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Watchdog: Accountability

Veteran tells Congress he was handed a 'death sentence' by botched care at Veterans Affairs hospital

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Barry Coates knows he will die soon and thus become another preventable patient death resulting from botched care at a Department of Veterans Affairs hospital.

In November 2010, Coates sought treatment for severe abdominal pain and rectal bleeding at a VA hospital in Hartsville, S.C.

The doctor recommended a colonoscopy to determine if his suffering resulted from early stages of colorectal cancer.

For more than a year, Coates faced delay after delay, churning through one doctor after another until finally the routine medical test was performed in December 2011.

It showed he had advanced colorectal cancer, which could have been treated more effectively if had been detected that first day.

Now, the 44-year-old Army veteran is forced to use a colostomy bag and catheter, lamenting that he is unable to play with his grandchildren as men his age should be able to do.

“It is likely too late for me,” Coates told the House Committee on Veterans Affairs Wednesday during a hearing on delays in care at veterans' medical centers.

“The gross negligence of my ongoing problems and crippling backlog epidemic of the VA medical system has not only handed me a death sentence, but ruined the quality of life I have for the meantime.

“I am not here today for me,” Coates said in an emotional testimony and a written statement he provided to the committee. “I am here to speak for those to come so that they might be spared the pain I have already endured and know that I have yet to face.”

That pain is borne out in a report released earlier in the week by VA. It shows 23 patients died from gastrointestinal cancers linked to delays in care, including routine colonoscopies and other procedures that would detect the early onset of the disease.

Another 53 cancer patients have been given “institutional disclosures,” alerts that problem with their care at veterans’ hospitals may have contributed to their conditions.

The VA did not report preventable patient deaths from other medical conditions. Nor did it say when the 23 patients died.

Rep. Jeff Miller, R-Fla., chairman of the committee, said the deaths probably occurred between 2010 and 2012, but that he cannot get a clear answer from the agency.

The figures provided by VA are a low estimate of the number of veterans who have died because of delayed or inadequate care, Miller said.

At least 18 deaths from other causes have been identified in recent years by the agency’s inspector general and media reports.

Miller also said staff investigators at the Veterans’ Committee have found evidence that there may be as many as 40 patient deaths due to delayed care at the VA hospital in Phoenix alone.

Miller did not elaborate and his staff would not provide details after the hearing because they do not want to compromise the committee’s ongoing investigation.

Miller and other committee members expressed frustration that they cannot get straight answers from VA, and that those responsible for fatal mistakes are not disciplined or fired.

They also apologized to Coates for what he has endured because of the inadequate care he received.

“It seems so petty to sit here and apologize on behalf of a bureaucratic system that is broken. But I do apologize,” said Rep. Jackie Walorski, R-Ind., at one point choking back tears.

“There is a bureaucracy that is out of control,” said Walorski, whose veteran father died of colon cancer.

“If this happened in the civilian world, where negligence was proven time and time again, we would be in the streets with signs saying shut them down. It’s an outrage is what it is. This is an American disaster,” Walorski said.

Of the VA doctors and administrators responsible for the failures, Walorski added, “I don’t know how they sleep at night.”

Two doctors on the committee said it was inexcusable that Coates had to wait a year for a routine colonoscopy.

Rep. Raul Ruiz, D-Calif., a medical doctor, said it is “infuriating” that someone who sought treatment for rectal bleeding did not immediately get a basic test that could have detected cancer.

Rep. Dan Benishek, R-Mich., a former VA surgeon, said he is tired of hearing excuses from agency officials as patients are needlessly dying.

“I get so frustrated by people like you that come here and calmly say we are going to fix it and it never gets fixed,” Benishek told the two witnesses from the VA.

Carolyn Clancy, assistant deputy under secretary for health for quality, safety and value at the VA, told Benishek she is also angry when she hears stories from veterans like Coates, and is working to fix deficiencies in the system.

“We share your anger and are very, very upset,” Clancy said. “We know we can’t take that back. A young man who will die prematurely, we get that.”

A pair of investigations last year by the VA inspector general exposed patient deaths due to delays in colonoscopies and other routine medical tests that would identify colorectal cancers.

The deaths of six patients with gastrointestinal cancer were linked to delayed screenings at the VA Medical Center in Columbia, S.C., and another three were identified in Augusta, Ga.

Those findings triggered a review by the agency of more than 250 million orders for medical follow-ups, known as “consults.” Those orders are supposed to be filled within 90 days, under VA policy.

Many of those orders were found to be non-medical, things such as reservations for patient transportation, according to VA reports. Others were closed because the patients repeatedly did not show up.

Last year, an initiative was launched within VA to standardize procedures for tracking unresolved consults. New rules authorized orders older than 90 days to be closed if they were no longer needed.

The Washington Examiner reported in February that a mass purge of backlogged orders for medical consults at the VA hospital in Los Angeles began about 2009, resulting in as many as 40,000 cancellations. A similar mass purge was done in Dallas in 2012, when about 13,000 unfilled appointments were closed.

Debra Draper, director of health care at the Government Accountability Office, said during the hearing that there are no standard rules for closing consult orders, nor independent verification that they were appropriately closed. Therefore, there is no way to verify whether the appointments should have been cancelled, she said.

Coates said he knows that he probably cannot be saved. Yet he is “thankful” to be the one who suffered if it will save other veterans from sharing his fate.

He never received an apology from the VA, and does not remember ever receiving a notice from the agency taking responsibility for its mistakes.

“Hopefully, my being here today, maybe I’m saving another father, another mother, from having to go through the same tragedy that I went through,” he said.

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Author:

Mark Flatten

Senior Watchdog Reporter
The Washington Examiner