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Watchdog: Accountability

Korean War veteran dies after Veterans Affairs hospital ignored his medical history, daughter says

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Photo - Army veteran Phillip Perez twice survived cancer before dying at a Veterans Affairs hospital in Fresno, Calif., earlier this year. (Courtesy photo)
Army veteran Phillip Perez twice survived cancer before dying at a Veterans Affairs hospital in Fresno, Calif., earlier this year. (Courtesy photo)
Watchdog,Mark Flatten,Veterans Affairs,California,Health Care,Accountability,Minusextra,Veterans,Korean War

The third in a five-part series.

Phillip Perez cheated death many times before it took him in March.

The Army veteran survived the Korean War. He beat colon cancer in 1998 and kidney cancer in 2013.

But a lingering infection in his toe landed him in a Department of Veterans Affairs hospital in Fresno, Calif., where his daughter says his complex medical history and fragile physical condition were ignored.

He died two days after being admitted.

“It was just horrible,” said Esther Garcia, who was her father’s caretaker and went with him to all of his medical appointments.

Faces of Delay

A five-part series by the Washington Examiner on some of the individual veterans who have suffered from poor care and long delays by the Department of Veterans Affairs.

Part One: Delays, denials by VA deliver 'death sentence' to cancer victim

Part Two: A fatal level of trust in VA care

Today: Korean War veteran dies after VA hospital ignored his medical history, daughter says

Part Four: Treatment at a VA hospital nearly killed an agency whistleblower

Part Five: Missed leukemia diagnosis by VA leaves vet who put his trust in doctors living 'day to day'

Click here to see a summary of the series and find more resources

“The caretakers of these patients, they need to be heard. You are expecting that they [medical providers] are going to look up his records, that they’re not going to start like an empty piece of paper and start him as a new patient. That’s what happened,” she said.

After his discharge from the military in 1957, Perez spent another six years in the Army Reserve while working as a cement finisher in the San Francisco Bay area.

In 1998, he was diagnosed with colon cancer. It was removed and did not return.

Perez had diabetes and high blood pressure, which were treated with medication. Other than that, his annual physicals at the VA did not show any serious problems.

Then a routine physical in July 2013 identified a tumor on one of his kidneys. The cancer was surgically removed at the San Francisco VA, and Perez seemed to be making a quick recovery.

Then things went bad.

Perez was sensitive to insulin, so his diabetes had to be treated with pills, not injections, according to his daughter.

Garcia said she warned the medical staff, but Perez received a standard dose of injectable insulin anyway and went into shock.

His lungs filled with fluid, and hospital staff had to draw out the liquid in a procedure known as "aspiration."

He slowly recovered, but just before he was to be released from the hospital, one of the drainage tubes in his stomach ripped out as a nurse was helping him out of bed. The rupture required a second surgery. Eventually he developed pneumonia, further weakening his lungs.

During his stay at the San Francisco hospital, Perez had what appeared to be a sore on his toe. It did not seem serious, particularly given his other medical conditions. But it did not go away.

In November 2013, Perez was having trouble breathing and was rushed to the emergency room of a private hospital in Fresno.

Perez nearly died then. He spent more time on a respirator and had to undergo dialysis. After a slow recovery, Perez was discharged.

But by then his lungs were so badly damaged that he had to breathe through a tube inserted in a hole surgeons created in his throat. He also had to be fed through a tube.

By December, Perez was strong enough that the tube in his throat was removed, and he was taken off dialysis. He still required daily breathing treatments and required a feeding tube.

Solid food or even water could flow into his lungs and kill him.

Phillip Perez died in a Veterans Affairs hospital after detailed instructions for his care weren't followed. (Courtesy photo)

By March 2014, Perez was growing stronger. Tests showed his heart was strong, the cancer was gone and he was making a good recovery.

The only pressing problem was the sore on his toe, which kept getting worse. The pain was so bad that he could barely walk.

A routine visit to a podiatrist at the VA medical center in Fresno determined blood was not flowing to the area. Poor circulation in the extremities is a common danger for diabetes patients, and can eventually lead to amputation or more severe illness.

Since Perez was already at the facility, Garcia decided to have her father’s feeding tube checked at the Fresno VA emergency room.

Doctors there said the foot looked so bad that they wanted to admit Perez and run some tests. Garcia, who always took her father’s complete medical history to all of his appointments, gave detailed instructions to the nurse.

No solid food or liquids. Administer daily breathing treatments. Insulin pills, not injections. Not following any of those rules could kill Perez, she warned.

“I gave them all the records,” she said. “I always kept all the records with me because it seemed like no one ever wanted to go back and see what his history was. It was always, ‘Let’s start a new patient chart.’ It was never, ‘Let’s go back. Let’s see how delicate his condition was.’ ”

When Garcia returned to the hospital two days later, she noticed a food tray and pitcher of water on the table at her father’s bedside. Then she saw the oxygen tube on his nose.

She demanded to talk to the doctor, but none came. She confronted the nurse, explaining again the medical procedures that had to be followed.

Throughout the day, Garcia learned that Perez was not only being given food and water by mouth, he was also receiving injectable insulin and had not received his breathing treatments.

She also found out from her father that he threw up that morning before she got there, and his lungs had filled up with fluid and had to be aspirated again.

Perez, 78, died that night.

"The caretakers of these patients, they need to be heard."
 

Others have died in VA care because their medical histories were ignored.

In Memphis, Tenn., for instance, a veteran died after being given medication despite a documented allergy to the drug, according to an inspector general's report issued in October 2013.

Another patient at the same hospital died after being given multiple sedatives, then left unmonitored, and a third died when doctors failed to properly treat his extreme high blood pressure despite his history of hypertension, diabetes, congestive heart failure and renal disease.

Perez didn’t have to die, his daughter said. Though his health was fragile, her father was doing well as long as the medical instructions were followed.

“He had a strong will to live,” Garcia said. “I will never forgive myself for taking him back to [the] VA hospital. I should have known better.”

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Author:

Mark Flatten

Senior Watchdog Reporter
The Washington Examiner

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