Phoenix VA horror stories: Case file vignettes from VA IG investigation
By STARS AND STRIPES Published: August 27, 2014
Here are some excerpts from some of the case files in the Department of Veterans Affairs inspector general's investigation:
Case No. 29
In late summer 2013, a man in his early 60s with heart disease, hypertension, diabetes and hepatitis B and C, had severely depressed cardiac function, indicating heart failure and increased risk for sudden death. He had an implantable defibrillator placed in his heart but it had been removed. A Phoenix cardiologist recommended that he have a similar device implanted in four to five weeks. In early 2014, still without the procedure, the man collapsed in his kitchen and died three days later. According to the report, timely placement of the device "might have forestalled that death."
Case No. 12
A man in his 70s with an elevated prostate-specific antigen was scheduled for a urology appointment in three months, but the appointment was canceled with the notation "provider not available." Four months after the initial request, the patient’s primary care provider requested non-VA urology care, which the VA denied. After four more months, the VA facility closed out the request. Nearly a year after his initial request, the patient was seen by a non-VA urologist and was diagnosed with prostate cancer.
Case No. 35
A man in his late 40s with a history of depression came to the Phoenix VA ER with his parents after reporting paranoid delusions. After being evaluated by a nurse, he declined hospital admission, saying he would report to the hospital the next morning. Instead, he committed suicide. The report concludes that with "depression-induced" psychosis, the patient should have been involuntarily admitted for treatment.
Case No. 2
A man in his late 60s with hypertension, diabetes, cirrhosis, congestive heart failure and emphysema came to the Phoenix VA emergency department complaining of weakness and diarrhea. He was put on a list for a consult. After two hospitalizations at non-VA hospitals, the man died. Three months later, Phoenix VA staff called to schedule his appointment.
Case No. 16
A man in his mid-30s with a history of hospitalization for suicidal thoughts and anxiety called for an appointment with the Phoenix VA and was placed on a wait list for five weeks, then scheduled for an appointment in an additional four weeks. Three months after his initial contact, he was given a referral to a mental health clinic.
Case No. 7
A man in his late 60s was evaluated at the Phoenix VA ER for chest pain. His blood pressure was 180/124, and a test showed a heart abnormality. He was scheduled for a primary care appointment seven months later, but a physician had him come in sooner. Five months after his initial visit, he underwent coronary bypass surgery.