Memphis VA Center Deaths Under Congressional Investigation

(Memphis) The Committee of Veterans’ Affairs will conduct an oversight investigation into the deaths of three Mid-South veterans in the emergency department of the Memphis VA Medical Center.

Chairman Jeff Miller said in a letter to Veterans Affairs Sec. Eric Shinseki, “Given the patient deaths and the apparent inability of the VA to implement corrective actions at the Emergency Department in Memphis, I request the following information for purposes of an oversight investigation being conducted by this Committee:”

- the root cause analysis action plans related to the patients’ deaths
– all peer reviews of the medical professionals involved in treating the patients who died
– all performance reviews of the medical professionals involved in patient deaths from Jan. 1, 2010 to the present (including those responsible for oversight of patient safety, like the facility director and chief of staff)
– all disciplinary actions, counseling, and/or reprimands for the medical professionals involved in patient deaths from Jan. 1, 2010 to the present

The committee also wants to know where those involved in the three deaths currently work within the VA, or, if they no longer work for the VA, why they left.

According to the Memphis VA Medical Center, a physician involved in the care of two of the patients who died no longer works there.

The Office of the Inspector General of the Department of Veterans Affairs has previously found that the medical center’s implementation of root cause analysis action plans, made because of previous incidents, was delayed and incomplete.

In a report from August 2012, the OIG reviewed management responsiveness and looked into reports of excessive wait time, among other complaints.

The investigation concluded that “management was aware of these issues but had not taken adequate action for resolution” and, although there no patients were negatively affected by excessive weight times, “The potential for harm exists, however, if the (Emergency Department) flow problems continue.”

Then, in September of this year, the OIG filed a report that uncovered half the lab tests done at the center are not processed in the required time, and last month looked into allegations of inadequate care for the three veterans who died in the 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.”

Read the full report from the Department of Veterans Affairs Office of Inspector General.

Rep. Miller also released the following statement Wednesday:

“VA owes the families affected by these tragic preventable veteran deaths a full explanation of what went wrong, the steps the department is taking to prevent future lapses in care and how it is holding accountable those who let patients fall through the cracks. Our investigation will continue until we have a complete accounting of these facts, and we are calling on VA to comply with our information requests in short order.”

Click here to read the medical center’s statement.

Veterans we spoke with insist there are problems with care at the VA, but not enough to cause them to abandon the center all together.

“We don’t have no where else to go, that’s why we go,” said John Williams, a Vietnam vet who says he knows many people who complain about doctors not keeping appointments and problems with medications.

Most veterans we talked to welcome the investigation as an opportunity to improve their medical care, which they say is lacking.


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