In a shocking announcement, the Department of Veteran’s Affairs (VA) says that doctors at a VA hospital in Marion, Illinois provided substandard care that may have led to 19 patient deaths. The announcement followed two investigations of continuing problems at the facility.

What happened

The VA’s Illinois facility, which serves veterans from southern Illinois, southwestern Indiana and western Kentucky, employed several doctors that provided substandard care in a facility that may not have been adequately equipped to handle the types of surgeries performed there. Beginning in 2006, the Inspector General and the Medical Inspector both investigated operations at the facility after receiving reports that something was seriously wrong and that patients were dying.

Investigations

According to press release from the VA, reports from both the Inspector General and the VA’s Medical Inspector concluded that there had been “numerous instances of poor medical care at the facility.” Both reports, “criticize the facility for allowing surgeries to be performed that were more complex than the facility could handle based on its staff and capabilities. Concerns include the fact the Medical Center did not have 24-hour coverage in respiratory therapy, pharmacy and radiology.”

In addition:

• The Inspector General’s report states the care of three patients who died following surgical procedures during Fiscal Year 2007 had significant problems and . . . found instances in which surgeons performed procedures they were not authorized to perform.
• The VA Medical Inspector’s report, which reviewed Fiscal Years 2006 and 2007, and therefore substantially more cases, identifies a total of nine deaths directly attributable to substandard care. There were 34 cases in which care complicated patients’ health, including 10 others who died.

One Doctor Barred From Practicing

While several doctors are thought to have been involved in the scandal, one doctor in particular may have been responsible for nearly half of the 19 patient deaths reported. According to an article in the Washington Post, Dr. Jose Veizaga-Mendez began working at the facility in January 2006 after leaving a Massachusetts practice where he was being investigated for substandard care which resulted in two patients’ deaths. He had also allegedly paid two medical malpractice claims. The Post reported that Veizaga-Mendez was permanently barred from practicing medicine in November of 2007.

The VA responds

The VA has taken the following actions in response to the reports. It has:

• Removed Marion’s hospital director, chief of staff, chief of surgery and an anesthesiologist from their positions and placed them in other administrative positions or on administrative leave.
• Initiated an Administrative Board of Investigation to review quality of care issues and issues raised by employee groups. Neither the previous director nor the chief of staff will be returned to work at the facility, even if they are exonerated.
• Fired a surgeon who had not previously disclosed information related to his license to practice medicine.
• Set up a toll-free phone number for patients and their families who are concerned about the care they received at the Marion VA hospital to call to receive additional information. The number is 1-800-983-0932.

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