CHARLOTTE, N.C. (Tribune News Service) — A U.S. Army veteran died in a stairwell of a Veterans Administration housing facility and sat there for a month because no one thought to check the stairs — despite them being just down the hall from his room, according to a new report from the Office of Inspector General (OIG) for the Department of Veterans Affairs.

The report, issued Sept. 9, says the remains of 62-year-old Timothy White were found in the emergency exit stairwell by another resident of the VA’s Bedford Veterans Quarters (BVQ) in Bedford, Mass. The discovery was made June 12, 2020, and White was “significantly decayed,” the report said.

“The veteran was wearing the same clothes that he had been reported wearing on May 8, 2020, the last time he was seen prior to his disappearance: a Boston Red Sox jersey, jeans, and a baseball cap,” officials said.

“White had no cellphone, no car on campus, and ‘had never been known to leave the (BVQ) without explanation.’ Yet tragically those who were informed about his disappearance — including BVQ management, and VA police and staff — never searched the emergency exit stairwell ... at any time during the month.”

The investigation was launched to identify “deficiencies in VA’s practices at the facility and ... recommendations aimed at preventing such an incident from reoccurring.”

Among the discoveries: Bureaucracy and “widespread confusion” prevented a full-scale search of the building, due in part to White’s status as a resident rather than an “at-risk patient” or a “missing patient,” officials said.

“The OIG found that VA police would have been required to search the emergency stairwell if Mr. White had been considered an at-risk missing patient under VHA’s directive,” the report said.

Investigators also found VA police officers had been “improperly instructed” to stop patrolling the building a month earlier, and “medical center staff never cleaned the stairwell” due to confusion over who was responsible for the stairs. The building is on the campus of VA’s Edith Nourse Rogers Memorial Veterans Hospital, but is operated under a lease with Caritas Communities Inc., officials said.

“At a basic level, VA failed to ensure that the medical center had a clear understanding of what space belonged to VA and what its maintenance responsibilities were under the lease — even with respect to spaces that affected tenant safety, such as the emergency exit stairwells,” the report said.

White had been living at the facility for about five months when he died, the report said. He had “struggled with homelessness” prior to moving to the site, officials said. A cause of death could not be determined “due to the delay in discovering the body and its resulting state,” officials said.

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