United States Government Publishing Office publisher pbl distributor dst United States Government Accountability Office Office of Special Investigations author aut Government Organization text government publication eng GAOREPORTS Legislative Agency Publications gao legislative 2010-08-12 U.S. Government Printing Office 1998-05-13 monographic deposited born digital 52 p. GA 1.13:OSI-98-9 https://www.govinfo.gov/app/details/GAOREPORTS-OSI-98-9 P0b002ee18039c0b1 f:os98009 DGPO 2010-08-12 2011-03-28 GAOREPORTS-OSI-98-9 machine generated eng fdlp REPORT GAOREPORTS-OSI-98-9 OSI-98-9 Investigations by federal agencies Physicians Veterans hospitals Inspectors general Whistleblowers Ethical conduct Health services administration Law enforcement Confidential communication Homicide Letter Report OSI 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). https://www.govinfo.gov/content/pkg/GAOREPORTS-OSI-98-9/html/GAOREPORTS-OSI-98-9.htm https://www.govinfo.gov/content/pkg/GAOREPORTS-OSI-98-9/pdf/GAOREPORTS-OSI-98-9.pdf GAO/OSI-98-9 https://www.govinfo.gov/app/details/GAOREPORTS-OSI-98-9 Letter Report GAO/OSI-98-9; Inspectors General: Veterans Affairs Special Inquiry; Investigations by federal agencies Physicians Veterans hospitals Inspectors general Whistleblowers Ethical conduct Health services administration Law enforcement Confidential communication Homicide Title 5 Appendix 3 5 U.S.C. App. 3