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VA inspectors grill Pittsburgh workers

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Investigating an outbreak

The Legionnaires' disease outbreak at Veterans Affairs hospitals in Pittsburgh spawned at least seven investigations.

• Centers for Disease Control & Prevention — determined the outbreak lasted two years, linked it to five deaths and 16 other illnesses.

• VA Office of Inspector General local report — found widespread lapses in Legionnaires' prevention efforts.

• VA Office of Inspector General national report — found Legionnaires' prevention lapses similar to Pittsburgh's in hospitals around the country.

• VA Office of Inspector General criminal inquiry — ongoing.

• U.S. Attorney, Western District of Pennsylvania investigation — ongoing.

• Congressional investigation — ongoing; hearing scheduled for Sept. 9.

• VA Office of the Medical Inspector — ongoing.


By Adam Smeltz and Mike Wereschagin

Published: Wednesday, Aug. 21, 2013, 12:01 a.m.

Top VA health officials in Washington dispatched medical inspectors to quiz dozens of Pittsburgh VA workers Tuesday over a deadly Legionnaires' outbreak, the latest of seven government investigations into the ordeal.

Officials targeted more than 40 employees for 15-minute interviews at the VA Pittsburgh Healthcare System, a labor union said. The purpose of the inspectors' probe remained uncertain.

The American Federation of Government Employees represents many of the employees in the sessions, said AFGE assistant general counsel J. Ward Morrow.

Morrow described the interviewers as VA medical inspectors and said they largely asked about how staff tried to control the waterborne Legionella bacteria that cause Legionnaires' disease. Documents show VA medical inspectors report to the VA undersecretary for health, Dr. Robert Petzel.

“It seems they've been directed to find out how the abatement process has been working — or not. That's what they're doing, although they're not doing it as widely and as deeply as might be helpful,” Morrow said. “They are talking to a lot of people. Whether they're asking all the questions they possibly could ask — that's not clear.”

Pittsburgh VA spokesman David Cowgill referred an inquiry to the Department of Veterans Affairs in Washington, which did not answer questions about the interviews.

Instead, national VA spokeswoman Gina Jackson wrote via email, “VA shares the community's concerns about the prevalence of Legionella in Western Pennsylvania, and we sincerely apologize to any veterans and families who became ill or who have lost a veteran to this disease.” She said the VA would continue to improve its processes and control the bacteria.

Morrow said those interviewed include electricians, carpenters, mechanics, nurses and housekeeping workers. The sessions will continue through Thursday and could involve up to 80 workers, he said.

The Centers for Disease Control and Prevention found as many as 21 veterans contracted the disease in Pittsburgh VA facilities from February 2011 to November 2012, though a Tribune-Review analysis of VA records found the problem might have been much worse.

Families and individuals have initiated at least five legal claims against the VA stemming from the outbreak. Questioning workers in internal interviews could help VA leadership to prepare for the litigation and the September hearing, independent legal observers said.

“You've got five claims out there and possibly more. It would not necessarily surprise me if the VA has gone out and used an independent consultant to do an investigation and try to coordinate experts' opinions” for the litigation, said W. Robb Graham, a Cherry Hill, N.J., attorney who specializes in VA malpractice cases.

He said the VA could use outside experts to help build a litigation strategy “just because of how screwed up things are.”

The AFGE and attorneys for the victims applauded the internal review.

“I think it's absolutely necessary, and there needs to be accountability,” said Butler-based attorney Bill Schenck, who represents widow Evelyn McChesney of Columbus in Warren County. “The press helps with accountability; the legal system helps with accountability; and the congressional investigations have helped with accountability. But the VA itself should be checking into accountability.”

McChesney's husband, John, is among the fatalities linked to the Legionnaires' outbreak, which the CDC traced to contaminated water at the VA campuses in Oakland and O'Hara. Families of the victims vowed to supply testimony for a Sept. 9 congressional hearing scheduled at the Allegheny County Courthouse, where the House Veterans Affairs Committee will focus on preventable deaths in the VA system.

The VA undersecretary of health began the Office of the Medical Inspector in 1980 to function as the Veterans Health Administration's investigative arm. Its approximately 20 employees are far fewer than the sprawling VA Office of Inspector General, which has offices in more than 20 states and investigates all VA departments.

The inspector general's office started three separate investigations after the Pittsburgh outbreak of Legionnaires' disease, a form of pneumonia. Conclusions from its criminal review in Pittsburgh have yet to be announced.

Medical inspectors, meanwhile, are “responsible for investigating the quality of medical care provided by the VHA (Veterans Health Administration),” according to a 2011 directive from Undersecretary Petzel, the official to whom the inspectors report.

Petzel last month ignored a Tribune-Review reporter's questions about the Pittsburgh outbreak, walking through a hallway and lobby with his eyes facing forward as the reporter walked beside him.

David J. Hickton, the U.S. attorney for Western Pennsylvania, has said his office will look into the outbreak and its handling.

“My prediction is that this is not the end,” Morrow said. “Between now and Sept. 9, I think there's going to be more coming out.”

Adam Smeltz and Mike Wereschagin are staff writers for Trib Total Media. Smeltz can be reached at 412-380-5676 or asmeltz@tribweb.com. Wereschagin can be reached at 412-320-7900 or mwereschagin@tribweb.com.

 

 
 


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