“We’re Learning to Improve”: VA Secretary Demands System Overhaul After Tragic Veteran Death in Phoenix Parking Lot

PHOENIX — The Secretary of the Veteran’s Administration is advocating for a comprehensive review of policies after an Office of Inspector General (OIG) report highlighted conflicting procedures that may have led to the death of an Arizona veteran.

“We recognize that we are far from perfect, so we have to learn,” stated Sec. Denis McDonough during his visit to Phoenix. His comments followed his speech at the Disabled American Veterans conference. McDonough credited Phoenix VA Hospital workers for initiating the investigation.

The OIG report, released in March 2023, documented an incident where a veteran experienced a medical emergency in the parking lot of the Phoenix VA Hospital. Despite being just feet from medical help, it took 11 minutes for Phoenix Fire to arrive and administer basic life-saving measures. The veteran was subsequently transported to another hospital, where he passed away a few days later.

At the core of the incident was a policy misalignment: the Phoenix VA’s protocol allowed its Rapid Response Team (RRT) to be activated only for emergencies inside the building. For incidents outside, including the parking lot, the policy required calling 911 instead. An employee, aware of this policy, had nonetheless activated the RRT in an attempt to expedite care for the veteran, but to no avail.

McDonough emphasized the need for systemic changes to prevent such incidents. “We plan to take a hard look at how this happened. We’re not fixing it here where it happened, but we plan to fix it across the system,” he remarked.

The report also identified a critical gap in staff training, noting a lack of CPR training and the absence of an automatic external defibrillator (AED) at the facility. It made ten recommendations for improving emergency response protocols, including bringing the Phoenix VA’s policies in line with broader VA guidelines on rapid response capabilities.

This incident has drawn attention from Arizona’s congressional delegation, which sent McDonough a letter seeking further details and remedial actions. McDonough acknowledged their concerns and indicated his willingness to work with lawmakers but has not yet responded formally.