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.
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