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

******************************************************************
** This file contains an ASCII representation of the text of a  **
** GAO report.  Delineations within the text indicating chapter **
** titles, headings, and bullets are preserved.  Major          **
** divisions and subdivisions of the text, such as Chapters,    **
** Sections, and Appendixes, are identified by double and       **
** single lines.  The numbers on the right end of these lines   **
** indicate the position of each of the subsections in the      **
** document outline.  These numbers do NOT correspond with the  **
** page numbers of the printed product.                         **
**                                                              **
** No attempt has been made to display graphic images, although **
** figure captions are reproduced.  Tables are included, but    **
** may not resemble those in the printed version.               **
**                                                              **
** Please see the PDF (Portable Document Format) file, when     **
** available, for a complete electronic file of the printed     **
** document's contents.                                         **
**                                                              **
** A printed copy of this report may be obtained from the GAO   **
** Document Distribution Center.  For further details, please   **
** send an e-mail message to:                                   **
**                                                              **
**                                            **
**                                                              **
** with the message 'info' in the body.                         **
******************************************************************
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 ***