Ignored, mistreated and turned away: Tales from the Phoenix VA

Darrell Richardson talks about his brother, Vietnam veteran Dennis Richardson, who he said had trouble getting treatment for his liver cancer from the Phoenix VA. Dennis Richardson died Nov. 8, 2012, at the age of 66, Richardson said. Darrell Richardson was one of about 200 veterans and family members who gathered at American Legion Post 41 in May 2014 to discuss problems and allegations of wrongdoing at the Phoenix VA.


By JENNIFER HLAD | STARS AND STRIPES Published: May 16, 2014

PHOENIX — The veterans who use the Phoenix Veterans Affairs Health System are angry, sick and scared.

They say they call and call, but get no answer.

They say they are ignored, disrespected and turned away by employees with no medical training.

They say they wait months for an appointment with a primary care doctor, then wait several more months to see a specialist.

More than 200 veterans and family members packed into American Legion Post 41 to share horror stories of delays, misdiagnoses and poor treatment with the national commander of the American Legion and the interim director of the Phoenix VA. Steve Young took over after whistleblowers revealed secret waiting lists used to cover up backlogs and extensive wait times. One of the whistleblowers, Dr. Samuel Foote, said there are at least 13,000 patients without primary care doctors, and even more who can’t get timely specialty appointments or follow-ups.

He said 40 veterans died while waiting for appointments in Phoenix VA clinics, and VA wrongdoings have surfaced in at least 10 states.

The Legion’s Daniel Dellinger told the crowd that the VA has “a pattern of unresponsiveness that has infected the entire system.”

People in the room waited their turn, then spoke of broken promises, fear and frustration. Some choked back tears; others spoke harshly of misplaced loyalty, angered that they had proudly served in the military yet weren’t being served by the VA in return.

Turned away

Dennis Morris’ arm was swollen, and he wasn’t feeling well, so he and his wife, Lynn, went to the Phoenix VA’s emergency room. They spent the whole night there, she said, and were sent home with a bag of ice.

The next day, his arm was worse — even more swollen and turning black. They went back to the ER and he was released with another bag of ice, she said.

On the third day, she insisted her husband go to the civilian hospital near their home in Sun City. Dennis was diagnosed with cellulitis and two strains of pneumonia, and he spent several days in the hospital. She said she had to write to Sen. John McCain, R-Ariz., to get the VA to cover the medical bills.

Three years later, when her husband turned 65, she told him there was no longer any reason for him to go to the VA. She signed him up for Medicare, she said, but he still liked the VA.

Late last summer, Dennis, then 66, started feeling bad and began calling the VA to get an appointment with his primary care doctor. After about eight weeks and no appointment, the couple went to the ER at the VA. Dennis was seen immediately, she said, and the doctors did blood tests and took a chest X-ray. They discovered he was extremely anemic and admitted him for six or eight hours to administer iron directly into his blood.

But he didn’t get better. Early the next week he got a call from the VA saying he might have pneumonia. They sent him to a VA clinic closer to home for a second X-ray. He was given antibiotics, but he still felt bad.

Finally, Lynn decided to take her husband back to the civilian hospital. Within 12 hours, he was diagnosed with Stage IV lung cancer, she said. He died 21 days later.

“I’m convinced they never looked at the X-rays,” she said of the VA.

She acknowledges that it might have been too late to save her husband even if the doctors had found the cancer when they went to the VA emergency room in August. But, she said, the couple would have had time to make plans. Instead, he was nearly unconscious by the time he came home from the hospital 15 days after the diagnosis, and he died less than a week later.

“He just totally disintegrated,” she said. “I was not prepared to lose Dennis in five days.”

'He stayed loyal to the military'

Navy veteran Dennis Richardson had struggled with post-traumatic stress and survivor syndrome since he returned from Vietnam, his brother Darrell said.

“But he stayed loyal to the military,” he said, and was proud to get his care at the VA.

Dennis Richardson split his time between Wisconsin and Arizona. When he was diagnosed with liver cancer by a civilian doctor in Wisconsin in late July 2012, he decided to get his treatment from the VA in Arizona.

He hand-carried his medical records and diagnosis to Phoenix, but when he tried to get an appointment with his primary care doctor at the VA so he could be referred to oncology, he was told he would have to wait seven months, his brother said.

“They wouldn’t even look at his records,” Darrell Richardson said. Family members tried calling to get him an appointment, but had no luck.

Richardson waited about three months, until he could no longer stand the pain. At the end of September 2012, he went to the VA emergency room and doctors started him on chemotherapy, but it was too late, his brother said. Dennis Richardson stopped chemo after a few weeks, saying he was simply too sick to handle it. He died Nov. 8, 2012, at the age of 65.

Darrell Richardson said he later found out that the Houston VA has one of the best liver cancer treatment programs in the country. If his brother had gotten a transfer to that program when he first arrived in Phoenix, he said, maybe he could have lived longer.

'You have to be almost dead'

Carolyn Stoor struggled to hold back tears as she recounted the two times she said she almost lost her husband, Ken, in the past year.

“You have to be almost dead for them to do something” at the Phoenix VA clinics, she said.

Ken Stoor served in the Army from 1965 to 1969, and suffers from medical issues including diabetes, heart problems, PTSD and pre-cancerous tumors in his bladder, she said. He has been going to a VA clinic in Phoenix for about three years, even though it is about 65 miles away from their home in Superior, Ariz.

Ken Stoor kept his arm around her shoulders at the meeting, as she talked about how they have struggled to get him help.

In October, she took him to his primary care doctor with low blood pressure and a high fever. The doctor told her to take him home and “pump him full of fluids.”

She said she had already done that, so she took him to a civilian hospital, where doctors diagnosed him with a severe infection.

“They said, ‘We don’t know if he’s going to make it,’” Carolyn said, now crying.

After that, she requested a different primary care doctor for her husband.

“I actually told that last primary doctor what a rotten job she did: ‘Thank you very much but you almost killed him,’” she said. “I should have moved him out of the whole clinic,” she said, but they both really like the physician’s assistant he sees for his heart.

In April, Ken was having severe chest pains and Carolyn took him to the VA. He and six others were waiting for a test when the machine went down, she said.

They left to go to the civilian hospital, where doctors told her Ken was having a heart attack and might not survive.

“I just said, ‘I’m not letting him die on me,’” she said. “I’m not going to lose him over something stupid” like a broken machine.

Forgotten on the 4th floor

Robert Sertich served in the Air Force from 1947 to 1961. He went to the VA hospital in 2011 after being diagnosed with sepsis. His daughter, Kim Sertich, said doctors told her that he might be there for a few weeks.

He was 81, with underlying health issues, but she said he was coherent and could move around when she left him the first night.

By the second night, he was no longer coherent. She said she walked in to find him sitting in the dark, with his oxygen tube pinched under the wheels of his chair.

Doctors had requested an MRI to find the source of the infection, and he was put on a breathing machine in the intensive-care unit for a few days. He never got the test, she said.

When he started having trouble swallowing, the doctors put in a feeding tube.

One night, Robert pulled out the tube in his sleep. Kim gave permission for his hands to be loosely secured when he slept, so he couldn’t pull it out. Then he was moved to a different floor, Kim said, and the problems began adding up.

The MRI was never done, she said, and though a test of his swollen arm had been ordered on the third floor, the staff on the fourth floor never did it. They also refused to secure his hands, she said, and when he pulled the tube out, they wouldn’t put it back in.

Kim tried to feed her father, she said, but he could barely swallow. After a few days, Kim insisted they put the feeding tube back in. She paid for someone to watch her father 24 hours a day so he wouldn’t pull it out.

Her father’s blood tests were improving and he was getting more coherent, Kim said, but his arm continued to swell. When doctors realized it was a blood clot and began giving him blood thinners, “that was pretty much the end,” she said.

Robert Sertich died Nov. 14, 2011, after 33 days in the VA hospital. A week later, the hospital sent a condolence letter for “Richard Sertich.”

They keep coming back

Despite having serious problems with their care, many veterans return to the VA again and again for myriad reasons.

Stoor said her husband continues to go to the VA, where he has appointments and therapy a few times a week and gets many of his medications.

“It’s kind of scary, every time you go,” she said. “But if you don’t go, then you don’t get your benefit.”

Richardson said his brother always “stayed loyal to the military,” he said, and was proud to get his care at the VA, even with a cancer diagnosis, access to the Mayo Clinic and a seven-month wait for a referral.

Lynn Morris said she never really liked the VA, but her husband, Dennis, insisted on going there.

“The waiting room was horrendous,” she said, “and the attitude of the people working there was even worse.”

Still, he had served in the Army and liked his doctors at the VA, she said.

When he turned 65, his wife signed him up for Medicare, she said, but he still went to the VA.

She didn’t understand.

The emergency room was full of people with their heads between their legs because they were in such intense pain, she said. Foote said the average wait time there was frequently 12 to 16 hours.

“I thought it was a horrible mess from Day 1,” she said.

Robert Sertich lived nearly 90 miles from Phoenix, in Payson, Ariz., but going to the VA was “like this badge of honor,” his daughter Kim said.

The hospital floors were filthy, she said, and there were several days when the bathrooms for visitors and the hot water for patient showers didn’t work.

Young, the interim director of the Phoenix VA system, told the crowd he didn’t have answers for the veterans and families. But he stayed at the meeting for hours and took notes.

“I’m just here to listen and understand,” he said. “I don’t have the perfect solution yet.”

Twitter: @jhlad

Diagnosed with liver cancer, Navy veteran Dennis Richardson chose the VA for treatment. After waiting months for a referral, he finally went to the ER in severe pain. He was started on chemotherapy, but died weeks later.

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