Investigators say the surgical unit at a southern Illinois veterans' hospital was in such disarray that doctors were allowed to perform operations they weren't qualified to perform and that hospital administrators were too slow to respond once problems surfaced, leading directly to the deaths of at least nine surgical patients and as many as 19.
Two internal Department of Veterans Affairs investigations also found that the medical mistakes seriously harmed more than a dozen additional veterans who were patients at the Marion, Ill., VA Medical Center.
"I can't tell you how angry we all are and how frustrated we all are. Nothing angers me more than when we don't do the right thing," Michael Kussman, U.S. Veterans Affairs undersecretary for health, said in a conference call with reporters late Monday. The conference call was scheduled to release the findings of the VA's investigation and to summarize a separate Inspector General's investigation.
The investigations found serious quality problems in the Marion VAMC's surgical unit in pre-operative care, intra-operative care and post-operative care.
Kussman said at least nine deaths between October 2006 and August 2007, when officials suspended in-patient surgeries at the Marion facility, were "directly attributable" to substandard care.
The Marion hospital serves veterans from southern Illinois, southwestern Indiana and western Kentucky, and while Kussman declined to identify those cases by patient or doctor, one case appears to be that of 50-year-old Air Force veteran Bob Shank, which NPR reported in November.
Shank was scheduled to undergo a relatively minor gall bladder procedure last August. The laparoscopic procedure is minimally invasive and considered fairly routine. His wife, Katrina, says her husband was eager to get relief from painful gall stones that had been bothering him for months.
"Before he went in, you know, before they wheeled him off, he told me that he loved me and told me to pay real close attention to the doctor, that I'd understand what he was sayin'... that was the last time I saw him... alive, or awake, anyway," Katrina Shank recalls.
The surgery was performed by Dr. Jose Veizaga-Mendez, a physician who was hired at Marion despite having settled two malpractice lawsuits and having seven additional cases of substandard care under investigation at his former hospital in Massachusetts.
As her husband bled internally, his blood pressure sinking, Katrina Shank says, Veizaga-Mendez gave her the runaround about what was wrong and delayed several hours before opening him back up to find out what he did wrong.
"He pretty much let my husband bleed to death," says Shank, who will share her tragedy Tuesday at a House subcommittee hearing on the Marion VA hospital's problems.
Sen. Richard Durbin (D-IL) says he had been told last fall that at least 10 suspicious post-surgical deaths had been linked to Veizaga-Mendez, who resigned from Marion a few days after Shank died.
"There was gross mismanagement here," Durbin said on the release of the report. "Decisions were made here to undertake surgical procedures beyond the competence of the doctors involved and beyond the competence of the institution. That is absolutely unacceptable."
Rep. Jerry Costello (D-IL) said the nine deaths confirmed in the investigation were linked to two surgeons he did not name. Of an additional 34 cases the VA investigated, 10 patients died as the result of questionable care that complicated their health, Kussman said, but investigators could not determine conclusively that poor care actually caused the deaths.
Kussman said all six surgeons on staff at Marion were each responsible for at least one case of substandard care. Four remain on staff, but are handling "only minor cases at this time."
When the VA began investigating the Marion VAMC in August, officials immediately removed the hospital's director, chief of staff, chief of surgery and an anesthesiologist, moving them to other positions or placing them on leave, Kussman said. The anesthesiologist has since quit and Kussman says "the previous leadership will not return."
Kussman says that "what happened in Marion is an exception to what otherwise is a truly quality health care system" across the VA. He apologized to affected veterans and their families and says the VA will begin contacting them soon to address the issue.
Congress begins hearings on the matter Tuesday.
Sen. Daniel Akaka (D-HI), who chairs the Senate Veterans' Affairs Committee, said, "It is simply unacceptable that veterans could survive the battlefield only to die prematurely due to shoddy medical care."
The Associated Press contributed to this report.