Substandard care leaves 9 dead at VA Hospital

Illinois VA Hospital causes needless deaths

Treatment at VA hospital cost 9 lives
By Deborah L. Shelton | Tribune reporter
January 29, 2008

Substandard care at the Marion VA Medical Center left nine patients dead and 34 others seriously injured during a two-year period ending last September, investigators reported Monday.

Ten of the 34 injured patients later died, but investigators were unable to determine if the substandard care they received at the Downstate medical facility was the cause.

A report by the medical inspector of the Veterans Health Administration, released Monday, detailed a long list of serious problems at the hospital, including a surgical program "in disarray" and "fragmented and inconsistent" administrative oversight.




The inspector general in the Department of Veterans Affairs issued a separate report that came to many of the same conclusions. Both reports called for a series of reforms.

The reports describe a dysfunctional, sometimes dangerous, environment in which the hospital hired physicians without fully checking their credentials, allowed surgeons to perform procedures for which they were not trained and failed to act on information that suggested that patients were at risk.

Dr. John Daigh Jr., the Department of Veterans Affairs' assistant inspector general for heath-care inspections, said he was appalled by extent of the problems at the hospital. "To those who have suffered injury as a result of care at Marion, I express my condolences and sadness," Daigh said.

Dr. Michael Kussman, undersecretary for health for the Veterans Health Administration, pledged to correct the problems and announced a series of reforms, including steps to improve quality of care, physician credentialing and administrative oversight. He also announced the formation of an administrative board to investigate whether additional actions should be taken.

"We are sorry for what happened, and we will hold those who allowed these problems to go on accountable," Kussman said.

The reports outline a litany of problems. In one case, an unnamed surgeon received privileges to perform colonoscopies even though he had not been allowed to do the procedure at his previous hospital. A Marion employee reported that the surgeon had difficulty identifying colon anatomy and maneuvering the colonoscope.

The investigations by the medical inspector and inspector general were triggered by a VA computer analysis last year that uncovered an unexpected spike in post-surgical deaths at the Marion facility, 15 miles east of Carbondale. The hospital serves veterans from 52 counties in southern Illinois, southwestern Indiana and western Kentucky.

The analysis found that nine patients had died between October 2006 and March 2007, more than four times the rate that would be expected over a six-month period.

Hospital officials suspended inpatient surgeries at the medical facility in August. Currently, minor surgeries are allowed, but patients who need complex procedures are referred to other hospitals across the region.

Officials said personnel actions have been taken against 12 hospital employees, including six surgeons. Two of the surgeons are no longer practicing there. The other four are allowed to do only minor surgeries.

Last September, the VA removed Marion's hospital director, chief of staff, chief of surgery and an anesthesiologist from their positions and placed them in other positions or on administrative leave.

The anesthesiologist later resigned. A surgeon who had not previously disclosed information related to his license to practice medicine was fired.

In September, the Tribune reported that another surgeon, Dr. Jose Veizaga-Mendez, who has a troubled professional history, was operating on veterans at the hospital for more than a year after surrendering his license in Massachusetts during a disciplinary proceeding. A state licensing board there accused him of providing "grossly substandard care" that led to serious complications and deaths.

He resigned his position at the Marion hospital in August. Illinois regulators indefinitely suspended his state medical license in October.

Citing federal privacy laws and the ongoing nature of the investigation, officials would not answer specific questions about Veizaga-Mendez, other than to say that proper procedures were followed in checking his credentials.

Daigh said the Marion situation was "an exception in a quality health-care system."

He said he was not aware of "other Marions out there" in the VA system.

But U.S. Sen. Dick Durbin said he was disappointed that "after a five-month investigation, so little has been added to the original facts and the VA is still dragging its feet." Durbin said he would like the VA to move faster to correct problems.

VA officials said they will contact veterans who received substandard care and families of those who died to disclose the facts of their case and to offer help in filing claims.

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