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.