12 suspicious deaths reported at Salisbury VA Hospital

Congressmen grill VA execs about care
Lawmakers seek more info on revelations about Salisbury hospital
Staff Writers posted on April 20, 2007

WASHINGTON --Lawmakers questioned VA officials Thursday about "serious inadequacies of care" at the Salisbury veterans hospital and demanded follow-up reports -- a strong signal they're not finished.

Federal investigators took too long to respond to a report of 12 suspicious deaths at the Salisbury VA, charged members of the House Veterans' Affairs Committee. They also complained that investigators didn't reveal findings of poor patient care and didn't verify the hospital made recommended improvements.

The 2005 investigation came six months after an anonymous complaint was referred to a VA team of inspectors.

"Come on, that's six months with 12 deaths," said California Democrat Bob Filner, the committee chairman. He directed that comment to Dr. John Daigh, who helps oversee VA health care inspections.

"We are talking about deaths of human beings -- people ought to be figuring out what is going on, do it fast and make corrections," Filner said.

Current and former leaders of the Salisbury hospital agreed there have been problems, but said they have been addressed.

"There were mistakes made, there were serious problems, and we think they have been corrected," said Dr. Sidney Steinberg, chief of staff at the Salisbury VA hospital who is also a surgeon who has been part of hospital management since 2001. He was the hospital's interim director until earlier this month, when the new director started.

Dr. Barbara Fleming, the VA's chief quality and performance officer, praised the Salisbury staff for a "phenomenal" turnaround. She said based on VA performance measures, the hospital is now among the top 25 percent of VA hospitals.

Committee members ordered VA officials to produce additional information, an investigation into patient care at the Asheville VA Medical Center.

Thursday's hearing, spurred by Observer articles over the past six weeks, was intended to bring tougher oversight to the nation's largest health care system. The Salisbury hospital is the main veterans medical center for the Charlotte area.

Investigation questioned

The VA is one of the largest federal agencies. Its 150 hospitals and 850 outpatient clinics nationwide are used by more than 5.5 million veterans a year who either can't afford private care or prefer a cheaper option.A key issue during Thursday's three-hour hearing: Last year, the VA closed its 2005 investigation without a second visit without a second visit, after the hospital said it made recommended changes.

At the hearing, VA officials gave their first public explanation of what they found after looking into the 12 deaths.

The Salisbury staff handled five cases correctly, according to a review by non-VA physicians. Five others were considered acceptable judgment calls. And in two cases, care was questionable.

The report from that investigation was not made public until the Observer obtained it last month. The newspaper also found that VA inspectors conducting a routine hospital inspection last year didn't know about the earlier report. The 2006 inspectors found more problems.

Chairman Filner said the two investigative teams should have known about each other's efforts, a lapse of coordination that he worries could be a systemwide problem.

In response to those concerns, the VA's Daigh told the Observer that last week he made sure his investigators have access to reports from other investigations.

"I made a mistake," Daigh testified. "We corrected the problem we should not have the disconnect again."

The 2006 report found that a nurse had not properly monitored care for frail veterans the VA housed in private nursing homes. The report also said the nurse filed inaccurate patient reports, such as recording a patient in "stable" condition 12 days after he died.

The unnamed nurse has been disciplined and could be fired, according to a letter Wednesday from Daniel Hoffmann, regional VA director in Durham, to two N.C. congressmen, Republicans Howard Coble of Greensboro and Robin Hayes of Concord. The letter also said she is under investigation by the N.C. Board of Nursing.

"What the hell is she still doing there?" Filner asked.

Donald Moore, director of the Salisbury hospital from mid-2004 until last year, said he recommended firing her, but lawyers and human resources advised him that the nurse, who had an otherwise clean record for nearly 30 years, would likely prevail on appeal.

Thursday's hearing was requested by Hayes, Coble and Charlotte Democrat Mel Watt.

One committee member criticized a witness for focusing attention on buildings instead of patient care.

When Steinberg, the chief of staff, described the Salisbury hospital's new operating rooms and other capital improvements, Rep. Brian Bilbray, a California Republican, said:
"You can buy the most modern vehicle in the world, but if it's a reckless driver ...we're still going to have problems."

Stella M. Hopkins: 704-358-5173,; Peter Smolowitz: 704-358-5249,; Karen Garloch: 704-358-5078,

More Reports Sought

Several lawmakers asked for follow-up reports, including:

• Details of care for 12 patients who died and whose care the VA reviewed with outside medical experts.

• Details of contact, if any, with families of those patients who died. VA regulations require notification of care problems, but officials said Thursday that didn't happen in some cases reviewed at Salisbury.

• A report on what, if any, disciplinary action hospital officials took against doctors, nurses or other workers identified as providing poor care. Rep. Zachary Space, an Ohio Democrat on the investigative subcommittee, referred to "callous disregard by a bureaucracy" as he made the request.

• Bonuses paid to hospital management during the time they acknowledge problems. (The Observer requested this information earlier in the week.)

• A 2006 VA report on Salisbury under a systemwide internal quality review program.

Stella M. Hopkins
Video Reporter Stella Hopkins on this issue
Archive Coverage of VA hospital issues


Aug. 30, 2004: Anonymous complaint to Office of Inspector General about more than 12 suspicious deaths at Salisbury veterans hospital over last two years.

June 9, 2005: Report from Office of Medical Inspector, after March inspection, finds care in certain surgical cases was "marginal at best, and in some cases, substandard."

Early March 2007: The Observer reported on that 2005 OMI report and a 2006 report by the Office of Inspector General, which found that a Salisbury VA nurse filed inaccurate reports on the health of veterans in nursing homes and listed one as being in "stable" condition 12 days after he had died. In a separate article, Donald Doering, former chief of nursing at Salisbury VA, said he was forced to step down in 2004 after urging top management to call a surgical "time out" to allow review of what might be causing unexpected deaths. The hospital has disputed Doering's account but provided no details.

March 21, 2007: Three N.C. members of Congress: U.S. Rep. Mel Watt, a Charlotte Democrat, and Republicans Howard Coble of Greensboro and Robin Hayes of Concord: urged the House Committee on Veterans' Affairs to hold hearings on Salisbury VA care.

April 1, 2007: The Observer reported on a 2001 survey by outside consultants, hired by the VA, which found sloppy patient records, poor tracking of drugs and IV solutions mixed in unsanitary areas. The hospital's infection rate had doubled in the previous year, the consultants said, but the hospital did not take "concrete actions to address this."

April 8, 2007: The Observer reported that the Joint Commission, a national accreditation organization, granted the Salisbury VA "accreditation with full standards compliance" in 2003, and renewed the accreditation in 2005, although it had no knowledge of the 2005 OMI report or that of the outside consultants.

April 15, 2007: The Observer reported that Dr. Paul Karmin, a former Salisbury VA radiologist, warned five years ago that pneumonia patients were at increased risk of dying because many weren't getting medicine promptly. VA officials said they have improved its pneumonia treatment times.

April 19, 2007: House Committee on Veterans' Affairs holding hearings on Salisbury VA care.

1 comment:

  1. The Observer needs to come in NOW at the Ashevile VA and do an article on the primary care physicians and poor care in the out patient clinics. I am at my wits end. If you complain about care you get knocked down to level three which has happened to my husband. 100 percent his physician has failed him in so many ways from prostate exams only done because I insisted that he insisted he ask him to do them to husband has so much abdominal pain day and night
    with multiple trips to the bathroom
    this has been an ongoing battle to get them to do something. he has diabetes from agent orange and multiple other things puting him at high risk for cancer.we are given the constant run around. Someone needs to come in and do a story about negligence badly here it is as if they want the Vietnam vets to just die and go away too many and too much of an expense on our goverment. Gaye Ellis
    Lincolnton NC