By Staff Reporter |

A federal investigation into the death of a Phoenix Marine Corps veteran published on Wednesday revealed that a Veterans Administration (VA) facility was to blame, due to insufficient and lacking health care practices and policies. 

The VA Office of Inspector General (OIG) found that the deceased Marine veteran experienced a delay in basic life support and numerous deficiencies with regard to initiating emergency medical care at Carl T. Hayden Medical Center in Phoenix: conflicting facility policies inconsistent with Veterans Health Administration requirements, lack of layperson CPR training, lack of an automatic external defibrillator, lack of wearable cardioverter defibrillator as ordered, and failure to assess vital signs at an appointment preceding the medical emergency. 

The OIG report determined that the facility leaders’ lack of response to treating the veteran was out of alignment with the VA’s high reliability organization (HRO) principals and I CARE values. It further found that the patient safety manager failed to investigate the related patient safety report, therefore resulting in an inaccurate harm assessment. And, the OIG found that both the patient safety manager and facility director failed to ensure a timely review of the report and investigation. 

Congressman Ruben Gallego, also a Marine Corps combat veteran, issued a statement in response to the report. Gallego said the VA center investigation revealed the treatment to not only be insufficient, but “disturbing [and] dangerous.” 

“The fact that something as simple as vital signs were not taken at the beginning of the appointment is particularly shocking,” said Gallego. 

The 55-page report indicated that the veteran’s death may have been preventable, had better policies and procedures been exercised. Upon the veteran collapsing following an outpatient appointment, the facility operator rebuffed a rapid response attempt by a hospitality employee and advised to call VA police instead. The employee then called 911. As a result, the veteran waited 11 minutes prior to paramedics arriving, administering basic life support, and transporting him to a community hospital where the veteran died two days later. 

The Phoenix facility’s policy restricted rapid response teams to events inside buildings and relegated all other emergencies to 911 and VA police, regardless of the proximity of the emergency to the building. The hospitality employee who attempted to save the veteran’s life called for a rapid response team due to the emergency’s proximity to the building, in the knowledge that they would arrive faster than the other responders. The OIG in its report expressed concern that the facility had elevated policy above all else, including lifesaving measures.

“The OIG is concerned that facility policy regarding responses to medical emergencies does not align with Veterans Health Administration (VHA) policy to ‘optimize patient safety for those requiring resuscitation’ and ensure ‘emergency response capability to manage cardiac arrests on VHA property,’” read the report.

Even prior to the emergency event, the OIG found that the veteran suffered from apparent deficiencies in medical care, such as the absence of the needed wearable cardioverter defibrillator as ordered by the veteran’s cardiologist, and no health care personnel took complete vital signs as required during the veteran’s outpatient exam.

The OIG issued 10 recommendations to the facility, which involved aligning policies with VA policies and procedures so they no longer conflict.

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