Veterans Affairs
5:33 pm
Mon September 9, 2013

Congressional Hearing Scrutinizes Preventable Deaths at VA Hospitals

Members of the House Committee on Veterans’ Affairs were in Pittsburgh Monday morning for a field hearing to examine instances of preventable deaths at VA facilities across the country.

A major focus of the hearing was on the Legionella outbreak at the Pittsburgh VA in 2011 and 2012, which killed at least six veterans and sickened many others.

Bob Nicklas’s father, William Nicklas, was one of those veterans. He died on Nov. 24, 2012, more than two weeks after scientists from the Centers for Disease Control and Prevention arrived to investigate cases of Legionella at the Pittsburgh VA.

“We were left with many questions. Why were we not warned that the CDC was on site? Why wasn’t something done after the first person died, the second, the third, the fourth?” he asked the committee. “Why was the testing not done sooner on my father when they knew there was a Legionella problem?”

Mauren Ciarolla, daughter of John J. Ciarolla, expressed similar concerns. Her father was the first veteran to die of Legionnaires' disease at the Pittsburgh VA, on July 18, 2011.

She called the outbreak of Legionella at the facility “predictable.”

Until 2006, the Pittsburgh VA housed the premier Legionella research facility in the world, the Special Pathogens Laboratory.

“An administrative decision was made to close this research department and destroy decades of research in the process,” Ciarolla said. “This decision was deemed so bizarre and irresponsible, that Congress had a hearing over that matter.”

Nicklas and Ciarolla were outraged that Michael Moreland, Network Director for the VA, received a Presidential Distinguished Rank Award earlier this year.

Members of the House Committee were equally dismayed that Moreland was eligible for the award and for the $63,000 in bonuses he received.

“It is absolutely unconscionable that we would award bonuses to anybody who had a preventable death occur on their watch,” said committee chairman Jeff Miller (R-FL).

Rep. Tim Murphy (R-PA) then challenged Dr. Robert Petzel, undersecretary for health at the Veterans Health Administration, about whether he still thought Moreland deserved such an award.

“If you knew then what you know now, would you recommend him for this award?” Murphy asked.

“I would,” Petzel replied.

Murphy pressed him further, “Even though people died, even though he did not follow VA guidelines, even though he did not follow CDC guidelines?”

“Mr. Moreland’s Presidential Rank Award is based upon a lifetime of service to America’s veterans, congressman,” Petzel said.

Whistleblowers and family members of deceased veterans also testified about incompetency and mismanagement at VA hospitals in Atlanta; Dallas; Buffalo, N.Y.; and Jackson, Miss.

Brandie Pettit tearfully recounted the story of her brother Joseph Pettit’s suicide at a VA facility in Atlanta. She said that he originally visited the VA in 1991 due to knee problems from parachute landing falls, but that he did not receive any help or treatment for almost two decades.

“He was very happy to have them look at his knees after all that time. He was in a great deal of pain,” Pettit testified. “The VA saw Joseph and said the problem was in his head and sent him home with meds for his head, not his knees. They said if he took those meds and did specific exercises, his knees would quit hurting.”

Pettit said the VA prescribed more than 20 pills a day to her brother, who quickly spiraled into depression and anxiety, and began suffering from hallucinations and suicidal thoughts.

“He went to the VA on Nov. 8, hearing voices, hallucinating and asking for help,” said Pettit, fighting back tears. “He did not commit suicide because he felt sorry for himself. He committed suicide to protect others from his hallucinations.”

Committee chairman Jeff Miller closed the hearing by assuring the families and the many veterans present that the committee would work to put an end to preventable deaths in VA facilities across the country.