the lab tests done at the center are not processsed in the required time.

“It’s sad, it’s very sad…They come home, and have to die at home,” Brittany Dollar said.

She and her husband Ricky, an Iraq war vet, aren’t surpised by the findings.

“They’re not taking care of them like they are promised.”

The couple has had their own troubles.

“I said he’s already taking that, and she said what…and I said, yes, you gave it to him. She didn’t event realize that,” Brittany said.

Veterans say they hope these reports shine a light on a systemic problems with the VA.

“I’m really glad somebody might look into it and get something done,” Bruce Lynn, an Army veteran, said.

The OIG found the center “had completed protected peer reviews of the care for all three patients. Two of the deaths were also evaluated through root cause analyses (RCAs), however, we found that RCA action plan implementation was delayed and incomplete.”

The OIG concluded its summary of its inspection with:

“We recommended that the Facility Director confer with Regional Counsel for possible disclosure to the surviving family member(s) of Patient 3, and ensure that processes are strengthened to monitor RCA action plans. We also recommended that processes be strengthened to improve patient monitoring in the ED, and that unit specific competency assessments be completed for ED nursing staff. The Veterans Integrated Service Network and Facility Directors concurred with our recommendations and provided an acceptable action plan.”

Rep. Jeff Miller, chairman of the House Committee on Veterans’ Affairs, provided the following statement:

“Like other hospital systems, VA isn’t immune from human error – even fatal human error.  But what the department does seem to be immune from is meaningful accountability. Given that these tragic events are part of a pattern of preventable veteran deaths and other patient-safety issues at VA hospitals around the country, it’s well past time for the department to put its employees on notice that anyone who lets patients fall through the cracks will be held fully responsible. It’s the only way to ensure veterans get the medical care they deserve and prevent heartbreaking events like this from happening in the future. Until VA leaders make a serious attempt to address the department’s widespread and systemic lack of accountability, I fear we’ll only see more of these lapses in care.”