    Inspectors General: Veterans Affairs Special Inquiry Report Was
    Misleading (Letter Report, 05/13/1998, GAO/OSI-98-9).

    An unexplained increase in patient deaths occurred in one ward of the
    Harry S. Truman Memorial Veterans Hospital in Columbia, Missouri, during
    the spring and summer of 1992. In October 1992, the Office of Inspector
    General (OIG) at the Department of Veterans Affairs (VA) and the FBI
    began a joint investigation into the suspicious deaths; in February,
    they received information alleging a coverup by the hospital director
    and the VA Central Region Chief of Staff. GAO reviewed the special
    inquiry conducted by the OIG, focusing on how VA's OIG planned,
    conducted, and reported its inquiry. In its report, the OIG concluded
    that management's actions could be attributed to bad judgment but found
    no conclusive proof of an intentional cover-up and no evidence of
    criminal conduct by top managers. GAO believes that the conclusion that
    no evidence of an intentional cover-up had been found was misleading
    because the OIG did not collect or analyze evidence in a manner that
    would identify intentional cover-up efforts. GAO summarized this report
    in testimony before Congress; see: Inspectors General: Veterans Affairs
    Special Inquiry Report Was Misleading, by Eljay B. Bowron, Assistant
    Comptroller General for Special Investigations, before the Subcommittee
    on Oversight and Investigations, House Committee on Veterans' Affairs.
    GAO/T-OSI-98-12, May 14 (14 pages).

    --------------------------- Indexing Terms -----------------------------

     REPORTNUM:  OSI-98-9
         TITLE:  Inspectors General: Veterans Affairs Special Inquiry
    	     Report Was Misleading
          DATE:  05/13/1998
       SUBJECT:  Investigations by federal agencies
    	     Physicians
    	     Veterans hospitals
    	     Inspectors general
    	     Whistleblowers
    	     Ethical conduct
    	     Health services administration
    	     Law enforcement
    	     Confidential communication
    	     Homicide

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    GAO/OSI-98-9

    Cover
    ================================================================ COVER

    Report to the Chairman, Subcommittee on Oversight and Investigations,
    Committee on Veterans' Affairs, House of Representatives

    May 1998

    INSPECTORS GENERAL - VETERANS
    AFFAIRS SPECIAL INQUIRY REPORT WAS
    MISLEADING

    GAO/OSI-98-9

    VA OIG's Misleading Special Inquiry Report

    (600441)

    Abbreviations
    =============================================================== ABBREV

      FBI - Federal Bureau of Investigation
      GAO - U.S.  General Accounting Office
      IG - Inspector General
      OIG - Office of Inspector General
      OSI - Office of Special Investigations
      TQI - Total Quality Improvement
      VA - Department of Veterans Affairs

    Letter
    =============================================================== LETTER

    B-279646

    May 13, 1998

    The Honorable Terry Everett, Chairman
    Subcommittee on Oversight and Investigations
    Committee on Veterans' Affairs
    House of Representatives

    Dear Mr.  Chairman:

    This letter responds to your request that we review the Special
    Inquiry conducted by the Department of Veterans Affairs (VA) Office
    of Inspector General (OIG) and its resulting report, entitled Special
    Inquiry:  Alleged Cover-up of an Unexplained Increase in Deaths,
    Harry S.  Truman Memorial VA Medical Center, Columbia, Missouri.
    Specifically, you asked that we determine (1) whether the Special
    Inquiry report represents the results of the OIG's review, (2)
    whether the OIG complied with its policies in conducting the Special
    Inquiry, (3) why a delay occurred between receipt of the cover-up
    allegations in February 1993 and the beginning of the Special Inquiry
    in January 1995, (4) whether the OIG protected the confidentiality of
    the staff physician who made the allegations of a cover-up, and (5)
    if OIG processes and procedures are adequate for ensuring
    confidentiality requested by individuals.

       BACKGROUND
    ------------------------------------------------------------ Letter :1

    An unexplained increase in patient deaths occurred in one ward at the
    Harry S Truman Memorial Veterans Hospital (hereinafter referred to as
    Hospital) in Columbia, Missouri, during the spring and summer of
    1992.  In October 1992, based on information provided by a Missouri
    state legislator, the Federal Bureau of Investigation (FBI) and the
    VA OIG initiated a joint criminal investigation into the suspicious
    deaths.\1 In February 1993, the OIG received specific allegations
    that the Hospital Director\2 and the VA Central Region Chief of
    Staff\3 had attempted to cover up the unexplained increase in patient
    deaths, including by not referring the matter to law enforcement
    authorities.

    In January 1995, the OIG initiated an administrative investigation
    (known as a Special Inquiry),\4 which focused on management's
    response to the patient deaths.  Subsequent to the start of the
    Special Inquiry, the VA OIG received a series of additional letters
    from the complainant alleging that the cover-up (1) involved not only
    Hospital and VA management but the VA OIG as well and (2) had
    continued even after the October 1992 start of the joint FBI and VA
    OIG investigation.  The OIG issued the Special Inquiry report in
    September 1995.  In its report, the OIG analyzed and criticized
    Hospital and VA management's response to the increase in deaths and
    noted that it had "found a dysfunctional top management team [in the
    Hospital] .  .  .  in place." The OIG reported that while the
    evidence might indicate to some individuals that at least the
    appearance of a cover-up existed, management's actions could be
    attributed instead to bad judgment.  The OIG further reported that it
    had found no conclusive proof of an intentional cover-up by Hospital
    and Central Region officials and no evidence of criminal conduct by
    top managers.  As to its own role, the OIG stated that it had made
    mistakes but avowed that it had not participated in a cover-up.  (A
    more extensive background is provided in app.  I.)

    --------------------
    \1 In October 1992, the FBI and the VA OIG initiated a joint
    investigation into a possible crime on a government reservation.
    They soon learned, however, that the Truman Memorial Veterans
    Hospital is one of the approximately 20 "proprietary" VA hospitals
    and is not a federal reservation.  The FBI and the OIG then began a
    civil rights investigation immediately after the Department of
    Justice determined that they could properly investigate the matter as
    a civil rights case.  The focus of the investigation--to determine
    whether a crime (homicide) had occurred at the Hospital and, if so,
    who was responsible--never changed.

    The FBI made a February 2, 1998, report to the Congress on its
    investigative results regarding the 1992 suspicious deaths at the
    Hospital.  The FBI concluded that, after extensive investigation, the
    federal statute of limitations had expired without a determination
    that a crime had, in fact, been committed.

    \2 The Hospital Director retired in June 1994.

    \3 The Central Region Chief of Staff resigned in September 1994.

    \4 The OIG opened a Special Inquiry after the complainant notified
    the media of allegations of a cover-up and an additional allegation.

       RESULTS IN BRIEF
    ------------------------------------------------------------ Letter :2

    The VA OIG conducted the Special Inquiry as a management review to
    determine how Hospital and VA Central Region management had responded
    to "an 'out of norm' situation" regarding unexplained deaths at the
    Hospital.  We determined that the OIG did not collect or analyze
    evidence in a manner that would identify intentional cover-up
    efforts.  Thus, the Special Inquiry's conclusion that no evidence of
    an intentional cover-up had been found was not consistent with the
    inquiry conducted and was misleading.

    Concerning the additional questions raised in your request, we
    determined the following:

      -- The OIG failed to comply with its own reporting policies
         concerning completeness and accuracy by presenting statements
         that were not supported by the evidence contained in OIG files,
         including reference to a discussion that the Special Inquiry
         never verified.

      -- The OIG attributed the delay in acting upon the cover-up
         allegations received in February 1993 to administrative error.

      -- The confidentiality of the staff physician who had made the
         allegations of a cover-up was breached on at least three
         occasions.

      -- The OIG's current policies and procedures on confidentiality are
         adequate.

       VA OIG'S CONCLUSION REGARDING
       ALLEGED COVER-UP IS MISLEADING
    ------------------------------------------------------------ Letter :3

    The title and text of the Special Inquiry report suggest that
    allegations of a cover-up had been investigated.  We determined that
    the OIG did not plan or conduct its review or analysis in a way that
    could determine if a cover-up had occurred.  Had the OIG conducted
    such a review, its documentation would have included an effort to
    link individual pieces of evidence that together suggest additional
    lines of inquiry--including elements of a cover-up.  Further, both
    the Assistant IG\5 and the analyst\6 responsible for the Special
    Inquiry told us that the OIG did not review or investigate the
    allegations of cover-up.  The Assistant IG told us that the Special
    Inquiry report overstates its conclusion regarding no evidence of a
    cover-up.  Therefore, the Special Inquiry's conclusion was not
    supported by work done or evidence collected and is misleading.

    --------------------
    \5 The Assistant IG retired in July 1997.

    \6 The lead analyst responsible for conducting the Special Inquiry
    retired in July 1995 after completing the field work and writing the
    draft report.

          MISREPRESENTATION OF FACTS
          AND MISLEADING REPORT
          LANGUAGE
    ---------------------------------------------------------- Letter :3.1

    In the Special Inquiry report, the OIG represents that its review
    included the allegation of a cover-up on the part of the Hospital
    Director and the Central Region Chief of Staff.  However, according
    to the lead analyst who conducted the review and the Assistant IG who
    wrote the final report, the issue of cover-up was "off the table"
    because, in their view, their "charge" from OIG management did not
    include looking at cover-up allegations.  They defined cover-up as
    being related to criminal issues and added that neither of them was a
    criminal investigator.

    Prior to his retirement, the lead analyst responsible for the Special
    Inquiry completed the interviews and field work and wrote a draft
    report entitled Special Inquiry:  Management Response to Unexplained
    Patient Deaths, Harry S.  Truman VA Medical Center, Columbia,
    Missouri.  The body of that draft report made no reference to
    allegations of a cover-up by the Hospital Director and Central Region
    Chief of Staff.  In the draft report, only one issue was
    addressed--whether management officials complied with VA policy when
    responding to the revelation of the unexplained deaths.

    According to the Assistant IG who prepared the final report, he did
    not review the underlying evidence while preparing the final report,
    nor did he reconcile the stated facts in the report with the
    underlying evidence prior to issuing the report.  He stated that in
    writing the final Special Inquiry report, he changed the original
    title and edited the report in an attempt to tie the text to the
    complainant's allegations.  He characterized this as wordsmithing and
    added that he had no intent to mislead.  He concluded that in
    hindsight he probably should not have changed the title and that the
    report probably overstated its case concerning no evidence of a
    cover-up, as the OIG did not investigate the cover-up allegations.

    Although the Assistant IG stated that there was no intent to mislead,
    the report title--Special Inquiry:  Alleged Cover-up of an
    Unexplained Increase in Deaths, Harry S.  Truman Memorial VA Medical
    Center, Columbia, Missouri--and two of the report's three major
    sections--"Alleged Cover-up by Medical Center and Central Region
    Officials Subsequent to the Criminal Investigation" and "Alleged
    Cover-up by the Office of Inspector General"--specifically refer to
    the cover-up allegations.  Further, the OIG reported that it had
    found "no conclusive proof of an intentional cover-up by Medical
    Center and Central Region officials" and "no evidence of criminal
    conduct by top management." This language is misleading, because the
    OIG did not conduct its Special Inquiry so as to support its
    conclusion concerning an intentional cover-up.  Instead, it addressed
    whether management had complied with VA and Hospital policy and
    procedures in its response to the increase in deaths.

    The then IG\7 told us that he had intended for the Special Inquiry to
    investigate allegations of a cover-up and that, based on his reading
    of the report, it appeared that it had.  He added that if the review
    did not include an investigation of the cover-up allegations, he
    believes that the report, as written, is misleading.

    --------------------
    \7 The Inspector General retired in January 1996.

          REVIEW PLANNED AND EXECUTED
          FROM A MANAGEMENT
          PERSPECTIVE
    ---------------------------------------------------------- Letter :3.2

    We determined that the OIG did not plan or conduct its Special
    Inquiry in a manner to determine if improper acts pertaining to a
    cover-up had occurred.  According to the Assistant IG, in preparing
    the report, he examined components of the complainant's allegation
    separately, rather than linking or relating the information gathered.
    He added that had the inquiry included investigation of a crime, it
    would have been appropriate to show whether a pattern of conduct
    existed.  One method of establishing such a pattern, as is required
    by the OIG's Investigative Policy and Procedure Guide for special
    inquiries, is to create a chronology of events and actions.  The OIG
    did not do this.

    Frequently a single act, taken by itself, is not sufficient to
    establish that the act was done willfully and intentionally with
    improper purpose.  However, a series of acts considered collectively
    may suggest a pattern of conduct indicative of intentional
    impropriety rather than accident or error.  For example, the
    following actions or alleged actions concerning the Hospital Director
    were not linked or followed up on by the OIG.  If the OIG had done
    so, the linkage would have suggested a pattern of conduct requiring
    additional investigation and lines of inquiry by the OIG.

      -- The Hospital Director did not notify law enforcement authorities
         of the unexplained deaths despite the District Counsel's
         recommendation that he do so.

      -- The Hospital Director did not notify law enforcement authorities
         of a statistical relationship between a nurse and the
         unexplained deaths despite telling the staff physician who had
         developed the analysis that he would do so.

      -- The Hospital Director, after learning that a staff physician had
         accused the nurse in question of killing his patients, did not
         refer the matter to the OIG.

      -- The Hospital Director demoted the Hospital's Chief of Police
         reportedly because of the Chief's efforts to obtain information
         about the Hospital's response to the unexplained deaths.

      -- The Hospital Director did not provide the Peer Review Board
         examining the unexplained deaths with the statistical analysis
         that established a relationship between a nurse and the deaths.

      -- The Hospital Director's initial reaction to the FBI
         investigation was to attempt to obtain confidential information
         provided to the FBI, potentially to identify the source of that
         information.

      -- The Hospital Director, in an apparent attempt to impede an
         investigation, instructed the staff physician who prepared the
         statistical analysis to have no further contact with the FBI.

      -- The Hospital Director's son--the Chief of Human Resources at the
         Hospital--instructed the TQI Coordinator to determine from the
         FBI and the OIG whether they had had recent contact with the
         complainant.

    Our review of the OIG case files, interviews with individuals
    involved with the Special Inquiry, and statements from knowledgeable
    Hospital employees reflected that potential lines of inquiry were not
    pursued.  For example, in the incident of a conference call between
    the VA Central Region Chief of Staff, the Hospital Director, the
    Hospital pathologist, and the TQI Coordinator, it was alleged that
    the Central Region Chief of Staff, in response to the issue of
    notifying law enforcement, stated that the last time law enforcement
    authorities had been called in, both the Chief of Staff and the
    Hospital Director were fired.  The Special Inquiry analysts
    interviewed the pathologist and the TQI Coordinator.  One individual
    recalled the statement being made; the other did not.  However, the
    analysts never interviewed the Hospital Director or the Central
    Region Chief of Staff about this issue.  Because of this, it was
    never verified that the conversation had taken place as alleged; and
    the OIG never attempted to resolve the conflicting testimony by
    questioning the person who had allegedly made the statement or the
    person to whom the statement had allegedly been made.

    Based on our review of relevant memorandums and tape recordings of
    interviews, we determined that the analysts questioned the Hospital
    Director and the Central Region Chief of Staff about compliance with
    VA policies.  The analysts told us they accepted "I don't know"
    answers instead of asking follow-up questions.  For example, the
    analysts accepted, without probing further, the Hospital Director's
    response that he did not recall the District Counsel's advice in
    August 1992 that he notify the FBI or OIG about the unexplained
    deaths.  In another instance, the Hospital Director responded to the
    analysts that he could not recall the actions he had taken to monitor
    Hospital management's investigation of the deaths.  At a minimum, the
    analysts should have provided the Hospital Director available
    information to refresh his recollection.

       OIG NONCOMPLIANCE WITH
       POLICIES, REPORT INACCURACIES,
       AND UNSUPPORTED STATEMENTS
    ------------------------------------------------------------ Letter :4

    In conducting the Special Inquiry, the OIG failed to follow its own
    policies concerning completeness and accuracy of its reports.\8 As a
    result, the OIG's Special Inquiry report contained statements that
    were either inconsistent with or unsupported by the evidence
    contained in the OIG's files.  We noted inaccuracies in the way the
    OIG (1) reported the Hospital Director's failure to notify law
    enforcement\9 of the possible association of a particular nurse to an
    unexplained increase in deaths, (2) attributed remarks to the
    Hospital Director and the Central Region Chief of Staff about
    withholding statistical analysis information from a Peer Review
    Board, and (3) assessed the Hospital Director's instructions to the
    complainant that he refrain from making further contacts with the FBI
    and the OIG about the case.

    --------------------
    \8 The Quality Standards for Investigations established by the
    President's Council on Integrity and Efficiency are guidelines
    applicable to all types of federal investigative efforts.  The VA OIG
    has adopted these standards and has incorporated them into the
    standards in its policy and procedure guide.  VA OIG reporting policy
    states, in part, "Reports must cover all relevant aspects of the
    investigation (complete); [and] correctly and succinctly describe the
    facts uncovered and evidence obtained (accurate) .  .  .  ."

    \9 The Hospital Director never reported the suspicious deaths to the
    FBI or any other law enforcement organization.

          FAILURE TO INFORM LAW
          ENFORCEMENT
    ---------------------------------------------------------- Letter :4.1

    The Special Inquiry report stated that the Hospital Director had
    asked the Central Region Chief of Staff for his opinion on whether to
    report to authorities the unexplained deaths and the possible
    relationship of a particular nurse to the deaths.  According to the
    report, the Central Region Chief of Staff responded that he "thought
    the situation warranted far more review before [the Hospital
    Director] either relieved [the nurse] of patient care duties or
    notified law enforcement authorities [and he] advised the Hospital
    Director not to notify law enforcement authorities until the reviews
    were completed." The OIG report concluded that "[the Hospital
    Director] followed the advice of the Central Region Chief of Staff
    and did not report the issue to law enforcement."

    As written, the report leads one to believe that the Hospital
    Director followed the advice of the Central Region Chief of Staff not
    to report the situation to law enforcement authorities.  However, we
    found insufficient documentation to support the OIG report's
    conclusion that the Central Region Chief of Staff had told the
    Hospital Director not to report the issue to law enforcement
    authorities.  Our review of memorandums of interview and transcripts
    of recorded interviews found inconclusive evidence that the Central
    Region Chief of Staff and the Hospital Director discussed whether to
    report the issue.\10 Further, when asked to do so, the OIG was unable
    to cite the evidence supporting its conclusion.

    --------------------
    \10 A telephone interview of the Central Region Chief of Staff's
    remarks is documented in a memorandum.  The Hospital Director's
    interview was recorded and a memorandum of interview was also
    prepared.

          MISINFORMATION ABOUT
          WITHHOLDING THE
          COMPLAINANT'S STATISTICAL
          ANALYSIS
    ---------------------------------------------------------- Letter :4.2

    On September 3, 1992, a Hospital Peer Review Board was convened to
    evaluate five August deaths on Ward 4 East at the Hospital; but the
    Board was not provided with a staff physician's statistical analysis
    that had reported a statistical relationship between the increase in
    deaths and a particular nurse.  The Special Inquiry report concludes
    that "The Peer Review Board was not a 'sham' as alleged by the
    complainant, but was limited in scope and did not consider the
    statistics developed by [the staff physician]." According to the
    report, the Central Region Chief of Staff and the Hospital Director
    stated that they had withheld the statistical analysis from the Board
    members to allow them to take an objective look at the cases.

    However, documentation shows that the Central Region Chief of Staff
    told the OIG that he had never issued instructions to deny the Peer
    Review Board access to the data.  According to the memorandum of
    interview prepared by the OIG, the Hospital Director told the OIG
    that he recalled no one asking him whether the Peer Review Board
    could look at the statistical data and that it did not occur to him
    to let the Board members have the data.

          LIMITATIONS ON COMPLAINANT'S
          COMMUNICATIONS WITH LAW
          ENFORCEMENT
    ---------------------------------------------------------- Letter :4.3

    In a March 1994 letter, the Hospital Director instructed the
    complainant, "You should .  .  .  refrain from further contacts with
    the FBI and OIG about this case.  If you are contacted directly by
    either the FBI or OIG you should inform me of the content of your
    discussion." Noting that the Director had improperly attempted to
    limit the complainant's communications with the OIG and the FBI in
    March 1994, the Special Inquiry report stated that nothing requires
    an employee to provide information to a supervisor regarding
    discussions with the FBI or the OIG.  The report also noted that

         "By making such a requirement, management is in effect stifling
         an employee's ability to discuss matters openly and freely with
         the investigators.  The Director's action can be viewed as an
         effort to impede an official investigation by intimidating
         employees, and is clearly improper.  However, from a practical
         standpoint, [the Hospital Director's] action to the best of our
         knowledge did not limit the OIG or the FBI in obtaining
         appropriate information from [the complainant] or other
         [Hospital] employees." (Emphasis added.)

    We found no documentation to support the Special Inquiry report's
    conclusion that the Hospital Director's action did not limit the OIG
    or the FBI in obtaining information from the complainant or other
    Hospital employees.  Except for an OIG memorandum of interview with
    the Hospital Director, we found no evidence of an investigative
    effort in support of the report's conclusion.  At a minimum, one
    would expect to find documentation that the OIG had talked to the
    complainant and the cognizant FBI and OIG criminal investigators
    before arriving at such a conclusion.

       CIRCUMSTANCES SURROUNDING
       SPECIAL INQUIRY'S 2-YEAR DELAY
    ------------------------------------------------------------ Letter :5

    The OIG received the complainant's allegations of a cover-up of
    patient deaths in February 1993, immediately acknowledged its
    receipt, provided a copy of the letter to the FBI in March 1993, and
    filed the complainant's letter without investigating the allegations.
    The OIG did not begin its inquiry until after the complainant
    discussed the allegations with the media in January 1995.\11 The
    OIG's Special Inquiry report issued in September 1995, attributed the
    delay to administrative error.

    --------------------
    \11 On January 10, 1995, a newspaper article identified the
    complainant as the source of cover-up allegations and an additional
    allegation.

          COMPLAINANT'S ALLEGATION
          LETTER FILED WITHOUT
          INVESTIGATION
    ---------------------------------------------------------- Letter :5.1

    In February 1993, when the OIG received the complainant's allegations
    of a cover-up of patient deaths, it referred the allegations to its
    Office of Investigations.  The OIG investigator told us that he had
    contacted the complainant to acknowledge receipt of the allegations
    and had advised him that all his assets were being expended on other
    matters.  Further, he told us that in addition to a murder
    investigation, he was investigating a death threat and a sexual
    assault.  Although the OIG criminal investigator and the Assistant IG
    for Investigations did not recall if they had sent a copy of the
    allegation letter to the FBI, we learned that a copy of the letter
    containing the allegations had been provided to the FBI in March
    1993.  The original letter was filed in the OIG's field office in
    Kansas City, Missouri; and no follow-up action was initiated.

    The Assistant IG for Investigations told us that when his office
    received the complainant's letter in February 1993, the criminal
    investigation with the FBI was ongoing and all resources were being
    devoted to that investigation.  He said that it was a "collective
    decision" on the part of the Office of Investigations that no further
    investigation was necessary.  Further, according to the Assistant IG,
    the FBI and OIG criminal investigation had not disclosed any evidence
    that VA officials were involved in a cover-up, and the complainant's
    letter contained no new information.  He stated that the OIG's
    failure to follow up on the allegations was a failure of its process.

    The former IG told us that he was upset in January 1995 when he
    became aware, as a result of media inquiries, that the complainant's
    allegations had not yet been investigated.  He further stated that
    when the OIG received the allegations in February 1993, the most
    important thing in his mind was the unexplained deaths.

          FBI PERCEIVED ALLEGATIONS TO
          BE ADMINISTRATIVE
    ---------------------------------------------------------- Letter :5.2

    In response to our inquiries, the FBI told us that because the
    complainant's February 1993 letter primarily concerned "the issue of
    the administrative response" of VA managers, the allegations were not
    within the investigative jurisdiction of the FBI.  Also, because the
    FBI found no evidence of criminal activity in connection with the
    unexplained deaths, the FBI criminal investigation did not inquire
    into the allegations of a cover-up on the part of VA management.
    Further, according to the FBI, had the FBI investigation developed
    evidence of criminal activity at the VA, it would have explored the
    potential culpability of any person--whether management, employee, or
    staff--before, during, and after the deaths, to include deliberate
    attempts to cover up.

          OIG ATTRIBUTED DELAY TO
          ADMINISTRATIVE ERROR
    ---------------------------------------------------------- Letter :5.3

    The Special Inquiry report stated that, due to administrative error,
    the OIG had waited too long to initiate the Special Inquiry.  During
    the interval (February 1993 to January 1995), the Hospital Director
    retired and the Central Region Chief of Staff resigned from the VA.

       VA OIG FAILED TO PROTECT
       COMPLAINANT'S CONFIDENTIALITY
    ------------------------------------------------------------ Letter :6

    When the complainant sent his February 1993 letter to the OIG
    alleging cover-up by the Hospital Director and the Central Region
    Chief of Staff, he requested confidentiality.\12 The Special Inquiry
    review looked at whether the OIG protected the complainant's right to
    confidentiality.  In the Special Inquiry report, two instances were
    discussed in which the OIG had disclosed its contacts with the
    complainant to the Central Region and, ultimately, to the Hospital
    Director.  The OIG report concluded that the OIG should have been
    more careful in protecting the complainant's confidentiality, and it
    attributed one of the confidentiality disclosures to an "error" and
    the other to an "honest mistake." We found a third instance in which
    the complainant's contact with the OIG was provided to Hospital
    management.  All three disclosures were related to the March 1994
    Hospital Director's letter to the complainant advising him not to
    have contact with the FBI or OIG.

    --------------------
    \12 Section 7(b) of the Inspector General Act of 1978, 5 U.S.C.  App.
    3, provides that "The Inspector General shall not, after receipt of a
    complaint or information from an employee, disclose the identity of
    the employee without the consent of the employee, unless the
    Inspector General determines such disclosure is unavoidable during
    the course of the investigation."

          OIG OFFICE OF INVESTIGATIONS
          GAVE COMPLAINANT'S DOCUMENTS
          TO DISTRICT COUNSEL
    ---------------------------------------------------------- Letter :6.1

    In March 1994, the OIG Office of Investigations received documents
    from the FBI that had been prepared by the complainant.  In turn, the
    Office of Investigations passed the information to the District
    Counsel,\13 who forwarded it to the Central Region and the Hospital
    Director.  The complainant alleged that the ultimate disclosure to
    the Central Region indicates that the OIG was participating with the
    Central Region to suppress an inquiry of a cover-up.  The Special
    Inquiry report, however, characterized what happened as an error,
    stating that the OIG had provided the documents to the Office of the
    District Counsel, which represents both the Hospital and the Central
    Region, without any restrictions on their dissemination.

    --------------------
    \13 The OIG investigator perceived the information received from the
    FBI as dealing with quality assurance issues and forwarded the
    materials to the District Counsel in the mistaken belief that the
    Counsel had responsibility for quality assurance issues.

          OIG OFFICE OF HEALTHCARE
          INSPECTIONS RELEASED
          INFORMATION TO VA CENTRAL
          REGION
    ---------------------------------------------------------- Letter :6.2

    The complainant alleged that in March 1994, the Assistant IG for
    Healthcare Inspections\14 gave Central Region officials a report of
    contact with the complainant as part of an OIG effort to suppress
    information about actions by Hospital and Central Region officials.
    The Special Inquiry report stated that (1) in this instance the OIG
    had an obligation not to release the complainant's identity to other
    VA officials without the complainant's consent and (2) controls to
    prevent such release were not properly applied.

    --------------------
    \14 The Assistant IG for Healthcare Inspections retired in June 1996.

          OIG OFFICE OF HEALTHCARE
          INSPECTIONS RELEASED
          INFORMATION TO HOSPITAL
          MANAGEMENT
    ---------------------------------------------------------- Letter :6.3

    The Hospital Total Quality Improvement (TQI) Coordinator told us that
    on January 11, 1995, prior to the Special Inquiry, the Assistant IG
    for Healthcare Inspections telephoned her and requested information
    concerning the Hospital's original response to the unexplained deaths
    on Ward 4 East.  During the conversation, the TQI Coordinator asked
    about OIG plans to investigate the complainant's
    obstruction-of-justice allegation.  The Assistant IG acknowledged
    recent contact with the complainant and stated that the OIG had no
    plans to investigate the allegations unless it was forced to do so.
    The Special Inquiry did not identify this incident, which involved
    the same Assistant IG who had released the complainant's name once
    before to the Central Region.

    On the same day of this incident, the TQI Coordinator, at the request
    of the Hospital Chief of Human Resources and the Associate Director,
    contacted the FBI and the Kansas City OIG to determine if they had
    recently been in contact with the complainant.  The FBI referred her
    to the Kansas City OIG.  In contrast with the Assistant IG's
    previously discussed answer acknowledging contact with the
    complainant, the Kansas City OIG advised that it would have to
    consult with OIG Counsel prior to any discussions concerning the
    complainant.  The Kansas City OIG later contacted the TQI Coordinator
    and stated that OIG Counsel had advised that it could not respond to
    the Hospital's inquiry.

    The Hospital Chief of Human Resources\15 told us he was not sure why
    he and the Associate Director had the TQI Coordinator make the
    inquiries concerning contact with the complainant but thought it
    concerned a March 9, 1994, letter from the Hospital Director advising
    the complainant not to have any contact with the FBI or the OIG.

    --------------------
    \15 The Chief of Human Resources at the Hospital is the son of the
    Hospital Director, one of the subjects of the allegations.  The son
    was selected for the position in July 1994.

          REVISED POLICIES AND
          PROCEDURES
    ---------------------------------------------------------- Letter :6.4

    Our review of the August 1995 revision of the OIG Policy and
    Procedure Guide, Part I, Chapter 12 - Hotline, indicates that the
    OIG's policies and procedures concerning Protection of Complainants
    (Section 5) mirror accepted standard hotline policies and procedures
    in federal agencies.  Consistent adherence to and ongoing awareness
    of these policies by OIG personnel should result in effective
    protection of complainants.

       OIG COMMENTS AND OUR EVALUATION
    ------------------------------------------------------------ Letter :7

    The Department of Veterans Affairs' Office of Inspector General
    provided written comments on a draft of this report.  The IG
    disagreed with our report, stating that the OIG had found a number of
    errors in the findings and conclusions presented in the report and in
    the analyses offered to support the conclusions.  The IG is of the
    opinion that there is no evidence to support our overall conclusion
    that the OIG Special Inquiry report was misleading.

    Mainly, the IG disagrees with (1) our statement that the OIG did not
    investigate the cover-up allegation, (2) one of the three statements
    in the Special Inquiry report--an OIG conclusion--that we cite in our
    report as being inaccurate and unsupported by evidence, and (3) the
    inclusion in our report of a finding--based on an alleged violation
    of confidentiality--that "lacks credibility." Concerning the first
    point, regardless of how the OIG characterizes its work, its review
    was not planned or executed in a manner that would support its
    conclusions.  Neither did the OIG link or follow up on information it
    had available during its review.  Concerning the second point, as we
    have shown, no underlying documentation supports the OIG's conclusion
    that the complainant's communication with law enforcement entities
    had not been limited.  With regard to the third point, our discussion
    of an alleged breach of confidentiality is based on substantive
    documentation and testimonial evidence that the improper disclosure
    occurred.  The fact that the media had disclosed the complainant's
    name did not relieve the OIG from its responsibility to maintain
    confidentiality.  The OIG had an obligation not to release the
    complainant's identity without his authorization.

    An underlying theme of the IG's comments is that we took individuals'
    comments out of context or misrepresented facts.  Also, according to
    his comments, some of the individuals that we interviewed either
    denied or did not recall discussing a particular matter with us.  It
    is important to note that our findings and conclusions are based on
    in-depth analyses of documentation we obtained and interviews of
    witnesses that are documented in our reports of interview.  We have
    included additional information in our report supporting our
    findings.

    The IG objected to a proposed recommendation regarding the adequacy
    of the OIG policies and procedures for protecting the privacy of
    complainants.  He stated that the issue is compliance and training,
    not formulating or rewriting existing policy.  We concur with the IG
    and have withdrawn the proposed recommendation.  The IG's complete
    written comments, and our evaluation, are presented in appendix II.

       SCOPE AND METHODOLOGY
    ------------------------------------------------------------ Letter :8

    We conducted our review from April 1997 to March 1998 at the VA OIG
    headquarters in Washington, D.C., and the Harry S Truman Memorial
    Veterans Hospital in Columbia, Missouri.  Initially, we reviewed the
    draft and final OIG Special Inquiry reports and related files and
    workpapers.  We interviewed both current and former OIG officials and
    Hospital personnel involved with the review of the suspicious deaths.
    We also reviewed (1) all congressional testimony and related
    documents, (2) the OIG Investigative Policy and Procedure Guide, and
    (3) all transcripts and tapes of the recorded interviews conducted
    during the Special Inquiry.  We transcribed all tapes that had not
    been transcribed by the OIG.  We reviewed available files at the
    Hospital and documentation provided by individuals interviewed.  In
    conducting our review, we also assessed the OIG's policies and
    procedures concerning confidentiality.

    ---------------------------------------------------------- Letter :8.1

    As agreed with your office, unless you announce its contents earlier,
    we plan no further distribution of this report until 30 days after
    the date of this letter.  At that time, we will send copies of the
    report to interested congressional committees; the Secretary of
    Veterans Affairs; and the Inspector General, Department of Veterans
    Affairs.  We will also make copies available to others on request.
    If you have any questions concerning this report, please contact me
    at (202) 512-6722 or Assistant Director Robert E.  Lippencott at
    (312) 220-7600.  Major contributors to this report are listed in
    appendix III.

    Sincerely yours,

    Eljay B.  Bowron
    Assistant Comptroller General
     for Special Investigations

    BACKGROUND
    =========================================================== Appendix I

    From March 8, 1992, through August 23, 1992, when a certain
    registered nurse worked the night shift alone on Ward 4 East at the
    Harry S Truman Memorial Veterans Hospital, the number of deaths on
    the ward increased, with dramatic spikes in May, June, and July.  The
    death rate returned to normal when the nurse was assigned to another
    unit.  A statistical analysis conducted by a Hospital staff physician
    in September 1992 confirmed that a statistically significant
    relationship existed between increased deaths on Ward 4 East and the
    duty times of the nurse.  The staff physician concluded in his
    original statistical analysis that the probability that no
    relationship existed between the deaths and the duty times of the
    nurse was less than 1 in 1,000 (in 1994, it was determined to be less
    than 1 in 1 million).  The VA Central Region Chief of Staff requested
    in October 1992 that the OIG Office of Healthcare Inspections help
    resolve questions involved with the Hospital staff physician's study.
    The OIG Office of Healthcare Inspections issued a report in September
    1994, confirming the results of the initial statistical study.

    In October 1992, based on information provided by a Missouri state
    legislator, the FBI and the OIG initiated a joint civil rights
    criminal investigation concerning the suspicious deaths at the
    Hospital.  On February 2, 1998, the FBI issued a report to the
    Congress concluding that it had conducted an extensive investigation
    and that the federal statute of limitations had expired in August
    1997 without any determination that a crime had, in fact, been
    committed.

    In a February 1993 letter, the staff physician who conducted the
    statistical study at the Hospital alleged to the OIG that both the
    Hospital and VA Central Region management had covered up the increase
    in patient deaths on Ward 4 East.  In the letter, the staff physician
    requested confidentiality.  The Inspector General referred the
    allegations of a cover-up to the OIG's Office of Investigations for
    investigation.  The Office of Investigations determined that due to
    the priority of the investigation of the suspicious deaths, no
    immediate action would be taken on these allegations.  The letter was
    placed in the investigative file, and a copy was provided to the FBI
    in March 1993.

    In January 1995, after the complainant went to the media, the IG
    instructed the Assistant IG for Departmental Reviews and Management
    Support to conduct an administrative review (known as a Special
    Inquiry) of the allegations that included a cover-up.  In a series of
    letters that followed the start of the Special Inquiry, the
    complainant reiterated his allegations of a cover-up, not only by
    Hospital and VA management but by VA OIG as well.  He also alleged
    that the cover-up had continued even after the start of the joint
    FBI/VA OIG investigation.  In the Special Inquiry report issued in
    September 1995, the OIG concluded that the evidence pointed to bad
    management rather than to a deliberate plan to cover up or suppress
    information.

    A congressional hearing was held in October 1995, and VA healthcare
    and OIG officials testified about the Special Inquiry and other
    matters.  In their testimony, VA and OIG officials agreed with the
    findings of VA OIG Special Inquiry report and stated that no evidence
    of a cover-up by management had been found.  OIG officials admitted,
    however, that the OIG had taken too long in dealing with the
    complainant's allegations and attributed the 2-year delay to other
    priorities and administrative error.  OIG officials concluded that
    even though no evidence of criminal misconduct had been found, they
    did find "a dysfunctional management team .  .  .  in place" that had
    made significant judgmental errors in responding to the unexpected
    deaths.  In its prepared statement, the OIG expressed concerns about
    its shortcomings in protecting the complainant's identity and stated
    that it had issued a written apology to the complainant.

    (See figure in printed edition.)Appendix II
    COMMENTS FROM THE OFFICE OF
    INSPECTOR GENERAL DEPARTMENT OF
    VETERANS AFFAIRS
    =========================================================== Appendix I

    (See figure in printed edition.)

    (See figure in printed edition.)

    Now on pp.  3-6.

    Now on p.  3.

    See comment 1.

    (See figure in printed edition.)

    (See figure in printed edition.)

    Now on p.  4.

    Now on p.  4.

    See comment 2.

    (See figure in printed edition.)

    See comment 1.

    (See figure in printed edition.)

    Now on p.  10.

    (See figure in printed edition.)

    Now on p.  4.

    See comment 2.

    See comment 3.

    See comment 4.

    (See figure in printed edition.)

    Now on p.  4.

    Now on p.  6.
    See comment 5.

    See comment 2.

    See comment 2.

    (See figure in printed edition.)

    See comment 2.

    Now on pp.  6-8.

    (See figure in printed edition.)

    Now on p.  6.

    (See figure in printed edition.)

    Now on pp.  7-8.

    (See figure in printed edition.)

    See comment 6.

    Now on p.  8.
    Now on p.  8.

    (See figure in printed edition.)

    See comment 6.

    Now on pp.  8-10.

    (See figure in printed edition.)

    See comment 7.

    Now on p.  9.

    See comment 8.

    (See figure in printed edition.)

    Now on pp.  10-12.

    Now on pp.  10-11.

    (See figure in printed edition.)

    (See figure in printed edition.)

    Now on p.  11.

    See comment 9.

    Now on p.  12.

    (See figure in printed edition.)

    See comment 10.

    See comment 11.

    Now on pp.  3 and 12.

    See comment 12.

    (See figure in printed edition.)

    (See figure in printed edition.)

    See comment 13.

    (See figure in printed edition.)

    Now on p.  3.

    See comment 14.

    Now on p.  1.

    (See figure in printed edition.)

    Now on p.  18.

    Now on p.  18.

    Now on p.  18.

    (See figure in printed edition.)

    Now on p.  9.

    Now on pp.  6-7.

    Now on p.  9.

    Now on p.  13.

    Now on p.  13.

    Now on p.  18.

    (See figure in printed edition.)

    The following are GAO's comments on the Department of Veterans
    Affairs Office of Inspector General's letter dated April 24, 1998.

    GAO COMMENTS

    1.Despite how the OIG may characterize its work, we determined that
    its review was not planned or executed in a manner that would support
    the conclusion that it had found "no conclusive proof of an
    intentional cover-up" by Hospital and Central Region officials and
    "no evidence of criminal misconduct by top management." The work
    done, as described by those who did it and as reflected in the
    workpapers, did not include collecting and analyzing evidence to
    identify intentional cover-up efforts.

    2.In addition to in-depth analyses of pertinent documentation, our
    findings and conclusions are based on extensive interviews of
    witnesses, including the Assistant IG and lead analyst.  Further,
    these interviews were conducted without the presence of OIG
    management and the influence that may result from such presence.
    Information contained in our report was taken from documentation we
    examined and witnesses we interviewed.  To help refresh their
    recollections and focus them on the issues, we provided the witnesses
    with copies of relevant sections of the OIG manual and supporting
    documentation for the Special Inquiry.  We have also included
    additional information in our report to support our findings.

    3.According to the VA OIG criminal investigator who conducted the
    criminal investigation with the FBI, he never read the Special
    Inquiry report that was issued in 1995.  Further, he said he has no
    idea as to whether statements in the report were true or accurate.

    4.Section A of the Special Inquiry report is the Hospital and Central
    Region management's response to the unexplained deaths.  That section
    concludes that the OIG found "no conclusive proof of an intentional
    cover-up by Medical Center and Region officials" and "no evidence of
    criminal conduct by top management." No attempt was made to formally
    reconcile the final Special Inquiry report to the underlying evidence
    until we asked whether such a reconciliation had been done.  Further,
    following our request in 1997, the analyst who was responsible for
    referencing the report told us that she was unable to reconcile some
    of the stated facts.

    5.  We have added to our report a discussion of the types of issues
    we believe the OIG should have probed further and examples of
    instances in which further probing could have elicited additional
    information.

    6.We disagree that a conclusion needs no supporting evidence.  Since
    conclusions represent review and analysis of evidence, it is
    essential to include documentation and its analysis in the
    workpapers.  But the OIG had no evidence or analysis to support its
    conclusion.  Further, contrary to the OIG's conclusion, documentation
    in the OIG file suggested that the Hospital Director's actions
    limited access.  For example, according to a memorandum for the
    record prepared by the lead analyst, the criminal investigator told
    the analyst that he suspected that the Hospital Director had told
    Hospital staff not to talk to investigators.

    7.We have added a reference to our report about the OIG's receipt of
    an additional allegation from the complainant.

    8.We have clarified our report to show the source of our statement
    about the reason for the OIG's delaying action on the complainant's
    allegations.

    9.While we did not interview the Assistant IG for Healthcare
    Inspections, the IG is incorrect in his assumption that the facts as
    stated in our report are based solely on the statements made to us by
    the TQI Coordinator.  Rather, the reason that we interviewed the TQI
    Coordinator was to corroborate statements contained in a January 1995
    contact memorandum that she had prepared--immediately following the
    contact--to document her telephone conversation with the Assistant
    IG.

    10.We have revised our report to reflect that the TQI Coordinator
    contacted the FBI at the request of the Associate Director and the
    Chief of Human Resources.

    11.The referenced footnote has nothing to do with the Hospital
    management's investigation of alleged nepotism concerning the
    appointment of the Director's son as Chief of Human Resources.
    Rather, the purpose of the footnote is to inform the reader that the
    person who requested the TQI Coordinator to make calls concerning the
    complainant is the son of the individual on whom the complainant
    focused his allegations.

    12.The IG's characterization of its June 1993 Hotline policies as the
    most recent is incorrect.  The current policy was issued in August
    1995 as reflected in our report.  The OIG's May 1, 1998,
    acknowledgement of this fact appears in the appended addendum.

    13.We have withdrawn our proposed recommendation for revising the
    OIG's August 1995 policies and procedures for protecting the privacy
    of complainants.  We concur with the IG that any corrective action
    would require training and compliance with policy, not formulating or
    rewriting policy.  Accordingly, we have made the appropriate changes
    to our report.

    14.We have considered these comments and made changes to the report
    where appropriate.

    MAJOR CONTRIBUTORS TO THIS REPORT
    ========================================================= Appendix III

    OFFICE OF SPECIAL INVESTIGATIONS,
    WASHINGTON, D.C.

    Jim Locraft, Special Agent
    Barbara W.  Alsip, Communications Analyst
    Trudy Moreland, Project Manager
    Thomas A.  Luttrell, Senior Evaluator

    CHICAGO FIELD OFFICE

    Robert E.  Lippencott, Assistant Director for Investigations

    OFFICE OF THE GENERAL COUNSEL,
    WASHINGTON, D.C.

    Aldo A.  Benejam, Senior Attorney
    *** End of document ***