12 OYS: Augusta VA tight-lipped about possible 4th death at facility

News 12 at 6 o'clock / Feb. 3, 2014

In response to a News 12 request for information regarding whether the additional death occurred in Augusta, officials refused to confirm or deny in its issued statement.

"I have been treated fantastically. I've had one or two problems," said Army Veteran Robert Taylor. He has volunteered with the VA for decades. He is also aware of the 3 deaths at the facility due to inadequate medical care. "If I was one of those 1 in 3 patients that did not get seen in time I would feel very angry," said Taylor.

Now News 12 has obtained documentation that a fourth patient may have died at Charlie Norwood.

According to the report, that additional fatality occurred within one of the 9 facilities that make up the VA's southeast network of medical centers. Norwood's deaths stemmed from backlogs in cancer screenings.

"That's serious. You can't wait 3, 4 or 5 months to get something like that taken care of," said Taylor. Air Force veteran Richard Johnson said he experienced those long delays. He sought treatment at a community hospital and is glad he did. "They did a colonoscopy and this time they found polyps and one was pre-cancer."

Johnson said had he waited on the VA he may have ended up a statistic. News 12 reached out Augusta's VA hospital about whether this additional death occurred here. Officials would not confirm or deny and declined to answer a list of questions. Instead, we received a statement that reads in part:

"based on preliminary findings from the initial system-wide review, VHA identified 29 patients in VISN 7 for whom institutional disclosures were provided or attempted, based on their gastrointestinal care, of the 29 patients, 10 have passed away"

News 12 asked Taylor if he had a gastrointestinal problem, would he be comfortable going to the Charlie Norwood facility. "I would make the appointment. In a reasonable amount of time (if nothing was addressed) I'd go out to Fort Gordon," said Taylor.

Taylor added that he believed the Charlie Norwood facility was used to train several interim directors after former Director Rebecca Wiley was reassigned to Columbia's Dorn VA Medical Center. He said that left no one accountable. Taylor also expressed criticism towards some media outlets reporting on the deaths and other issues at Charlie Norwood.

"The newspaper in this particular case, when the VA failed their accreditation, they put it on the front page in red, white and blue. When Mr. (Robert) Hamilton and his staff got them accredited, they put it on the back page of the want ads," said Taylor.

Meanwhile Augusta's VA was also tight-lipped about these additional questions we asked:

1. Which (Augusta) VA facilities were providing care to those who died
or were injured?

2. Were bonuses given to VA administrators at those hospitals?

3. Have any VA employees been held accountable for these preventable
deaths/injuries? (since the sight visit)

4. These (internal) documents appear to only reference deaths and
institutional disclosures related to delayed endoscopy procedures. Are
there problems with delays in care for other medical procedures aside
from endoscopy?

5. Are there any additional deaths/institutional disclosures related to
delays in care for other medical procedures aside from endoscopy?

6. Were any Georgia facilities providing care to those who died or were
injured?

However, in a lengthy prepared statement, the VA said:

"The Department of Veterans Affairs (VA) cares deeply for every Veteran we are privileged to serve. Our goal is to provide the best quality, safe and effective health care our Veterans have earned and deserve. We take seriously any issue that occurs at any one of the more than 1,700 VA health care facilities across the country."

"Any adverse incident for a Veteran within our care is one too many.
When an incident occurs in our system we aggressively identify, correct
and work to prevent additional risks. We conduct a thorough review to
understand what happened, prevent similar incidents in the future, and
share lessons learned across the system."

"As a result of the consult delay issue VA discovered at two of our
medical centers, the Veterans Health Administration (VHA) continues to
conduct a national review of consults across the system. We have
redesigned the consult process to better monitor consult timeliness. We
continue to take action to strengthen oversight mechanisms and prevent a similar delay at another VA medical center. We take any issue of this nature extremely seriously and offer our sincerest condolences to families and individuals who have been affected and lost a loved one."

INFORMATION ON BACKGROUND:
In response to the findings at the William Jennings Bryan Dorn VA
Medical Center in Columbia, SC and the Charlie Norwood VA Medical Center in Augusta, GA in 2012, VHA initiated a national review of consults across the VA health care system. VHA has developed processes and oversight mechanisms intended to prevent a similar occurrence at another VA medical center.

When an adverse event occurs, VHA contacts the patient or their
representative when the patient has either been harmed or may have been harmed during their care - this is known as an institutional disclosure. VHA's first priority is to notify the patient or their representative of the adverse event, as well as the patient's rights and recourse. VHA is committed to a process of full and open disclosure to Veterans and their families.

Based on preliminary findings from the initial system-wide review, VHA
identified 29 patients in VISN 7 for whom institutional disclosures were
provided or attempted, based on their gastrointestinal care. Of the 29
patients, 10 have passed away. Specifically, at the Wm. Jennings Bryan
Dorn VA Medical Center in Columbia, S.C. and the Charlie Norwood VA
Medical Center in Augusta, Ga., VA provided institutional disclosures to
27 patients based on their gastrointestinal care at those medical
centers. Of the 27 patients identified at those two medical centers, 9
patients have passed away. VHA is working aggressively to validate the
remaining VISN 7 findings from this initial review, and to confirm all
appropriate cases for institutional disclosures.

Last year VHA provided over 85 million total health care appointments
for patients. VHA also provided 25 million consults for patients last
year, which included approximately 1.3 million gastrointestinal (GI)
consults. As a result of the consult delay issue VA discovered at two
of our medical centers, VHA continues to conduct a national review of
consults across the system. This ongoing national level review includes
all consults over more than a ten-year period.


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