The Manchester VA Medical Center failed to take seriously whistleblower complaints of substandard care at the facility, including that a number of patients developed serious spinal cord diseases as a result of clinical neglect, according to a report from a federal whistleblower agency.
The findings announced Thursday from the Office of the Special Counsel follow reports last summer from The Boston Globe that 11 physicians and medical employees alleged the Manchester facility was endangering patients. They described a fly-infested operating room, surgical instruments that weren’t always sterilized and patients whose conditions were ignored or weren’t treated properly.
In response to the Globe report, Secretary of Veterans Affairs David Shulkin immediately removed three top officials and ordered an investigation. Shulkin visited the hospital in August, and said a task force would explore bringing a full-service veterans hospital to New Hampshire, teaming up with other hospitals in the state or forming a public-private partnership to improve care.
“The VA did not initiate substantive changes to resolve identified issues until over seven months had elapsed, and only did so after widespread public attention focused on these matters,” Special Counsel Henry J. Kerner wrote to President Donald Trump. “It is critical that whistleblowers be able to have confidence that the VA will address public health and safety issues immediately, regardless of what news coverage an issue receives.”
Veterans Affairs spokesman Curt Cashour disputed allegations that the VA failed to take the complaints seriously and insisted the medical center was well on its way to addressing those shortcomings. He said several members of the Manchester leadership team have been replaced.
Cashour said the VA had launched an independent clinical review of every case that whistleblowers identified. The investigation is ongoing.
“I hope ongoing investigations and studies related to care at the Manchester VA will shed more light,” New Hampshire Democratic Sen. Jeanne Shaheen said in a statement. “Our veterans deserve nothing less than high quality, convenient, accessible health care, and I will not accept anything less.”
Democratic Sen. Maggie Hassan, also from New Hampshire, said the report raises serious concerns about the VA system and whether it adequately addresses whistleblower concerns.
Hassan said the VA “must take additional steps” to hold accountable members of the VA leadership, both in Washington and in New England, “for their completely inadequate response to the concerns expressed by the whistleblowers and other providers.”
Much of the Globe‘s report focused on accounts from Dr. William “Ed” Kois, head of Manchester VA’s spinal cord clinic, who compiled a list of at least 80 patients at the hospital over five years suffering from advanced and potentially crippling nerve compression in the neck, and using canes, wheelchairs and walkers, instead of getting surgery. He said the condition is easy to diagnose and treat with surgery before it progresses too far.
The Office of the Special Counsel report called the Manchester VA’s response to the Kois’ concern’s “sluggish” and allege that it only started to look into the allegations of substandard care after they were published by the Globe. But even then, the report criticized the agency for choosing not to “review certain serious allegations.”
It found that its office had referred the whistleblower allegations to the VA in January 2017 but that the VA waited until after the newspaper’s story was published in July to take action against any VA personnel or initiate a comprehensive review of the facility.
“This is an unacceptable message to VA whistleblowers that only the glaring spotlight of public scrutiny will move the action to action, not disclosures made through statutorily established channels,” Kerner wrote.
Despite the Manchester VA’s failure to immediately act on the whistleblower complaints, the OSC said it was unable to substantiate that patient care suffered.
It said it couldn’t substantiate whistleblower claims that spinal care patients received improper medical care nor could it conclude that the rate of worsening neurological function related to the spinal cord condition myelopathy at the Manchester facility is “indicative of clinical neglect resulting from delayed referrals and surgical intervention.”
It did, however, substantiate that a physician inappropriately copied and pasted portions of patient progress notes for several years — a violation of VA policy. It also substantiated that facility’s operating room was repeatedly infested with flies but couldn’t substantiate that the infestation delayed care.
Kois dismissed the OSC findings on patient care, contending it was hamstrung by the fact it was basing its findings on an Office of the Medical Inspector investigation. He claims it reviewed only a handful of the 97 patients that he spotlighted.
“If the OMI wanted to look, there was documentation that these patients are damaged,” Kois said.