Report: Phoenix VA Patient Tragically Dies After 11-Minute Wait for Emergency Care

A new report found multiple issues that may have contributed to the patient’s delayed care.

PHOENIX — The Phoenix VA Health Care System exhibited a “deficient” response when a patient experienced an emergency, waiting up to 11 minutes before receiving basic care, according to the inspector general.

A report released Wednesday by the U.S. Department of Veteran Affairs Office of Inspector General criticized how the Phoenix VA handled a medical emergency that occurred outside a VA facility, resulting in the patient’s death. Initial care only began when the Phoenix Fire Department arrived and transported the patient to a community hospital, where the patient died a few days later.

The OIG highlighted deficiencies in the initiation of emergency medical care, the quality of the patient’s prior medical care, and the completion of quality reviews in their report.

This report comes a decade after a national scandal involving the Phoenix VA, where veterans died while waiting for medical care. Advocates are still pressuring Congress to address persistent issues in the VA system.

The latest OIG report highlights ongoing problems with Phoenix VA’s policies. The patient had visited the facility for a urology appointment and passed out in the parking lot afterward. A family member moved the patient to the entrance and sought help inside the facility.

An employee called 911 and attempted to request a rapid response, which is a “safety net” for sudden deteriorations in patients’ conditions. However, the rapid response was not initiated, and VA police were not called.

Because the patient was outside the building, calling for a rapid response was deemed “not the correct procedure.”

The OIG report expressed concerns that the facility policy does not align with VHA requirements designed to optimize patient safety and manage cardiac arrests on VHA property.

The OIG concluded that conflicting policies, untrained staff in CPR, and limited access to defibrillators might have contributed to the patient’s delayed care.

Investigators also found faults in the care the patient received before the emergency. A cardiologist did not order a cardioverter defibrillator despite documenting it in the patient’s care plan, and no vital signs were taken during the medical appointment.

Although it’s unclear if assessing vital signs would have predicted the patient’s deterioration, missing this step may have precluded early identification of clinical decline.

Despite these issues, the OIG was unable to determine whether different care would have changed the patient’s outcome.

Following the review, the OIG made 10 recommendations for policy improvements, and the Phoenix VA has submitted action plans for implementation.

U.S. Rep. Ruben Gallego, D-Arizona, sent a letter to the VA requesting more answers on the issues documented in the OIG report.