VA Links Poor Care To 19 Deaths In Ill.

Veterans Affairs Official Cites Substandard Care At State Hospital, Apologizes To Families

(AP)  Substandard care at a southern Illinois Veterans Affairs hospital may have contributed to 19 deaths over the past two years, a VA official said Monday as he apologized to affected families and pledged reform.

The hospital in Marion, Ill., initially drew scrutiny over deaths connected to a single surgeon, but two federal reports found fault with five other doctors.

The hospital undertook many surgeries that its staffing or lack of proper surgical expertise made it ill-equipped to handle, and hospital administrators were too slow to respond once problems surfaced, said Dr. Michael Kussman, U.S. veterans affairs undersecretary for health.

"I can't tell you how angry we all are and how frustrated we all are. Nothing angers me more than when we don't do the right thing," Kussman told reporters during a conference call after releasing findings of the VA's investigation and summarizing a separate inspector general's probe.

Still, Kussman insisted, "what happened in Marion is an exception to what otherwise is a truly quality health-care system" across the VA.

The VA will help affected families file administrative claims under the VA's disability compensation program, he said. Families also could sue.

The VA investigation found that at least nine deaths between October 2006 and March last year were "directly attributable" to substandard care at the Marion hospital, which serves veterans from southern Illinois, southwestern Indiana and western Kentucky.

Kussman declined to identify those cases by patient or doctor, though Rep. Jerry Costello, an Illinois Democrat, said those nine deaths were linked to two surgeons he did not name.

Of an additional 34 cases the VA investigated, 10 patients who died received questionable care that complicated their health, Kussman said. Investigators could not determine whether the care actually caused the deaths.

Inpatient surgeries have not been performed at the facility since problems first became public last August. They will remain suspended indefinitely, Kussman said.

In pledging reforms, Kussman said the VA has launched an administrative investigatory board to review care problems and matters raised by employee groups.

The VA last September also installed interim administrators to replace the Marion VA's director, chief of staff, chief of surgery and an anesthesiologist, moving them to other positions or placing them on leave, Kussman said. The anesthesiologist has since quit, Kussman said.

"The previous leadership will not return" to their former jobs, he said.

The VA's investigation cited by Kussman covered a two-year span, the VA said.

The inspector general's office blamed three deaths on substandard care at the Marion site, but that review covered only the past fiscal year, which ended in October, the VA said. That report was not immediately available Monday.

Telephone calls on Monday seeking comment from the Marion VA were directed to spokespeople with the agency's Washington headquarters.

Neither Kussman nor the VA investigation's 41 pages of findings named surgeons involved in the deaths, though Kussman acknowledged that much of the criticism has focused on Dr. Jose Veizaga-Mendez.

Veizaga-Mendez - identified in Monday's report as "Surgeon A" - resigned from the hospital Aug. 13, three days after a patient from Kentucky bled to death after gallbladder surgery. All inpatient surgeries stopped a short time later.

Sen. Dick Durbin, an Illinois Democrat, has said Veizaga-Mendez is linked to 10 patients' deaths at the Marion facility, about 120 miles southeast of St. Louis. Kussman declined to discuss that claim Monday, saying he didn't want to influence additional internal investigations of six of the site's surgeons he said had "at least one episode of substandard care."

Veizaga-Mendez and another surgeon no longer practice at the Marion VA. The remaining four surgeons remain on staff but are "only doing minor cases at this time," Kussman said.

"We don't think the physicians killed the patients," he said. "We think the physicians were trying to care for the patients and did so in an inadequate way."

Costello and fellow Rep. John Shimkus, a Republican from Collinsville, Ill., called Monday's findings "shocking." Durbin said the reports "confirm what many of us in Illinois feared" - that the Marion VA's medical care was substandard and that protocol for protecting patients was ignored.

"As the inspectors who reviewed the Marion hospital put it, the quality of care at Marion was 'horrible,"' Durbin said.

Veizaga-Mendez's whereabouts are unclear. He has no listed telephone number and has been unreachable for comment.

The Marion VA hired Veizaga-Mendez in January 2006 after he practiced in Massachusetts, where he was under investigation for substandard care in 2004 and 2005. The claims include allegations that he botched seven cases, two ending in deaths.

Veizaga-Mendez was permanently barred from practicing medicine in Massachusetts last November - a disciplinary move that also requires him to resign other state medical licenses he may hold and withdraw pending license applications. He has also made payouts in two Massachusetts malpractice lawsuits.

[jesusluvr]

i do some work at the va hospital and it disgusts me how some nurses treat the patients especially in the nursing home. i saw a group of students being led by a nurse who was teaching them how to help a patient go to the bath room and then the nurse let them do it themselves and the students were supposed to go back to class so they left the poor man sitting in the hallway completely naked in his wheelchair and didnt even allow him to use the bathroom. then as he asked a nurse passing by for help she said the students were supposed to help him and she was going home. it pissed me off. i ended up taking care of the man and giving him his dignity back but that really made me upset.

[sclaires]

My father was a WWII veteran and said he never would go to the VA for treatment. He did get hearing aids from them and also medication for service connected medical problems. But, as an in-patient, HE!! NO... Most of the doctors that I hear about at the VA seem to be foreigners, i.e., foreign medical schools, etc. They are here because they can make more money in the US then in their home countries.

I had one of my doctors tell me that the VA Hospital in one city had really gone down in quality of care but the VA Hospital in the town where he practices is better but only because a medical school is connected with it. Now this is from a doctor who knows what he is talking about.

At the same time I have said in the past and will continue to say that the army hospital at an army installation where I used to work was bad and I wouldn''t take even a sick snake there and I do not like snakes. That was years ago and now most of the patients are sent into the civilian community for care to include active duty personnel. How about that "barrel of apples"????

[kansas1946]

Bush adminstration supporting the troops.

[sgtrds]

The Pentagon and the Administration do not care. Once a soldier is no longer able to fight, due to age or wound, then they become just a liability to be dumped at the cheapest possible cost.

[michellem99-2009]

Dear man I can''t watch the news as that illegal war make me sick and as a lady get yer champer pot as ye going to need it.
I do want to thank ye vets..I know thanks don''t get ye the care yer need. I mean thanks for serving and my Dad is a vet. Every vet day I do thank him.

[michellem99-2009]

Some one told us to get off our butts and go to a VAMC..I don''t have to..I have a vet room mate. Seattle VAMC. Oh yes..I have been there with him. I will not use the ladies room at a VA hospital..I don''t need to tell ye why..They mail his meds to him. He is a patent with disbetes, a bad heart,COPD. He is grateful for the care. It could be better. I am legally blind from birth. I am 53. He is 56. He tell me they are raeding their notes on computer when they ought be treating him.. My eye doctor as had to save vets eyes after the va hospital messed his/her eyes up. The problem is yes the vet can get med care out side the vet hospital but the vet will pay thru the nose..the vets can''t get medicaid , they have the spend down,, It is some un godly figger before medicaid will pay a dime. Money needed to pay daily living rent and the like. The poor get poorer and the rich get richer.

[offtheback]

If I ever hear another politition say "supprt our troops" I''m gonna puke!

[corwlyn]

what people fail to realize is just like any other government entity, the VA Hospitals do procedures cheaply and also contract out procedures to the lowest priced hospitals. I found this out when I was scheduled for a heart surgery with the Cleveland Clinic by the VA. I was preped and ready to go and then received a phone call stating due to cost effectiveness, my surgery was contracted to another facility. Due to this, i know have extensive nerve damage and have found out that the hospital hadn''t performed but a handfull of these procedures and none with an anurism within the heart wall like mine. Now the VA Hospital and the contracted hospital refuse to accept responsibility for any of the damage. The VA states that it is not responsible due to the fact that it was contracted out and the gaining hospital states that all proper procedured were followed and proper care was given. This is continually ongoing and the VA calls it quality care. It makes you really nervous to think of the government taking over health care and contracting your services out to the cheapest physician or hospital, doesn''t it?

[slim1h2o]

Wish they would change that.

Posted by sandy777 at 07:37 AM : Jan 29, 2008

So do I..I find it disgusting, that these people get a "hand-up", while people who have worked in the system (Taxpayers) receive nothing in their time of need.
That''s just one reason that this country is in soooo much trouble right now.

[sandy777-2009]

One question; How can a illegal alien, at the age of 19, hop over the fence, work for a couple of years in the fields picking vegetables. And then, somehow, becomes a top Brain surgeon? BEFORE,,the age of 40. Saw it in Readers Digest this month.

How in the world did he get into Medical school, without High school, or college transcripts. This smacks of system failure, in my mind.

And this same system, is allowing people to die, everyday!

Posted by slim1h2o at 07:26 AM : Jan 29, 2008


From my experience with the VA, the VA does use doctors that are contracted by the VA. Apparently, it looks like the VA does not do background checks and if they do, they don''t do a very good job of it. I know background checks take many months to complete. I just know in my case with being in the military and having a security clearance, and with being a federal employee. They should not hire illegals. As you know, illegals seem to have more rights than legal US citizens. Wish they would change that.

[slim1h2o]

Posted by sandy777 at 06:59 AM : Jan 29, 2008

The whole system is bogus! From Civilian, to the VA, and everything in between.

One question; How can a illegal alien, at the age of 19, hop over the fence, work for a couple of years in the fields picking vegetables. And then, somehow, becomes a top Brain surgeon? BEFORE,,the age of 40. Saw it in Readers Digest this month.

How in the world did he get into Medical school, without High school, or college transcripts. This smacks of system failure, in my mind.

And this same system, is allowing people to die, everyday!

[sandy777-2009]

It''''s the same way with the Civil system as well.
With the new laws, pertaining to Malpractice, Doctors protecting their own, the list can go on.

We need a new Med. system, period!

Posted by slim1h2o at 06:42 AM : Jan 29, 2008

I totally agree. The VA system needs a complete overhaul cause it''s outdated. I even emailed Senator Clinton and told her how I was mistreated by the VA system. She is very good at fighting for Veteran''s rights.

[slim1h2o]

It is nearly impossible to sue the VA for medical negligence.

Posted by sandy777 at 06:29 AM : Jan 29, 2008

It''s the same way with the Civil system as well.
With the new laws, pertaining to Malpractice, Doctors protecting their own, the list can go on.

We need a new Med. system, period!

[shammy0202]

What a surprise...NOT!!!!! In working as a murse with assited living residents who choose to get their medications through the VA by mail, even that is a joke. You can''t even get them!!!!!!! I spend 50% of my day working with the VA trying to get these peoples medications, time I should be spending with them!!!!

[sandy777-2009]

Many of the doctors at the Houston Texeas Veteran''s Hospital come from the Baylor Colllege of Medicine. And many of those doctors are in their first year of residency. I know because I am a female Vietnam Era Veteran and I also worked there as a government employee. I had received lousy medical treatment there also for many years. I tried doing something about it but no one would listen to me and I did try to sue the VA there. It is nearly impossible to sue the VA for medical negligence.

[skyk-2009]

So, they overload the VA system. Where you might have a day at a typical hospital with several appointment slots open, at a VA center they are almost always booked week and months in advance. You can''''t get in to see a doctor within a few weeks unless you have a pre-scheduled appointment.

If the ''''civilian'''' hospitals would get their collective acts together, this wouldn''''t happen, and the VA wouldn''''t be in the mess it''''s in.

And by the way, most (if not all) of the staff and doctors at VA centers are local civilians as well, so you can''''t lay the blame on the military.


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Posted by TheGateway1 at 05:51 AM : Jan 29, 2008
+ report abuse

My God are you living in a cave. Our Civil Health Care system can''t even deal with what they have to deal with today. Have you been to an ER lately? The crisis in Health Care continues to grow with every minute in the Civil area and no vet in his right mind is going to try THAT avenue. It was nothing but an attempt to shift the burden of carring for our vets off on a failing system and it''s disgraceful. Get off you butt and GO to a VA Hospital sometime.. talk to those Vets. They are NOT getting the care they deserve and THAT there is NO doubt of. What the people who are responsible for this mess have tried to do is isolate it to what happened at Walter Reed... that''s just not the case. Go Visit them!! I do!!

[slim1h2o]

If the ''''civilian'''' hospitals would get their collective acts together, this wouldn''''t happen, and the VA wouldn''''t be in the mess it''''s in.
Posted by Thegateway1;

I agree, Our private hospitals are a messs. Doctors are no better, they have Big Pharma. in their back pockets., gladly accept payments, for despensing of drugs like candy. Which, do no good, for the underlieing problem.

The whole Medical system (from Med. school, to top Administrators of hospitals) is broken, and people die every day, from the lack of effective care!

[skyk-2009]

It seems that THIS President can KILL Thousands based on LIES but can''t take care of those who managed to stay alive. This isn''t just at this VA Hospital or it isn''t isolated to Walter Reed, it''s all accross the board. The people who cut and cut more to provide Tax Cuts to the Wealthy have put in place a system that does not work and can not work. They provide substandard care and substandard hospitals becasue the money isn''t there to do better. We pay out BILLIONS every year to support a debt and can provide Proper Medical Care to vets... disgraceful... absolutely disgraceful.

[michellem99-2009]

The vets need that csre. They earnt that care. They had no businss killing vets. I am a lay person who believe thr va staff can be sued.. I am a daughter of a vet. if the doc is barred from practising med in MA and why was he not barred in all 50 states for life..Doesn''t the VA do a back groud ckeck.. With computer they can..If judge in a court of law can do a back ground ckeck on a person nation wide before she will grant a person a name change. I know this. I have a clean record. WHY CAN''T THE VAMCs.

[Krazcarl]

Dr.Doom what a piece of work. Our vets deserve better period.