Families, lawmakers target Pittsburgh VA leaders after critical Legionnaire's report
Outraged families joined lawmakers Tuesday to demand consequences for Pittsburgh VA officials who a new report shows should have done more to prevent a deadly Legionnaires' disease outbreak.
The report released Tuesday by the Veterans Affairs' Office of Inspector General identifies wholesale failures in the Pittsburgh VA Healthcare System to monitor for the disease and the Legionella bacteria that cause it. The disease affected 21 people. Five of them died.
But the 32-page document stops short of assigning blame to specific officials or staff for the outbreak at VA campuses in Oakland (University Drive) and O'Hara (Heinz).
Terry Gerigk Wolf, director and CEO of the Pittsburgh VA Healthcare System, accepted responsibility for the failures in the report during an interview with the Tribune-Review. Wolf said she has not been asked to resign but added that anything could happen.
“Obviously, no one was doing their job,” said Robert Nicklas of Adams, whose 87-year-old father and Navy veteran, William Nicklas, was one of the deaths linked to the outbreak. Robert Nicklas' wife, Judy, added: “It's not the water system at the VA Pittsburgh that needs an overhaul. It's the administration.”
Maureen Ciarolla of Monroeville, whose father, John, 83, also a Navy veteran, was among the five deaths, said people are put on trial and go to jail “for a lot less than what these people did.” She said the new report raises as many questions as it answers.
The Ciarolla and Nicklas families have initiated civil claims against the Pittsburgh VA.
The Legionnaires' outbreak went on from February 2011 to November 2012, when the outbreak became public because the Pittsburgh VA contacted the federal Centers for Disease Control and Prevention. The new report capped a separate investigation by the VA inspector general in Washington that revealed critical communications failures and chronic poor maintenance of an in-house water treatment system meant to prevent the Legionella bacteria, which can cause a deadly form of pneumonia.
Part of the prevention system did not work and was taken out of service in the midst of the outbreak, the reviewers wrote. Pittsburgh VA failed to perform routine flushing of hot water faucets and showers, especially in areas where Legionella might grow. Medical staff also did not ensure adequate testing for Legionella in patients who probably developed pneumonia inside the hospital system, according to the report.
Pittsburgh VA officials said they have begun improving practices to meet and surpass recommendations in the document, announcing what they called “a new era of Legionella control.”
Doctors now look for Legion-ella in every pneumonia patient who might have contracted the disease in the hospital, a toughened standard that officials adopted in November but should have become routine sooner, Dr. Ali Sonel told the Tribune-Review during a briefing Tuesday offered in response to the report.
“In hindsight, yes, there would've been some things we would have done differently,” said Sonel, the Pittsburgh VA's chief of staff. “Can we guarantee that we never have Legionnaires' in any patient? I don't think so.”
Sonel and Wolf, the Pittsburgh VA chief executive, said the Pittsburgh VA now goes beyond national VA standards to sample water for Legionella. Administrators last month announced a $10 million plan to raise water temperatures and better prevent the bacteria in their pipes.
Regional VA Director Michael Moreland, who oversees VA hospitals in Pennsylvania and several other states, said previously he knows of no attempted cover-ups. He was not present Tuesday to answer questions after the report was released.
“We have nothing to hide,” Wolf said during the interview at the H.J. Heinz campus in O'Hara.
Lawmakers told the Trib they weren't satisfied .
“I can't imagine you can have the same people there, with the same culture of bypassing standards, still in charge and expect the system to change,” said U.S. Rep. Tim Murphy, R-Upper St. Clair, one of the lawmakers who sought the inspector general's review.
The inspector general's reviewers pored through documents, interviewed VA workers and conducted on-site visits for their report, which was intended to guide future policy and practices in the national VA system.
Wolf said Pittsburgh VA officials took issue with how some information appears in the report, which cites lapses in documentation about water-system monitoring.
VA plumbers had telephone conversations with a system manufacturer that were not recorded, but that doesn't mean workers failed to address the problem, Wolf said. She said she alerted the CDC herself.
“When I find something wrong, I take action,” Wolf said.
A separate congressional inquiry is under way into the outbreak. David J. Hickton, the U.S. attorney for Western Pennsylvania, promised his office would conduct an independent legal review once the inspector general's office report was out. He declined to discuss the report's findings, spokeswoman Margaret Philbin said.
Staff writers Mike Wereschagin and Lou Kilzer contributed to this report.
Show commenting policy
TribLive commenting policy
You are solely responsible for your comments and by using TribLive.com you agree to our Terms of Service.
We moderate comments. Our goal is to provide substantive commentary for a general readership. By screening submissions, we provide a space where readers can share intelligent and informed commentary that enhances the quality of our news and information.
While most comments will be posted if they are on-topic and not abusive, moderating decisions are subjective. We will make them as carefully and consistently as we can. Because of the volume of reader comments, we cannot review individual moderation decisions with readers.
We value thoughtful comments representing a range of views that make their point quickly and politely. We make an effort to protect discussions from repeated comments either by the same reader or different readers.
We follow the same standards for taste as the daily newspaper. A few things we won't tolerate: personal attacks, obscenity, vulgarity, profanity (including expletives and letters followed by dashes), commercial promotion, impersonations, incoherence, proselytizing and SHOUTING. Don't include URLs to Web sites.
We do not edit comments. They are either approved or deleted. We reserve the right to edit a comment that is quoted or excerpted in an article. In this case, we may fix spelling and punctuation.
We welcome strong opinions and criticism of our work, but we don't want comments to become bogged down with discussions of our policies and we will moderate accordingly.
We appreciate it when readers and people quoted in articles or blog posts point out errors of fact or emphasis and will investigate all assertions. But these suggestions should be sent via e-mail. To avoid distracting other readers, we won't publish comments that suggest a correction. Instead, corrections will be made in a blog post or in an article.
- Comeau’s hat trick leads Penguins; Crosby reaches career points
- Pitt plays best game of the season; routs Kansas State
- Steelers’ backups Archer, Harris ready to run
- Trib kicks off annual effort to help feed families for Christmas
- Fatal crash closes Flight 93 chapel in Somerset County
- Starkey: Rutherford will add when timing’s right
- State officials prompt UPMC, Highmark to go to mediation to resolve Medicare dispute
- Families welcome new members on Adoption Day in Westmoreland County
- Steelers notebook: Roethlisberger says Saints game is ‘must win’
- Pregnant woman struck by van in North Side dies; doctors save baby
- Police on hunt for suspects in unrelated Penn Township, Manor cases