Inspectors General: Veterans Affairs Special Inquiry Report Was
Misleading (Testimony, 05/14/98, GAO/T-OSI-98-12).

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.

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

 REPORTNUM:  T-OSI-98-12
     TITLE:  Inspectors General: Veterans Affairs Special Inquiry Report 
             Was Misleading
      DATE:  05/14/98
   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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Cover
================================================================ COVER


Before the Subcommittee on Oversight and Investigations
Committee on Veterans' Affairs
House of Representatives

For Release on
Delivery Expected
at 9:30 a.m., EDT
Thursday
May 14, 1998

INSPECTORS GENERAL - VETERANS
AFFAIRS SPECIAL
INQUIRY REPORT WAS MISLEADING

Statement of Eljay B.  Bowron
Assistant Comptroller General for Special Investigations
Office of Special Investigations

GAO/T-OSI-98-12

GAO/OSI-98-12T


(600472)


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


INSPECTORS GENERAL:  VA OIG
SPECIAL INQUIRY WAS MISLEADING
============================================================ Chapter 0

Mr.  Chairman and Members of the Subcommittee: 

Thank you for inviting me here today to discuss the results of our
review of 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.\1

Our review focused on how the VA OIG planned, conducted, and reported
the results of its inquiry.  In its Special Inquiry report,\2 the OIG
analyzed and criticized VA management's response to the deaths,
calling the top management team "dysfunctional." It concluded that
management's actions could be attributed to bad judgment and found no
conclusive proof of an intentional cover-up and no evidence of
criminal conduct by top managers. 

From our examination and analysis of the evidence in the OIG files
and from interviews with individuals having knowledge of the events,
we conclude the following: 

  -- 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 the
     unexplained deaths.  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. 

  -- The OIG failed to comply with its own reporting policies on
     completeness and accuracy by presenting statements in its report
     that were not supported by the evidence contained in the OIG's
     files.  These statements included, for example, reference to a
     discussion that the Special Inquiry never verified. 

  -- The OIG attributed the nearly 2-year delay in acting on 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 by the OIG on at least
     three occasions. 

  -- Current OIG policies and procedures on confidentiality are
     adequate. 


--------------------
\1 See also Inspectors General:  Veterans Affairs Special Inquiry
Report Was Misleading (GAO/OSI-98-9, May 13, 1998). 

\2 In February 1993, the OIG received specific allegations that the
Hospital Director and the VA Central Region Chief of Staff 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) after the complainant notified the media
of allegations of a cover-up and an additional allegation. 


   SPECIAL INQUIRY REPORT'S
   CONCLUSION REGARDING ALLEGED
   COVER-UP IS MISLEADING
---------------------------------------------------------- Chapter 0:1

The title and text of the Special Inquiry report suggests that
allegations of a cover-up on the part of the Hospital Director and
the Central Region Chief of Staff 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 efforts and documentation
would have included linking individual pieces of evidence that
together would suggest additional lines of inquiry--including
elements of a cover-up.  Further, both the lead analyst who conducted
the review and the Assistant IG who wrote the final report told us
that 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. 

The lead analyst 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 and Hospital
policies when responding to the revelation of the unexplained deaths. 

According to the Assistant IG who prepared the final report, he
neither reviewed the underlying evidence while preparing the final
report nor reconciled 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 to Special Inquiry:  Alleged Cover-up of an Unexplained
Increase in Deaths, Harry S.  Truman Memorial VA Medical Center,
Columbia, Missouri and edited the report in an attempt to tie the
text to the complainant's allegations.  Although the Assistant IG
stated that there was no intent to mislead, the report title 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.  The
Assistant IG characterized this as wordsmithing.  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. 
Therefore, the Special Inquiry's conclusion was not supported by work
done and evidence collected and is misleading. 

The then IG 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. 


   REVIEW PLANNED AND EXECUTED
   FROM A MANAGEMENT PERSPECTIVE
---------------------------------------------------------- Chapter 0:2

We determined that the OIG did not plan or conduct its Special
Inquiry in a manner to determine if improper acts pertaining to
cover-up had occurred.  The Assistant IG directly responsible for the
inquiry stated that when he prepared 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 required by the OIG's 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.  If certain actions by the
Hospital Director had been linked or followed up on, the need for
further investigation and additional lines of inquiry would have been
apparent.  For example, the Hospital Director (1) did not inform law
enforcement authorities about the unexplained deaths although
District Counsel advised him to do so; (2) did not inform the OIG
that a staff physician had accused the nurse in question of killing
his patients; and (3) did not provide the Peer Review Board with the
statistical analysis that established a relationship between a nurse
and the unexplained patient deaths.  Also, the Hospital Director
instructed the staff physician who had prepared the statistical
analysis to have no further contact with the Federal Bureau of
Investigation (FBI).  The OIG did not pursue or connect these events. 

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 policy.  The analysts told us that 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.  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
---------------------------------------------------------- Chapter 0:3

The OIG failed to follow its own policies concerning the completeness
and accuracy of its report.\3 Specifically, statements in the report
purported to be factual were inconsistent with or unsupported by the
evidence in the OIG's files.  The following three instances are
examples of such statements. 

  -- The report states that the Hospital Director followed the VA
     Central Region Chief of Staff's advice and did not inform law
     enforcement authorities of the suspicious deaths and the
     possible relationship of a particular nurse to the deaths.  Our
     review of memorandums of interview and transcripts of recorded
     interviews 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. 

  -- The report states that the Central Region Chief of Staff and the
     Hospital Director withheld the complainant's statistical
     analysis--which identified a statistical relationship between
     the increase in patient deaths and a particular nurse--from the
     Hospital Peer Review Board so as to allow the Board to look at
     patient deaths objectively.  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
     statistical analysis.  The Hospital Director told the OIG that
     he recalled no one asking to see the statistical data and it did
     not occur to him to provide the Peer Review Board with the data. 

  -- 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." The Special Inquiry report rightly
     states that the Hospital Director could not keep the complainant
     from talking with the FBI and the OIG and noted that the
     complainant was under no obligation to report those
     conversations to the Hospital Director.  However, the report
     concludes that the Hospital Director's action did not limit the
     OIG or the FBI in obtaining appropriate information from the
     complainant or other Hospital employees.  We found no evidence
     in the documentation of any investigative effort to support this
     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. 


--------------------
\3 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 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 the evidence obtained (accurate).  .  .  ."


   VA OIG OFFICIALS DID NOT
   ADDRESS THE COMPLAINANT'S
   COVER-UP ALLEGATIONS FOR NEARLY
   2 YEARS
---------------------------------------------------------- Chapter 0:4

As reflected in the Special Inquiry report, the OIG received the
complainant's allegations of a cover-up of patient deaths in February
1993, acknowledged its receipt to the complainant, and filed the
complainant's letter without investigating the allegations.  The
Assistant IG for Investigations told us that at the time the OIG
received the allegations the criminal investigation with the FBI was
ongoing,\4 and available resources were being devoted to that
investigation.  The OIG did not begin its Special Inquiry until after
the complainant had discussed the allegations with the media in
January 1995.\5 The OIG's Special Inquiry report issued in September
1995 attributed the delay to administrative error.  Further, the
Assistant IG for Investigations characterized the OIG's failure to
follow up on the allegations as a failure of its process. 


--------------------
\4 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. 

\5 On January 10, 1995, a newspaper identified the complainant as the
source of cover-up allegations and an additional allegation. 


   VA OIG BREACHED COMPLAINANT'S
   CONFIDENTIALITY
---------------------------------------------------------- Chapter 0:5

When the complainant sent his allegation letter to the OIG in
February 1993, he requested confidentiality.\6 In the Special Inquiry
report, the OIG acknowledged that it had twice released the name of
the complainant and that it should have been more careful in
protecting the complainant's confidentiality.  We found yet a third
instance in which the complainant's contact was provided to Hospital
management. 

  -- In one instance, 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, who forwarded it to the
     Central Region and the Hospital Director, one of the subjects of
     the allegations.  The Special Inquiry report characterized this
     incident as an error. 

  -- In another instance, in March 1994, the Assistant IG for
     Healthcare Inspections gave Central Region officials a report of
     contact that they had had with the complainant.  In the Special
     Inquiry report, the OIG said 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.  The
     report characterized the release of the information as an honest
     mistake. 

  -- We found a third instance in which the complainant's contact
     with the OIG was provided to Hospital management, but the
     Special Inquiry report did not identify this incident.  On
     January 11, 1995, the Hospital Total Quality Improvement (TQI)
     Coordinator asked the Assistant IG for Healthcare Inspections
     (1) if the complainant had had recent contact with the OIG and
     (2) if the OIG planned to investigate the complainant's
     obstruction-of-justice allegation.  The Assistant IG
     acknowledged recent contact with the complainant and stated that
     the OIG would not investigate unless forced to do so.  That same
     day, the Hospital Chief of Human Resources and the Associate
     Director had the TQI Coordinator contact the FBI and the Kansas
     City OIG to determine if they had recently been in contact with
     the complainant.  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\7
     told us he was not sure why he and the Associate Director had
     the TQI Coordinator make 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. 


--------------------
\6 Section 7(b) of the Inspector General Act of 1978, 5 U.S.C., App. 
3, provides that "[t]he 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."

\7 The Chief of Human Resources at the Hospital is the son of the
Hospital Director, one of the subjects of the allegations. 


   REVISED POLICIES AND PROCEDURES
---------------------------------------------------------- Chapter 0:6

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 other 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. 


   SCOPE AND METHODOLOGY
---------------------------------------------------------- Chapter 0:7

We conducted our investigation 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. 


-------------------------------------------------------- Chapter 0:7.1

Mr.  Chairman, this concludes my prepared statement.  I would be
happy to respond to any questions that you or Members of the
Subcommittee may have. 

*** End of document. ***