VA Links Poor Care To 19 Deaths In
Veterans Affairs Official Cites Substandard
Care At State Hospital, Apologizes To Families
ST. LOUIS, Jan. 28, 2008
(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
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
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
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
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