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Wednesday, Oct 01, 2014
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VA delays cause 19 deaths across U.S., report says

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Published:   |   Updated: February 1, 2014 at 09:04 AM

TAMPA — Five cancer patients died and nine others suffered injury because of delays in diagnosis or treatment through the Sunshine Healthcare Network of the U.S. Department of Veterans Affairs, which includes all of Florida, according to internal VA documents obtained by The Tampa Tribune.

The diagnoses, according to the documents, involved patients with gastro-intestinal malignancies and took place in the two years between October 2009 and September 2011.

Nationwide, 19 patients died and 63 suffered injury because of the delays, the documents show.

The documents do not specify which hospitals recorded the delays nor do they divulge the names of the dead or injured. These details were disclosed to families and surviving patients.

The revelations come from a review of the VA’s Central Cancer Registry data.

The Sunshine Healthcare Network, also known as VISN 8, is based in St. Petersburg and consists of Florida, part of southern Georgia, Puerto Rico and the Virgin Islands. This network recorded the second highest number of deaths or injuries nationwide, according to the documents, trailing only the VISN 7 region — Alabama, South Carolina and most of Georgia. VISN 7 recorded 10 patient deaths and 19 injuries.

Because of the problems, VA officials say they are reviewing records from their patient consultation system for the past decade.

“We have redesigned the consult process to better monitor consult timeliness” said Mary Kay Hollingsworth, communications manager in Lake City for the Sunshine Healthcare Network.

“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.”

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The deaths and injuries arise from operations of a VA health care system that last year provided more than 85 million appointments and 25 million consults, including about 1.3 million gastro-intestinal consultations, Hollingsworth said.

The deaths were the result of delayed endoscopy tests, according to the documents. In most cases, the delays were less than a year but more than 90 days.

The documents were obtained by the House Veterans Affairs Committee as part of its ongoing investigation into delays in care, said U.S. Rep. Jeff Miller, committee chairman and a Panhandle Republican.

Miller’s committee has been investigating health care at VA centers as a result of deaths and injuries there.

In addition to the 19 deaths laid out in the recent documents, at least 12 others have been recorded nationwide because of delays, according to VA Inspector General reports and news accounts.

The review was prompted by the discovery of delays at VA centers in Georgia and South Carolina. Miller said early findings showed that administrative problems are to blame.

VA officials then conducted a systemwide review that showed a total of 82 “institutional disclosures” about the delays, which resulted in 19 deaths, according to the documents.

Relatives and survivors were informed between September 2012 and March 2013.

In an email to the Tribune, Miller said, “The latest revelations, which include the tragic preventable deaths of five veterans who sought treatment in VA’s Sunshine Healthcare Network, ought to serve as a wake-up call for VA leaders at all levels. Clearly, a culture change at the department is in order.”

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In September, Rep. Mike Coffman, R-Colorado, chairman of the Veterans Affairs Committee Subcommittee on Oversight & Investigations, asked VA Secretary Eric Shinseki for information about patient deaths resulting from delays in screening.

Coffman said the list should include VA centers where “appointment backlogs, delays in care and/or unresolved consults persist ... including facilities not previously identified by the committee.”

That would include the Sunshine Healthcare Network.

The VA has yet to respond, according to committee spokesman Curt Cashour.

Miller said VA officials need to be held accountable for the deaths and injuries and that Congress will take action unless the problems are fixed.

“While the vast majority of the department’s more than 300,000 employees are dedicated and hard-working,” he said, “and many veterans are satisfied with the medical care they receive from VA, the department’s well-documented reluctance to hold employees and executives accountable for negligence may actually be encouraging more veteran suffering instead of preventing it.”

The VA is working to make those corrections, spokeswoman Hollingsworth said.

“Any adverse incident for a Veteran within our care is one too many,” she said.

“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.”

haltman@tampatrib.com

(813) 259-7629

Twitter: @haltman

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