VETERANS ARE DYING AT THE HANDS OF VA HOSPITALS " VA malpractice suits shorting California Vets"

[Jerry BallardUSNRet]

2 
Investigates: VA malpractice suits shorting California Vets 

OAKLAND, Calif. —

Medical 
mistakes, long after veterans’ service of our country, are leading to large 
settlements with VA Hospitals.

As 
part of a nationwide COX Media Group 
investigation, KTVU’s 2 Investigates poured through the millions of dollars in 
medical malpractice settlements involving our veterans.

In 
2009 Army Specialist John Lee Mackey of Richmond checking into a 
Martinez VA Hospital for dehydration. He never left.

“He 
came into the hospital for a very treatable condition and unfortunately never 
left,” Mackey family attorney Niley Dorit told 2 Investigates.

After 
Mackey checked in, Dorit says doctors put what’s called a peripherally inserted 
catheter, or a pick line, into his arm. They mistakenly inserted the 
catheter all the way into his heart, killing him.

Dorit 
sued the VA and settled for $145,000. The settlement likely would have 
been millions, but California and 20 other states 
have a $250,000 cap on medical malpractice damages, such as pain and 
suffering.

That 
cap is not in place in Pennsylvania. That’s where 
Gunnery Sergeant Chris Ellison, a proud marine of 20 years, is being forced to 
relearn how to talk and walk. His injuries also are not from combat.

“Mr. 
Ellison went into VA-Philly for routine extractions of teeth,” Ellison’s attorney, 
Shanin Spector said.

Spector 
says his client went to the VA hospital in Philadelphia to have eight teeth 
pulled. Doctors noticed his blood pressure was low, but still went ahead 
with the procedure.

“That 
was a very bad mistake. Within a few hours, he had sustained a severe 
stroke and was rendered terribly brain injured,” Spector said.

Ellison 
won a $17.5 million lawsuit against the Department of Veterans Affairs. 
It’s the largest malpractice lawsuit against the VA in over a decade.

According 
to Government databases, last year alone, VA malpractice claims were up almost 
30 percent from 72 million in 2011. Since 2003 the VA has settled or lost 
more than 4,400 malpractice cases. The payout and cost to taxpayers is 
over $844 million.

Republican 
California Congressman Jeff Denham says a lot of what is going on has been for 
way too long.

“And 
it’s not just about the dollars, it’s about the lives,” Denham said.

The 
VA pays out in about 25 percent of all claims. That’s slightly higher 
than the 20 percent payout in private sector health systems. However, 
those payments are increasing. The 454 payments issued in 2012 is the 
second most in the last 10 years.

Currently, 
when the VA is sued and loses, the payout comes from a US Treasury fund.

"I 
wish that we could shame the VA into doing the right thing, but I believe that 
they believe they're above being shamed,” Congressman Jeff Miller, who heads 
the House Committee on Veterans Affairs, said.

The 
VA declined our requests for interviews, but, in a written statement, said its 
highest priority is "the care and wellness of the brave men and women who 
have served our nation," and that it takes the issue of malpractice claims 
"very seriously".

MY RESPONSE TO THAT VA !

What about the 900,000 Veterans who are fighting VA 
for their disability?

What about the Primary Care Doctors that refuse to have 
X-Rays done to save money?

Let’s talk about how you claim that the Care and 
Wellness of America’s Veterans 
are your priority

Lets talk about the 30% of Veterans Claims for 
Disability are in error

Let’s Talk about VA Oakland CA firing “ 
Employees who try to help Veterans get their Disability

Let’s talk about the Senate Report that stated that 
17% of those who issue ratings for Veterans are not qualified to do so

Let’s talk about the missing Medical Records VA !

The Federal Tort Claims Act allows a civilian to claim 
compensation from the US government when 
damage is caused by the negligence of an employee or agency (such as VA 
hospital malpractice) of the US government, 
including the Veterans Administration (VA). VA medical malpractice law falls 
within negligence law, which is applicable to all lawsuits by attorneys against 
medical professionals, from VA hospitals to doctors and dentists to podiatrists 
and chiropractors. 



Increasingly, more 
medical negligence claims have been directed toward VA medical malpractice 
claims. According to the VA, the "environment of care" needed to be 
improved at 17 out of 23 medical facilities it inspected from 9/2004 to 10/2005.

2004

A "Primetime Thursday" investigation by Diane 
Sawyer uncovered disturbing information by hidden cameras about the quality of 
care and questionable management practices at some VA hospitals, including 
misdiagnosis. One patient, Terry Soles, who served in the Navy during the war 
in Vietnam, went to a V.A. 
hospital for two years complaining of intense abdominal pain and diarrhea. His 
wife finally took him to a private doctor, who diagnosed cancer: Soles died 
three days later. 



A former VA 
out-patient clinic psychiatrist was convicted of nine misdemeanor counts of 
assaulting three patients under his care. He was later convicted of 
"improper sexual relationship with patient." 



2005



The News Hour with 
Jim Lehrer reported on what the VA is doing to improve patient safety. It 
revealed many lapses in patient safety over the last decade, including lack of 
hand washing, wrong site surgery, and that the VA performs surgery on the wrong 
veteran about once a month. And VA infections frequently occur.

2006


Two years after a report regarding incompetent VA staff, US 
Government Accountability Office (GAO) reported that the VA was still doing a 
poor job of checking health care providers' backgrounds. (At least 63 cases of 
malpractice have been found between 1997 and 2002 that resulted because of the 
failure of a supervisor to oversee residents. These cases included 
misdiagnosis, surgical and medication errors, and inadequate care.) 



2008



The brachytherapy program at the VA Medical Center in Philadelphia was shut down, 
after it was learned that many veterans had received incorrect radiation doses 
over a six-year period. 



2009



VA centers in three cities were accused of reusing 
colonoscopy and endoscopy equipment without properly sanitizing the equipment. 
At least 50 veterans tested positive for blood borne pathogens. 



The VA sent letters 
to about 600 veterans with potential neurological diagnoses, but who do not 
have ALS—Lou Gehrig's disease—telling them 
they were diagnosed with this debilitating and deadly disease.

VA INFECTIONS

In November 2008, the VA Medical Center in Augusta, Georgia sent a letter to 
more than 1,200 patients who were treated for ear, nose and throat, warning 
them they may have been exposed to infections. 



Following a 
December 2008 investigation at the VA clinic in Murfreesboro, TN, officials 
discovered that clinic workers were not properly maintaining the medical 
equipment used to conduct colonoscopies. More than 6,000 patients were notified 
and offered free testing. 



In March 2009 VA 
officials announced that veterans in South Florida may have been 
exposed to Hepatitis and HIV after being examined with contaminated medical 
equipment. 



According to 
reports, more than 3,200 veterans who received colonoscopies at the Miami VA medical clinic 
between May 2004 and March 12, 2009 are at risk of 
exposure to both Hepatitis and HIV. 



If you or a loved 
was diagnosed with Hepatitis, HIV or another infection after being treated at a 
VA medical clinic, you should seek help from a veterans lawyer—you are likely 
eligible for compensation including medical expenses, lost wages, long-term 
treatments (if necessary) and emotional pain and suffering.

Malpractice Payouts to U.S. Veterans Reach 12-Year High

http://www.bloomberg.com/news/2013-09-09/malpractice-payouts-...

Christopher Ellison went 
to a veterans medical center in Philadelphia 
to get eight teeth extracted in 2007. What should have been a routine dentist 
visit left him permanently incapacitated.

The 
$17.5 million Ellison and his family received in a malpractice judgment against 
the Department of Veterans Affairs was the largest against the agency in 
a dozen years -- and one of more than 400 payments the U.S. government made last year to 
resolve VA malpractice claims, according to agency records obtained through a 
Freedom of Information Act request. The total cost came to $91.7 million, also the highest sum in 
at least 12 years.

The 
cases against the VA have included missed diagnoses, delayed treatment and 
procedures performed on wrong body parts. U.S. 
lawmakers and veterans’ advocates say they reflect deep flaws in the agency’s health-care system even as the department tends to 
more former troops, including those who fought in Iraq 
andAfghanistan.

“The 
rapid rise in malpractice judgments against VA mirrors the emerging pattern of 
preventable veteran deaths and other patient safety issues at VA hospitals,” 
Representative Jeff Miller, a Florida Republican and chairman of the House 
veterans committee, said in an e-mailed statement. “What’s missing from the 
equation is not money or manpower -- it’s accountability.”

‘Not 
Warned’

Miller’s 
committee held a hearing in Pittsburgh 
today to probe lapses that include a Legionnaires’ disease outbreak at a VA 
hospital that killed at least five veterans and also led to malpractice claims. 
The VA’s inspector general is conducting a criminal investigation into the 
outbreak, which involved bacteria in the hospital system’s water, Robert 
Petzel, the department’s undersecretary for health, said during the hearing.

Family 
members of veterans who died after being exposed to the bacteria said the VA 
didn’t immediately let relatives know there was a potential health problem.

“For sixteen days my 
father was allowed to shower and drink the water without any warning,” said 
Robert Nicklas, whose father, William, a Navy veteran, died last year after the 
Pittsburgh VA 
outbreak. “Why were we not warned?”

More Patients

More 
veterans are taking advantage of VA medical care, 
including those requiring more complex treatment. As many as 1.2 million 
additional soldiers are due to become veterans in the next four years. Some of 
the soldiers from the wars in Iraq 
and Afghanistan 
are suffering post-traumatic stress disorder while others are living with 
injuries that would have been fatal in World War II or the Vietnam War.

The 
age of recent veterans may be a contributing factor in the rise of claims 
payments, said W. Robb Graham, an attorney in Cherry Hill, New Jersey, who has represented former 
troops filing claims against the agency. Younger claimants tend to get larger 
malpractice payouts, often tied to how long victims will suffer, he said.

The 
median age range of veterans who served after the Sept. 11, 2001, terror attacks in New York and Washingtonwas 25 to 34 years old, according to a 
2011 Labor Department study. That’s compared to veterans who 
served during the World War II, Korean War and Vietnam 
eras, whose median age range was 65 and older, the study said.

Higher Payments

“If 
the VA cuts off the wrong leg of a veteran who is 70 years old and his life expectancy is 75, he’s entitled to five years of 
damages,” Graham said in a phone interview. “If they cut off the wrong leg of a 
veteran who is 25, you’re now dealing with someone who is entitled to 50 years 
of damages.”

The 
department has 152 hospitals and about 19,000 doctors. Last year, the VA tended 
to 5.6 million veterans, a 32 percent increase from fiscal 2002, according to 
agency data.

“It’s 
the largest health-care system in the U.S., 
and they do an incredible amount of good work,” said Jerry Manar, deputy 
director of national veterans service at theKansas City, Missouri-based Veterans 
of Foreign Wars. “However, there are so many more things they could do in terms 
of oversight that they don’t appear to be doing now. As a consequence, 
sometimes you wind up with poor results that were avoidable.”

The 
department is “deeply committed to providing the quality care and benefits our 
nation’s veterans have earned and deserve,” Gina Jackson, a VA spokeswoman, 
said in an e-mail. “If employee misconduct or failure to meet performance 
standards is found to have been a factor, VA will take appropriate corrective 
action immediately.”

Taxpayers’ Bill

The 
2012 malpractice payments stemmed from both court judgments and administration 
settlements. The payouts, made by the U.S. Treasury’s 
Judgment Fund, rose 28 percent last year from about $72 million in 2011, the VA 
records showed. Taxpayers have spent at least $700 million to resolve claims 
filed against the veterans agency since 2001, according to the data.

Many 
valid VA malpractice claims never get paid, said attorney Graham, who served as 
a judge advocate general in the Navy in the 1980s. Some are rejected because 
paperwork isn’t filed properly, he said.

“My 
strong belief is a lot of lawyers don’t know how to sue the VA,” he said.

Some 
law firms aren’t interested in representing people suing the federal government 
because of laws that limit attorney fees to 25 percent of malpractice awards, 
Graham said.

‘An Alarming Pattern’

In 
a May letter, Representative Miller asked President Barack Obama to help address “an alarming pattern 
of serious and significant patient care issues” at VA medical facilities.

The 
House panel is reviewing the Legionnaires’ outbreak in Pennsylvania, and the department’s 
handling of two overdose deaths and two suicides at an Atlanta 
veterans hospital. Also under scrutiny are poor sterilization procedures and 
possible patient exposure to infectious diseases such as HIV at VA locations.

“We 
are not here as part of a witch-hunt, to make VA look bad or to score political 
points,” Miller said during the hearing. “We simply want to ensure that 
veterans across the country are receiving the care and benefits they have 
earned.”

The 
agency isn’t holding employees, especially executives, accountable for 
preventable deaths, Miller said. Department officials also gave bonuses to 
doctors even if they practiced without a license or left residents unsupervised 
during surgery, according to a Government Accountability Office report last 
month.

VA Bonuses

The 
recipients of $150 million in bonuses to VA health-care providers in fiscal 
2011 included a radiologist unable to read a mammogram and an emergency-room 
doctor who refused to see patients, the report found.

Miller 
has said the VA employees should be punished -- not rewarded -- for their 
incompetence.

The 
number of malpractice claims filed with the VA has remained at 1,544 for the 
past two years, said Jackson, 
the agency spokeswoman. The leveling off came after a 33 percent spike in cases 
to 1,670 between 2010 and 2005, according to an October 2011 GAO report.

The 
VA’s malpractice payment rates may be similar to national levels, said Anupam 
B. Jena, an assistant professor at Harvard Medical 
School and 
physician atMassachusetts 
General Hospital.

Ellison’s Case

Less 
than 25 percent of the claims filed against the veterans agency result in 
payment, according to the VA. About 20 percent of malpractice claims filed with 
the largest insurer of physicians between 1991 and 2005 resulted in a payment, 
according to a 2011 study published in the New England Journal of Medicine, 
said Jena, 
who worked on the report.

Last 
year’s “noticeable increase” in medical malpractice payments was partly due to 
an “exceptionally large” $17.5 million court judgment, Jackson 
said in an e-mail. Such payments are “highly variable from year to year,” she 
said.

That 
record judgment went to Ellison, who was honorably discharged from the Marines 
in 2001. He was a 49-year-old electronics technician from Bridgeport, 
Pennsylvania, 
in 2007 when he visited the dentist to have eight teeth extracted because of 
tooth decay and gum disease.

During 
the procedure at a VA facility in Philadelphia, 
Ellison’s blood pressure dropped several times to “unusually low” levels, his 
attorney, Shanin Specter, a partner at Kline & Specter P.C., a law firm in the city, said during a 2011 trial.

‘Catastrophic’ Stroke

Ellison 
wasn’t sent to the emergency room, and the dentist continued with the 
extractions, said Specter, son of Arlen Specter, 
the former senator from Pennsylvania 
who served as a Republican for more than 28 years and became a Democrat during 
his last 20 months in office. Arlen Specter died last year.

Ellison 
had a “catastrophic” stroke while driving his car shortly after leaving the 
dentist office, Specter said.

The 
government argued that the veteran’s existing health problems caused the 
stroke, not the care he received at the VA. Ellison had a history of smoking, 
diabetes, hypertension and many other stroke risk factors, Thomas Johnson, an 
assistant U.S. 
attorney, said during the 2011 trial in U.S. District Court in Philadelphia.

After 
the stroke, Ellison was left with limited vocabulary, “severe and pervasive 
deficits in all mental abilities,” and “negative personality changes,” 
according to court documents.

“He 
wound up being totally incapacitated, requiring 24-hour-a-day care,” Specter 
said. “This is about as devastating an injury as a person can have, and that’s 
what the award reflects.”