VA Facility Blamed In Shocking Death of Phoenix Veteran: Investigation Reveals

By Staff Reporter |

A federal investigation into the death of a Phoenix Marine Corps veteran published on Wednesday revealed that a Veterans Administration (VA) facility was to blame, due to insufficient health care practices and policies.

The VA Office of Inspector General (OIG) found that the deceased Marine veteran experienced a delay in basic life support and numerous deficiencies in initiating emergency medical care at Carl T. Hayden Medical Center in Phoenix. These included conflicting facility policies, lack of layperson CPR training, absence of an automatic external defibrillator, and failure to assess vital signs during an appointment preceding the medical emergency.

The OIG report highlighted that the facility leaders’ inadequate treatment response contradicted the VA’s high reliability organization (HRO) principles and I CARE values. Additionally, the patient safety manager failed to investigate the related patient safety report, resulting in an inaccurate harm assessment. Both the patient safety manager and facility director also neglected to ensure a timely review of the report and investigation.

Congressman Ruben Gallego, a Marine Corps combat veteran, described the findings as not only insufficient but also “disturbing and dangerous.” He expressed particular shock over the omission of taking vital signs at the beginning of the appointment.

The 55-page report indicated that the veteran’s death might have been preventable with better policies and procedures. After the veteran collapsed following an outpatient appointment, a hospitality employee’s attempt at a rapid response was dismissed by the facility operator, who advised calling VA police instead, causing a delay in emergency support. The veteran waited 11 minutes before paramedics arrived to administer life support and transport him to a community hospital, where he died two days later.

The Phoenix facility’s policy restricted rapid response teams to events inside buildings and mandated that other emergencies be handled by 911 and VA police, even if in close proximity to the building. The OIG report expressed concern that the facility’s strict adherence to policy overshadowed lifesaving measures.

The report stated, “The OIG is concerned that facility policy regarding responses to medical emergencies does not align with Veterans Health Administration (VHA) policy to ‘optimize patient safety for those requiring resuscitation’ and ensure ’emergency response capability to manage cardiac arrests on VHA property.'”

Even before the emergency event, the OIG found deficiencies in the veteran’s medical care, like the absence of a wearable cardioverter defibrillator prescribed by the cardiologist, and the failure to complete vital signs during the veteran’s outpatient exam.

The OIG issued ten recommendations to the facility aimed at aligning its policies with VA standards to eliminate conflicts.