Referencing data obtained by a Center for Investigative Reporting (CIR) Freedom of Information Act (FOIA) request, the blistering report reveals that the VA spent over $200 million in wrongful death payments to 1,000 families of deceased veterans between 2001-2011.
The median payment per victim was $150,000.
“Veterans died because of long waiting lists and insufficient, inappropriate care,” the report, “Friendly Fire: Death, Delay, and Dismay at the VA,” stated.
It exposes a government-run health care system in which employees were rewarded for deleting records, ignoring criminal behavior and punishing whistleblowers while Congress looked the other way.
Coburn’s year-long investigation of VA hospitals around the nation chronicled the mismanagement, inappropriate conduct and incompetence within the VA that led to “well-documented deaths and delays,” according to Sen. Coburn’s office.
Meanwhile,”the Senate Veterans Affairs Committee largely ignored the warnings about delays and dysfunction at the VA for decades, abdicating its oversight responsibilities and choosing to make new promises to veterans rather than making sure those promises already made were being kept,” the report stated.
The committee “has only held two oversight hearings the last four years,” and was “even profiled in Wastebook 2012 for being among the committees in Congress holding the fewest number of hearings.”
The $200 million in wrongful death payments were just part of the $845 million in settlements the federal government had to pay for VA medical malpractice during the past decade. However, they are “likely not representative of the VA’s shortcomings, because some people may never file a claim,” the report pointed out, going on to describe the “slow and arduous” process of filing a malpractice claim against the VA.
“Families of victims who die under VA care must exhaust a months-long administrative review process before even making a legal claim,” the report explains. “Unlike the private sector, it is difficult to file a claim against the federal government, which likely discourages many qualified victims from ever pursuing a monetary settlement.”
“Additionally, malpractice claims against the federal government are capped at $250,000 – an amount that may not fully compensate victims in cases of real malpractice.”
Dozens of the wrongful deaths of veterans occurred while they were waiting to see a VA doctor.
“No issue has affected more veterans than the long wait times to receive medical care at VA facilities,” the report stated. "At least 82 vets have died or suffered serious injuries as a result of delayed diagnosis or treatment for colonoscopies or endoscopies at VA facilities.”
But even though the VA has extremely long waiting lists, “VA doctors are seeing far fewer patients than private doctors and some even leave work early,” Coburn’s report noted.
And even after veterans finally got in to see a VA doctor, they often did not receive appropriate and timely follow-up care.
“Thousands of medical test orders were 'purged en masse' to erase a 'decade-long backlog',” according to documents obtained by the Washington Examiner.
“About 40,000 appointments were ‘administratively closed’ in Los Angeles, and another 13,000 were cancelled in Dallas in 2012. That means the patients did not receive the tests or treatment that had been ordered, but rather the orders for the follow-up procedures were simply deleted from the agency’s records,” The Examiner reported.
Afterwards, the VA tried to hide what it had done by falsifying records. “For some veterans who died waiting for care, the VA did not disclose anything, and instead tried to bury the information,” the Coburn report stated.
On June 11, the FBI launched a criminal investigation into VA scheduling practices "to determine whether hospital officials ‘knowingly lied about wait times for veterans in order to receive performance bonuses.”
The report also found that the VA punished employees who tried to speak out about the waiting list mismanagement and other misconduct.
Lisa Lee, a whistleblower who sparked investigations into scheduling abuses at the VA clinic in Fort Collins, Colorado, was relocated to the Wyoming VA facility with a pay cut for “refusing to ‘cook the books’ when scheduling veterans’ medical appointments.”
Meanwhile, “nine VA employees accused of cooking the books to cover up the true extent of the backlog for veterans seeking medical care are on paid leave,” investigators discovered.
Calling doctor’s appointment waiting list cover-ups “the tip of the iceberg,” the report discussed the lack of accountability of VA employees: “VA employees fail to show up for work unexcused – termed 'absent without leave' (AWOL) – at a rate exceeding every other federal department and agency,” the report noted, adding that VA employees also sexually abused “at least five female patients,” “sold cocaine to patients receiving treatment for substance abuse problems,” and watched child pornography on government computers.
The Coburn report also reveals that instead of using funds to treat veterans, millions of dollars were spent on employee travel, lavish conferences, and furniture.
For example, two 2011 VA training conferences in Orlando cost a combined $6.1 million. The VA also spent $80 million on employee travel in 2010, and $1.8 million on office furniture in Puerto Rico from 2013-2014, according to the report.
“Veterans who have survived war should no longer have to battle with bureaucracy to access the best possible health care,” Coburn, who is also a physician, concluded. “The foundation of having other people serve depends on how well we take care of those that have.”