Draft Report: Nearly All Whistleblower Complaints About Manchester VA Were Unfounded

Sep 20, 2018

Credit Peter Biello

Complaints lodged by a dozen whistleblowers last year about the quality of care at the Manchester VA had consequences. At least four VA leaders lost their jobs and the government poured millions of dollars into improvements at the medical center.

But in an internal draft VA report obtained by NHPR, investigators say nearly all of those complaints were unfounded. (Scroll down to read the draft report.)

An infestation of flies canceled surgeries. Blood or rust tarnished surgical tools. Patients suffered at the hands of medical center leaders for whom the budget was paramount. The VA's Office of Medical Inspector did not substantiate these allegations. 

For Dr. Michael Mayo-Smith, former head of the VA New England system, this report is the vindication he’s been waiting for.

“I don’t want it to be my word against someone else’s word or my opinion against someone else’s opinion. Let there be an objective review of these allegations,” he says.

Mayo-Smith was forced to retire earlier this year after whistleblowers alleged he didn’t do enough to help the Manchester VA. He says this review by the OMI, the VA’s designated medical quality inspector, proves that some of the allegations made by whistleblowers were overblown.

Take the flies in the OR, for example.

"Yes, you saw flies in an OR. That makes great headlines, but it happens, believe it or not, in any OR, particularly in 50 or 60 year old buildings."

In the draft report, investigators found VA staff properly closed and cleaned the ORs whenever flies appeared. They also found no blood or rust on surgical instruments, just quote "benign particulate matter" from Manchester's water supply.

And when it comes to the allegation that medical center leaders were not doing their best to solve these problems, VA investigators disagreed.

At the time of the whistleblower complaints, Danielle Ocker was the Manchester VA’s director. She was removed from her position when these allegations became public. She did not respond to a request for comment, but Mayo-Smith says he agrees with the finding of the report - that she was aware of problems at the Manchester VA and answered complaints.

"The issue was that sometimes the people who brought them up weren’t happy with the answers that they got," she says.

The most serious allegations concerned veterans with a spine condition called cervical myelopathy. Whistleblowers said some of these veterans needlessly ended up in wheelchairs because they weren’t treated correctly, but the new OMI report says nearly all of these veterans were treated appropriately.

Dr. Ed Kois, the leader of the Manchester VA whistleblowers, says the VA is missing the point.

“They’re too stupid to realize they should have treated those people,” he says.

Kois says the cervical myelopathy is treatable and the VA should have stopped the disease from progressing.

“If you allow someone to progress to the point where they have a gait disturbance or they’re in a wheelchair, that’s malpractice.”

Overall, Kois says, the VA can’t fairly investigate itself.

The OMI report did find fault with HealthNet, the private company hired by the VA to run the Veterans Choice Program. And it faulted the Manchester VA’s business office with administrative errors.

In a statement, Representative Annie Kuster says she has concerns about this report, saying it’s at odds with the experiences of well-respected doctors. She says she’ll ask the Office of Special Counsel to review the OMI’s procedures.

A spokesman for the VA says the Department generally does not release reports like this one because of the Privacy Act.

This report is one of two “top to bottom” reviews ordered last year by then-VA Secretary David Shulkin. Carol Williams really wants to see the other one, which focuses on senior leadership performance. She was the Head of Nursing and Patient Services at the Manchester VA but was forced into retirement because of the whistleblower allegations.

"If it does say that leadership did something wrong, then I would like to know that. It would help me have some closure."

Because, she says, she still has nightmares about the day her 38-year VA career came to an end over allegations that at least one report says are unsubstantiated.

Read the full draft report here: