It's utterly astounding to think that officials of the U.S. Department of Veterans Affairs in Pittsburgh had such total disregard for the health and welfare of veterans in its care. But it did. And not only must heads roll, criminal charges must be considered.
“Failure” is the byword of a troubling report from the VA's inspector general investigating a deadly outbreak of Legionella bacteria at the Pittsburgh VA Healthcare System's hospitals in Oakland and O'Hara. Five people died and at least 16 others were sickened from February 2011 to November 2012.
The VA failed to test all patients with hospital-acquired pneumonia for Legionella. It failed to routinely or properly flush hot water faucets and showers, a ripe breeding ground for the bacteria. So, too, did it fail to maintain the system designed to kill the bacteria. A communication system that should have red-flagged the problem failed.
That's on top of a Trib investigation that found inadequate water sample sizes, allegations of record falsification, oversight from those with questionable credentials and a failure to learn from history. More than two dozen people died and more than 100 were sickened in a Legionella outbreak more than 30 years ago. It's quite likely that the bacteria never were eradicated from the system.
But just as incredible is the fact that the VA report, despite a detailed road map of culpability, stops short of assigning specific blame. That's not acceptable. For this is not a no-fault matter. Treating it as such only deepens the disregard for our veterans.
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.