The deaths of three recent patients at the Washington DC VA Medical Center are raising questions about whether the medical center thoroughly checks on its patients after discharge.
In each of the deaths, family members reported failures by the VA to follow through on medical issues raised by patients in the days after treatment or consults.
Officials at the medical center acknowledge its failures in handling the three cases, but declined to offer details about the cases. Internal VA records obtained by the News4 I-Team and interviews with families of two of the patients reveal how breakdowns occurred.
In a February case, a Fairfax County, Virginia, veteran sought to be admitted to the hospital, citing drug withdrawal, panic attacks and acute pain. An internal report on the man’s case said the hospital declined to admit the man and scheduled him instead for an outpatient appointment later in the week. The internal report said the man was not a patient of the medical center’s suicide prevention team, therefore they didn’t follow up on him. The report said the man had not received psychiatric care at the DC VA Medical Center since 2014.
According to the report, the man’s wife found him dead of a gunshot wound in their home one week later. Police and fire reports said the shooting was a suicide. According to the internal VA report, the man’s wife “expressed her concern that veteran was not hospitalized” on the day of his visit to the medical center’s emergency room a week earlier.
Through an attorney, the woman declined requests to speak with the I-Team.
Medical Center Director Michael Heimall did not discuss the details of the case.
“That was a veteran who came to us for help, and we failed,” he said. “We failed that veteran and that family. We have to do better."
In a May 2017 case, the I-Team found a patient died of a drug overdose in his car in the medical center parking lot after an appointment at the medical center. According to a police report and interviews with his family, the body of Navy veteran Woodrow Reed went undiscovered in the car for nearly two days after his death.
Reed’s sister, not medical center employees or police, found the body.
“I went looking for him,” Loretta Funderburk said. “I went back to try to see if I could find him.”
She said she found his car in the farthest parking lot from the main entrance.
Funderburk said her family had asked staff to search for her brother when he failed to promptly return home from his appointment. But she said they did not do so thoroughly, so she and a friend went searching.
“I put my hands on him,” Funderburk said. “For those two days it had been real hot. He was hard and hot. It was almost like he had regurgitated.”
Weeks after the death was first reported by the I-Team, a medical center administrator said police would add extra cameras and patrols in the lots to prevent further incidents.
VA staffers, who spoke with I-Team under the condition of anonymity because they are not authorized to speak with media, said the medical center learned just weeks ago about the 2016 death of a patient who had undergone a lung biopsy. The staffers and the victim’s daughter said the man died of blood clots in his lungs after being transported by family to a private hospital in D.C. just hours after undergoing lung biopsy at the DC VA Medical Center.
The 73-year-old man’s death was unknown to medical center officials until spring 2019, when the private hospital’s business office sent a bill to the VA seeking payment.
The man’s daughter said she and her family never received a follow-up call from the medical center after her father’s 2016 procedure, even though at least one relative was listed as an emergency contact.
Heimall, the medical center director, told the I-Team he is familiar with the man’s case, but said details cannot be released by the VA.
A VA spokesperson said, under medical center policies, patients are supposed to receive a follow-up call after undergoing procedures.
“If we did something wrong, we have to disclose it to the family,” Heimall said in describing each of the three cases. “That's one of the strengths of the medical center. (Staffers) do a great job sitting down with patients and families and explaining how we made mistakes.”
The I-Team asked the medical center to describe the procedures undertaken by staff when a patient enters the emergency room with mental health concerns. In a statement, the medical center said, “Veterans who present to the Emergency Department are triaged using the Emergency Severity Index, screened for suicidal ideations, and evaluated by an Emergency Department provider. When there is a clinical indication for a mental health evaluation, a psychiatry consult is obtained. This is available 24 hours a day, seven days a week. Depending upon the results of the evaluation from the Emergency Department provider and Mental Health provider, a care plan could include admission to medicine, admission to psychiatry or discharge from the Emergency Department with a follow up referral.”
Reported by Scott MacFarlane, produced by Rick Yarborough, and shot and edited by Steve Jones.