Employees at a Veterans Administration hospital in Mississippi have reported a range of “serious wrongdoing,” including improperly sterilized instruments and missed diagnoses of fatal illnesses, an independent federal investigative agency said in a letter to the White House.
The agency said the allegations raise doubt about the facility’s ability to care for veterans.
In the letter sent Monday to the White House and Congress, the Office of Special Counsel said an initial 2009 report by a whistle-blower employee at the G.V. (Sonny) Montgomery VA Medical Center in Jackson, Miss., alleged that the staff routinely failed to properly clean and sterilize reusable medical equipment such as scalpels and bone cutters.
In all, five whistle-blowers representing what the Office of Special Counsel called “a diverse group” of employees at the Jackson hospital made a variety of allegations over several years that imply improper care of patients. One doctor at the facility alleged in January 2013 that thousands of radiology images were unread or improperly read, resulting in missed diagnoses of “serious and, in some cases, fatal illnesses,” the special counsel said.
That case was referred earlier this month to VA Secretary Eric Shinseki for investigation, according to the letter sent to the White House by Carolyn Lerner, the special counsel. Her office does not have the authority to investigate whistle-blower complaints but can refer cases to the relevant agency if it determines – as it did in the cases involving the Jackson VA hospital – that there is “substantial likelihood” that the allegations are true.
The VA investigated the 2009 case and substantiated many of the allegations of persistent problems with the cleaning and sterilizing of reusable medical equipment; it said it took steps to fix the problems. In 2011, however, another whistleblower employee alleged that the problems continued. A VA investigation did not substantiate that allegation, but the Office of Special Counsel found the VA’s conclusion unreasonable.
Even though the VA substantiated that unsterilized equipment was sent to clinics and operating rooms in violation of VA policy, managers at the Jackson hospital “directed public affairs staff to state in a press release that no violations were found to have occurred,” Lerner wrote. Similar incorrect statements were made to veterans, employees and congressional staff, she added.
Of the five whistle-blower complaints about the Jackson facility, two are still under VA investigation.
“I am deeply concerned that these cases are representative of more pervasive challenges and threats to patient care at the Jackson Medical Center,” Lerner wrote in her letter to the White House.
“I find a troubling pattern of disclosures from these and other whistleblowers at the Jackson Medical Center,” she wrote. “Over a period of three and a half years, a diverse group of five employees disclosed serious wrongdoing at this facility.”
Not all of the whistle-blowers requested anonymity. One of the complaints was registered by an employee identified by Lerner as Gloria Kelley, an employee in the Jackson facility’s Sterile Processing Department. She alleged in 2011 that incorrect procedures persisted in her department, “placing the safety of employees and patients at risk.” Her complaint was referred to the VA for investigation in July 2011.
Lerner said the VA did not interview Kelley during the course of its investigation. Lerner called Kelley’s allegations “compelling” and said it did not appear that the VA has taken significant steps in improving the quality of management or staff training within the sterile processing department since the first allegations were made in 2009.