A whistleblower in Arkansas reported a patient choked on his own vomit and died the next day because emergency equipment was not properly stocked at the Department of Veterans Affairs hospital in Little Rock.
Another whistleblower said a patient died from a heart attack at a veterans’ hospital in Maine after the on-duty doctor failed respond to an emergency code, delaying proper treatment for more than two hours.
In Jackson, Miss., seven whistleblowers came forward with allegations that patients’ health was jeopardized by filthy conditions and unread imaging tests like X-rays.
Other practices in Jackson included scheduling patients to see doctors in fictional “ghost” clinics or double booking appointment times, which often resulted in the veteran going unseen.
It got so bad at the Jackson hospital that the Drug Enforcement Administration suspended prescription-writing authority for some of the staff at the facility.
Even after internal investigations substantiated many of the whistleblowers’ allegations, VA officials falsely reported to Congress and the public that no problems were found.
Those are just some of the allegations raised in 20 whistleblower complaints against the veterans' agency published since last year by the U.S. Office of Special Counsel.
OSC announced Thursday it is investigating 37 claims of retaliation against whistleblowers by the VA. While it did not provide names and locations, the OSC statement says the investigations involve allegations of retaliation in 19 states.
An OSC spokesman did not respond to a request for comment.
Last week, VA Secretary Eric Shinseki resigned after the agency's inspector general confirmed reports from whistleblowers that patient appointment lists were falsified in Phoenix and other medical centers to hide long waits for care.
The inspector general and the Government Accountability Office will update the House committee on the situation at Veterans’ Affairs at a hearing Monday night.
The Examiner investigation found a pattern in which agency employees have been ridiculed, threatened, transferred, demoted and sometimes fired after reporting wrongdoing to the IG, the OSC, Congress or the media.
Sen. Chuck Grassley, R-Iowa, a longtime advocate for enhanced whistleblower protection, commended the OSC for pursuing investigations of retaliation.
“Whistleblowers are usually at the heart of exposing a major scandal,” Grassley said. “They ought to be celebrated, not punished, for acting in the public interest.”
VA spokeswoman Walinda West said in a statement issued Thursday that the agency is “committed to whistleblower protection and creating an environment in which employees feel free to voice their concerns without fear of reprisal.”
OSC’s job is to investigate retaliation against whistleblowers, but not the veracity of underlying allegations of wrongdoing. That responsibility falls to the independent agency inspectors general.
If OSC finds retaliation occurred, it can pressure the agency to remedy the situation and fire the offending supervisors.
But final decisions on personnel actions are up to the agency and can be appealed to the Merit Systems Protection Board.
OSC documents the allegations made by the whistleblower and the agency’s response, then publishes its summary in letters to the president, which are posted on its website.
A total of 54 whistleblower reports from throughout the federal government were published by OSC since 2013, including the 20 from Veterans Affairs. They typically do not say whether the whistleblowers faced retaliation or judge who is telling the truth.
Among the most disturbing is the complaint filed Cindra Flowers, a radiologic technologist at the VA medical center in Little Rock.
Flowers said poor inventory management in her department led to chronic shortages of essential supplies.
In 2011, a patient began to vomit on the exam table, but there was no suctioning equipment available to clear his airway, which resulted in the “patient aspirating on his vomit.”
The patient died the next day.
The internal investigation by the VA confirmed most of what Flowers alleged, including the lack of suctioning equipment that should have been available.
However the agency’s internal investigation concluded “there was not enough evidence to sustain or refute the whistleblower’s allegation that the lack of available equipment caused the patient’s death.”
OSC was dissatisfied with the agency’s initial response, and asked for more information, which VA officials refused to provide.
OSC investigators found the VA’s response to the charges “fell short of fully responding to the allegations of a substantial and specific danger to public health” involving the patient’s death.
VA’s conclusion that the patient’s care was adequate was “conclusory and meaningless with regard to the allegation presented,” according to the letter to President Obama from OSC.
At the VA Medical Center in Augusta, Maine, the unidentified whistleblower alleged that in September 2010, the physician on duty failed to respond to a rapid response alarm, which alerts medical personnel to an emergency. Nurses on duty managed to revive the patient, but his mental state was still diminished.
After about two hours the doctor called and ordered the patient transferred to intensive care after learning from lab tests he had suffered a heart attack.
The whistleblower charged the delay of more than two hours in getting the patient proper care was a significant factor in his death two days later.
The VA’s internal investigation concluded the doctor did respond to the emergency call, even though his presence was not properly documented in the patient’s file.
As a result, hospital officials ordered more training on filling out paperwork.
In Jackson, whistleblowers complained of multiple practices that threatened patient safety.
Another said multiple patients were routinely scheduled for the same appointment time, forcing them to either wait for hours or be sent home without seeing a doctor.
Nurse-practitioners routinely wrote prescriptions for narcotics, even though they are not legally allowed to do so, according to another allegation. A DEA investigation ended that practice.
After VA officials confirmed another whistleblower's allegations of unsanitary conditions, hospital officials issued bogus statements to Congress and the public that no violations had been found.
Carolyn Lerner, OSC special counsel, challenged the constant claims by VA officials that deficiencies in Jackson did not endanger patient care.
“These whistleblower disclosures are the latest, and most severe, in a persistent drumbeat of concerns,” Lerner said in a September 2013 report on the latest round of whistleblower allegations.
“Throughout this process, the Department of Veterans Affairs has consistently failed to take responsibility for identified problems,” Lerner wrote.
“Even in cases of substantiated misconduct, including acknowledged violations of state and federal law, the VA routinely suggests that the problems do not affect patient care.
"Such statements fail to grasp the significance of the concerns raised by [whistleblowers], and call into question the facility’s commitment to implementing necessary reforms.”