United States General Accounting Office

GAO Report to the Chairman, Subcommittee

on Oversight and Investigations,

Committee on Veterans’ Affairs, House

of Representatives

May 1998 INSPECTORS

GENERAL

Veterans Affairs

Special Inquiry Report

Was Misleading

GAO/OSI-98-9

GAO United States

General Accounting Office

Washington, D.C. 20548

Office of Special Investigations

B-279646 

May 13, 1998

The Honorable Terry Everett, Chairman

Subcommittee on Oversight and Investigations

Committee on Veterans’ Affairs

House of Representatives

Dear Mr. Chairman:

This letter responds to your request that we review the Special Inquiry

conducted by the Department of Veterans Affairs (VA) Office of Inspector

General (OIG) and its resulting report, entitled Special Inquiry: Alleged

Cover-up of an Unexplained Increase in Deaths, Harry S. Truman

Memorial VA Medical Center, Columbia, Missouri. Specifically, you asked

that we determine (1) whether the Special Inquiry report represents the

results of the OIG’s review, (2) whether the OIG complied with its policies in

conducting the Special Inquiry, (3) why a delay occurred between receipt

of the cover-up allegations in February 1993 and the beginning of the

Special Inquiry in January 1995, (4) whether the OIG protected the

confidentiality of the staff physician who made the allegations of a

cover-up, and (5) if OIG processes and procedures are adequate for

ensuring confidentiality requested by individuals.

Background An unexplained increase in patient deaths occurred in one ward at the

Harry S Truman Memorial Veterans Hospital (hereinafter referred to as

Hospital) in Columbia, Missouri, during the spring and summer of 1992. In

October 1992, based on information provided by a Missouri state

legislator, the Federal Bureau of Investigation (FBI) and the VA OIG initiated

a joint criminal investigation into the suspicious deaths.1

 In February 1993,

the OIG received specific allegations that the Hospital Director2

 and the VA

Central Region Chief of Staff3 had attempted to cover up the unexplained

1

In October 1992, the FBI and the VA OIG initiated a joint investigation into a possible crime on a

government reservation. They soon learned, however, that the Truman Memorial Veterans Hospital is

one of the approximately 20 “proprietary” VA hospitals and is not a federal reservation. The FBI and

the OIG then began a civil rights investigation immediately after the Department of Justice determined

that they could properly investigate the matter as a civil rights case. The focus of the investigation—to

determine whether a crime (homicide) had occurred at the Hospital and, if so, who was

responsible—never changed.

The FBI made a February 2, 1998, report to the Congress on its investigative results regarding the 1992

suspicious deaths at the Hospital. The FBI concluded that, after extensive investigation, the federal

statute of limitations had expired without a determination that a crime had, in fact, been committed.

2

The Hospital Director retired in June 1994.

3

The Central Region Chief of Staff resigned in September 1994.

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increase in patient deaths, including by not referring the matter to law

enforcement authorities.

In January 1995, the OIG initiated an administrative investigation (known as

a Special Inquiry),4

 which focused on management’s response to the

patient deaths. Subsequent to the start of the Special Inquiry, the VA OIG

received a series of additional letters from the complainant alleging that

the cover-up (1) involved not only Hospital and VA management but the VA

OIG as well and (2) had continued even after the October 1992 start of the

joint FBI and VA OIG investigation. The OIG issued the Special Inquiry report

in September 1995. In its report, the OIG analyzed and criticized Hospital

and VA management’s response to the increase in deaths and noted that it

had “found a dysfunctional top management team [in the Hospital] . . . in

place.” The OIG reported that while the evidence might indicate to some

individuals that at least the appearance of a cover-up existed,

management’s actions could be attributed instead to bad judgment. The

OIG further reported that it had found no conclusive proof of an intentional

cover-up by Hospital and Central Region officials and no evidence of

criminal conduct by top managers. As to its own role, the OIG stated that it

had made mistakes but avowed that it had not participated in a cover-up.

(A more extensive background is provided in app. I.)

Results in Brief The VA OIG conducted the Special Inquiry as a management review to

determine how Hospital and VA Central Region management had

responded to “an ’out of norm’ situation” regarding unexplained deaths at

the Hospital. We determined that the OIG did not collect or analyze

evidence in a manner that would identify intentional cover-up efforts.

Thus, the Special Inquiry’s conclusion that no evidence of an intentional

cover-up had been found was not consistent with the inquiry conducted

and was misleading.

Concerning the additional questions raised in your request, we determined

the following:

• The OIG failed to comply with its own reporting policies concerning

completeness and accuracy by presenting statements that were not

supported by the evidence contained in OIG files, including reference to a

discussion that the Special Inquiry never verified.

4

The OIG opened a Special Inquiry after the complainant notified the media of allegations of a cover-up

and an additional allegation.

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• The OIG attributed the delay in acting upon the cover-up allegations

received in February 1993 to administrative error.

• The confidentiality of the staff physician who had made the allegations of

a cover-up was breached on at least three occasions.

• The OIG’s current policies and procedures on confidentiality are adequate.

VA OIG’s Conclusion

Regarding Alleged

Cover-Up Is

Misleading

The title and text of the Special Inquiry report suggest that allegations of a

cover-up had been investigated. We determined that the OIG did not plan or

conduct its review or analysis in a way that could determine if a cover-up

had occurred. Had the OIG conducted such a review, its documentation

would have included an effort to link individual pieces of evidence that

together suggest additional lines of inquiry—including elements of a

cover-up. Further, both the Assistant IG5

 and the analyst6 responsible for

the Special Inquiry told us that the OIG did not review or investigate the

allegations of cover-up. The Assistant IG told us that the Special Inquiry

report overstates its conclusion regarding no evidence of a cover-up.

Therefore, the Special Inquiry’s conclusion was not supported by work

done or evidence collected and is misleading.

Misrepresentation of Facts

and Misleading Report

Language

In the Special Inquiry report, the OIG represents that its review included

the allegation of a cover-up on the part of the Hospital Director and the

Central Region Chief of Staff. However, according to the lead analyst who

conducted the review and the Assistant IG who wrote the final report, the

issue of cover-up was “off the table” because, in their view, their “charge”

from OIG management did not include looking at cover-up allegations. They

defined cover-up as being related to criminal issues and added that neither

of them was a criminal investigator.

Prior to his retirement, the lead analyst responsible for the Special Inquiry

completed the interviews and field work and wrote a draft report entitled

Special Inquiry: Management Response to Unexplained Patient Deaths,

Harry S. Truman VA Medical Center, Columbia, Missouri. The body of that

draft report made no reference to allegations of a cover-up by the Hospital

Director and Central Region Chief of Staff. In the draft report, only one

issue was addressed—whether management officials complied with VA

policy when responding to the revelation of the unexplained deaths.

5

The Assistant IG retired in July 1997.

6

The lead analyst responsible for conducting the Special Inquiry retired in July 1995 after completing

the field work and writing the draft report.

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According to the Assistant IG who prepared the final report, he did not

review the underlying evidence while preparing the final report, nor did he

reconcile the stated facts in the report with the underlying evidence prior

to issuing the report. He stated that in writing the final Special Inquiry

report, he changed the original title and edited the report in an attempt to

tie the text to the complainant’s allegations. He characterized this as

wordsmithing and added that he had no intent to mislead. He concluded

that in hindsight he probably should not have changed the title and that

the report probably overstated its case concerning no evidence of a

cover-up, as the OIG did not investigate the cover-up allegations.

Although the Assistant IG stated that there was no intent to mislead, the

report title—Special Inquiry: Alleged Cover-up of an Unexplained Increase

in Deaths, Harry S. Truman Memorial VA Medical Center, Columbia,

Missouri—and two of the report’s three major sections—“Alleged

Cover-up by Medical Center and Central Region Officials Subsequent to

the Criminal Investigation” and “Alleged Cover-up by the Office of

Inspector General”—specifically refer to the cover-up allegations. Further,

the OIG reported that it had found “no conclusive proof of an intentional

cover-up by Medical Center and Central Region officials” and “no evidence

of criminal conduct by top management.” This language is misleading,

because the OIG did not conduct its Special Inquiry so as to support its

conclusion concerning an intentional cover-up. Instead, it addressed

whether management had complied with VA and Hospital policy and

procedures in its response to the increase in deaths.

The then IG7

 told us that he had intended for the Special Inquiry to

investigate allegations of a cover-up and that, based on his reading of the

report, it appeared that it had. He added that if the review did not include

an investigation of the cover-up allegations, he believes that the report, as

written, is misleading.

Review Planned and

Executed From a

Management Perspective

We determined that the OIG did not plan or conduct its Special Inquiry in a

manner to determine if improper acts pertaining to a cover-up had

occurred. According to the Assistant IG, in preparing the report, he

examined components of the complainant’s allegation separately, rather

than linking or relating the information gathered. He added that had the

inquiry included investigation of a crime, it would have been appropriate

to show whether a pattern of conduct existed. One method of establishing

such a pattern, as is required by the OIG’s Investigative Policy and

7

The Inspector General retired in January 1996.

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Procedure Guide for special inquiries, is to create a chronology of events

and actions. The OIG did not do this.

Frequently a single act, taken by itself, is not sufficient to establish that the

act was done willfully and intentionally with improper purpose. However,

a series of acts considered collectively may suggest a pattern of conduct

indicative of intentional impropriety rather than accident or error. For

example, the following actions or alleged actions concerning the Hospital

Director were not linked or followed up on by the OIG. If the OIG had done

so, the linkage would have suggested a pattern of conduct requiring

additional investigation and lines of inquiry by the OIG.

• The Hospital Director did not notify law enforcement authorities of the

unexplained deaths despite the District Counsel’s recommendation that he

do so.

• The Hospital Director did not notify law enforcement authorities of a

statistical relationship between a nurse and the unexplained deaths

despite telling the staff physician who had developed the analysis that he

would do so.

• The Hospital Director, after learning that a staff physician had accused the

nurse in question of killing his patients, did not refer the matter to the OIG.

• The Hospital Director demoted the Hospital’s Chief of Police reportedly

because of the Chief’s efforts to obtain information about the Hospital’s

response to the unexplained deaths.

• The Hospital Director did not provide the Peer Review Board examining

the unexplained deaths with the statistical analysis that established a

relationship between a nurse and the deaths.

• The Hospital Director’s initial reaction to the FBI investigation was to

attempt to obtain confidential information provided to the FBI, potentially

to identify the source of that information.

• The Hospital Director, in an apparent attempt to impede an investigation,

instructed the staff physician who prepared the statistical analysis to have

no further contact with the FBI.

• The Hospital Director’s son—the Chief of Human Resources at the

Hospital—instructed the TQI Coordinator to determine from the FBI and the

OIG whether they had had recent contact with the complainant.

Our review of the OIG case files, interviews with individuals involved with

the Special Inquiry, and statements from knowledgeable Hospital

employees reflected that potential lines of inquiry were not pursued. For

example, in the incident of a conference call between the VA Central

Region Chief of Staff, the Hospital Director, the Hospital pathologist, and

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the TQI Coordinator, it was alleged that the Central Region Chief of Staff, in

response to the issue of notifying law enforcement, stated that the last

time law enforcement authorities had been called in, both the Chief of

Staff and the Hospital Director were fired. The Special Inquiry analysts

interviewed the pathologist and the TQI Coordinator. One individual

recalled the statement being made; the other did not. However, the

analysts never interviewed the Hospital Director or the Central Region

Chief of Staff about this issue. Because of this, it was never verified that

the conversation had taken place as alleged; and the OIG never attempted

to resolve the conflicting testimony by questioning the person who had

allegedly made the statement or the person to whom the statement had

allegedly been made.

Based on our review of relevant memorandums and tape recordings of

interviews, we determined that the analysts questioned the Hospital

Director and the Central Region Chief of Staff about compliance with VA

policies. The analysts told us they accepted “I don’t know” answers instead

of asking follow-up questions. For example, the analysts accepted, without

probing further, the Hospital Director’s response that he did not recall the

District Counsel’s advice in August 1992 that he notify the FBI or OIG about

the unexplained deaths. In another instance, the Hospital Director

responded to the analysts that he could not recall the actions he had taken

to monitor Hospital management’s investigation of the deaths. At a

minimum, the analysts should have provided the Hospital Director

available information to refresh his recollection.

OIG Noncompliance

With Policies, Report

Inaccuracies, and

Unsupported

Statements

In conducting the Special Inquiry, the OIG failed to follow its own policies

concerning completeness and accuracy of its reports.8

 As a result, the OIG’s

Special Inquiry report contained statements that were either inconsistent

with or unsupported by the evidence contained in the OIG’s files. We noted

inaccuracies in the way the OIG (1) reported the Hospital Director’s failure

to notify law enforcement9

 of the possible association of a particular nurse

to an unexplained increase in deaths, (2) attributed remarks to the

Hospital Director and the Central Region Chief of Staff about withholding

8

The Quality Standards for Investigations established by the President’s Council on Integrity and

Efficiency are guidelines applicable to all types of federal investigative efforts. The VA OIG has

adopted these standards and has incorporated them into the standards in its policy and procedure

guide. VA OIG reporting policy states, in part, “Reports must cover all relevant aspects of the

investigation (complete); [and] correctly and succinctly describe the facts uncovered and evidence

obtained (accurate) . . . .”

9

The Hospital Director never reported the suspicious deaths to the FBI or any other law enforcement

organization.

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statistical analysis information from a Peer Review Board, and

(3) assessed the Hospital Director’s instructions to the complainant that he

refrain from making further contacts with the FBI and the OIG about the

case.

Failure to Inform Law

Enforcement

The Special Inquiry report stated that the Hospital Director had asked the

Central Region Chief of Staff for his opinion on whether to report to

authorities the unexplained deaths and the possible relationship of a

particular nurse to the deaths. According to the report, the Central Region

Chief of Staff responded that he “thought the situation warranted far more

review before [the Hospital Director] either relieved [the nurse] of patient

care duties or notified law enforcement authorities [and he] advised the

Hospital Director not to notify law enforcement authorities until the

reviews were completed.” The OIG report concluded that “[the Hospital

Director] followed the advice of the Central Region Chief of Staff and did

not report the issue to law enforcement.”

As written, the report leads one to believe that the Hospital Director

followed the advice of the Central Region Chief of Staff not to report the

situation to law enforcement authorities. However, we found insufficient

documentation to support the OIG report’s conclusion that the Central

Region Chief of Staff had told the Hospital Director not to report the issue

to law enforcement authorities. Our review of memorandums of interview

and transcripts of recorded interviews found inconclusive evidence that

the Central Region Chief of Staff and the Hospital Director discussed

whether to report the issue.10 Further, when asked to do so, the OIG was

unable to cite the evidence supporting its conclusion.

Misinformation About

Withholding the

Complainant’s Statistical

Analysis

On September 3, 1992, a Hospital Peer Review Board was convened to

evaluate five August deaths on Ward 4 East at the Hospital; but the Board

was not provided with a staff physician’s statistical analysis that had

reported a statistical relationship between the increase in deaths and a

particular nurse. The Special Inquiry report concludes that “The Peer

Review Board was not a ’sham’ as alleged by the complainant, but was

limited in scope and did not consider the statistics developed by [the staff

physician].” According to the report, the Central Region Chief of Staff and

the Hospital Director stated that they had withheld the statistical analysis

10A telephone interview of the Central Region Chief of Staff’s remarks is documented in a

memorandum. The Hospital Director’s interview was recorded and a memorandum of interview was

also prepared.

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from the Board members to allow them to take an objective look at the

cases.

However, documentation shows that the Central Region Chief of Staff told

the OIG that he had never issued instructions to deny the Peer Review

Board access to the data. According to the memorandum of interview

prepared by the OIG, the Hospital Director told the OIG that he recalled no

one asking him whether the Peer Review Board could look at the

statistical data and that it did not occur to him to let the Board members

have the data.

Limitations on

Complainant’s

Communications With Law

Enforcement

In a March 1994 letter, the Hospital Director instructed the complainant,

“You should . . . refrain from further contacts with the FBI and OIG about

this case. If you are contacted directly by either the FBI or OIG you should

inform me of the content of your discussion.” Noting that the Director had

improperly attempted to limit the complainant’s communications with the

OIG and the FBI in March 1994, the Special Inquiry report stated that

nothing requires an employee to provide information to a supervisor

regarding discussions with the FBI or the OIG. The report also noted that

“By making such a requirement, management is in effect stifling an employee’s ability to

discuss matters openly and freely with the investigators. The Director’s action can be

viewed as an effort to impede an official investigation by intimidating employees, and is

clearly improper. However, from a practical standpoint, [the Hospital Director’s] action to

the best of our knowledge did not limit the OIG or the FBI in obtaining appropriate

information from [the complainant] or other [Hospital] employees.” (Emphasis added.)

We found no documentation to support the Special Inquiry report’s

conclusion that the Hospital Director’s action did not limit the OIG or the

FBI in obtaining information from the complainant or other Hospital

employees. Except for an OIG memorandum of interview with the Hospital

Director, we found no evidence of an investigative effort in support of the

report’s conclusion. At a minimum, one would expect to find

documentation that the OIG had talked to the complainant and the

cognizant FBI and OIG criminal investigators before arriving at such a

conclusion.

Circumstances

Surrounding Special

Inquiry’s 2-Year Delay

The OIG received the complainant’s allegations of a cover-up of patient

deaths in February 1993, immediately acknowledged its receipt, provided a

copy of the letter to the FBI in March 1993, and filed the complainant’s

letter without investigating the allegations. The OIG did not begin its inquiry

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until after the complainant discussed the allegations with the media in

January 1995.11 The OIG’s Special Inquiry report issued in September 1995,

attributed the delay to administrative error.

Complainant’s Allegation

Letter Filed Without

Investigation

In February 1993, when the OIG received the complainant’s allegations of a

cover-up of patient deaths, it referred the allegations to its Office of

Investigations. The OIG investigator told us that he had contacted the

complainant to acknowledge receipt of the allegations and had advised

him that all his assets were being expended on other matters. Further, he

told us that in addition to a murder investigation, he was investigating a

death threat and a sexual assault. Although the OIG criminal investigator

and the Assistant IG for Investigations did not recall if they had sent a copy

of the allegation letter to the FBI, we learned that a copy of the letter

containing the allegations had been provided to the FBI in March 1993. The

original letter was filed in the OIG’s field office in Kansas City, Missouri;

and no follow-up action was initiated.

The Assistant IG for Investigations told us that when his office received the

complainant’s letter in February 1993, the criminal investigation with the

FBI was ongoing and all resources were being devoted to that investigation.

He said that it was a “collective decision” on the part of the Office of

Investigations that no further investigation was necessary. Further,

according to the Assistant IG, the FBI and OIG criminal investigation had not

disclosed any evidence that VA officials were involved in a cover-up, and

the complainant’s letter contained no new information. He stated that the

OIG’s failure to follow up on the allegations was a failure of its process.

The former IG told us that he was upset in January 1995 when he became

aware, as a result of media inquiries, that the complainant’s allegations

had not yet been investigated. He further stated that when the OIG received

the allegations in February 1993, the most important thing in his mind was

the unexplained deaths.

FBI Perceived Allegations

to Be Administrative

In response to our inquiries, the FBI told us that because the complainant’s

February 1993 letter primarily concerned “the issue of the administrative

response” of VA managers, the allegations were not within the investigative

jurisdiction of the FBI. Also, because the FBI found no evidence of criminal

activity in connection with the unexplained deaths, the FBI criminal

11On January 10, 1995, a newspaper article identified the complainant as the source of cover-up

allegations and an additional allegation.

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investigation did not inquire into the allegations of a cover-up on the part

of VA management. Further, according to the FBI, had the FBI investigation

developed evidence of criminal activity at the VA, it would have explored

the potential culpability of any person—whether management, employee,

or staff—before, during, and after the deaths, to include deliberate

attempts to cover up.

OIG Attributed Delay to

Administrative Error

The Special Inquiry report stated that, due to administrative error, the OIG

had waited too long to initiate the Special Inquiry. During the interval

(February 1993 to January 1995), the Hospital Director retired and the

Central Region Chief of Staff resigned from the VA.

VA OIG Failed to

Protect Complainant’s

Confidentiality

When the complainant sent his February 1993 letter to the OIG alleging

cover-up by the Hospital Director and the Central Region Chief of Staff, he

requested confidentiality.12 The Special Inquiry review looked at whether

the OIG protected the complainant’s right to confidentiality. In the Special

Inquiry report, two instances were discussed in which the OIG had

disclosed its contacts with the complainant to the Central Region and,

ultimately, to the Hospital Director. The OIG report concluded that the OIG

should have been more careful in protecting the complainant’s

confidentiality, and it attributed one of the confidentiality disclosures to

an “error” and the other to an “honest mistake.” We found a third instance

in which the complainant’s contact with the OIG was provided to Hospital

management. All three disclosures were related to the March 1994

Hospital Director’s letter to the complainant advising him not to have

contact with the FBI or OIG.

OIG Office of

Investigations Gave

Complainant’s Documents

to District Counsel

In March 1994, the OIG Office of Investigations received documents from

the FBI that had been prepared by the complainant. In turn, the Office of

Investigations passed the information to the District Counsel,13 who

forwarded it to the Central Region and the Hospital Director. The

complainant alleged that the ultimate disclosure to the Central Region

indicates that the OIG was participating with the Central Region to

12Section 7(b) of the Inspector General Act of 1978, 5 U.S.C. App. 3, provides that “The Inspector

General shall not, after receipt of a complaint or information from an employee, disclose the identity

of the employee without the consent of the employee, unless the Inspector General determines such

disclosure is unavoidable during the course of the investigation.”

13The OIG investigator perceived the information received from the FBI as dealing with quality

assurance issues and forwarded the materials to the District Counsel in the mistaken belief that the

Counsel had responsibility for quality assurance issues.

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suppress an inquiry of a cover-up. The Special Inquiry report, however,

characterized what happened as an error, stating that the OIG had provided

the documents to the Office of the District Counsel, which represents both

the Hospital and the Central Region, without any restrictions on their

dissemination.

OIG Office of Healthcare

Inspections Released

Information to VA Central

Region

The complainant alleged that in March 1994, the Assistant IG for

Healthcare Inspections14 gave Central Region officials a report of contact

with the complainant as part of an OIG effort to suppress information about

actions by Hospital and Central Region officials. The Special Inquiry report

stated that (1) in this instance the OIG had an obligation not to release the

complainant’s identity to other VA officials without the complainant’s

consent and (2) controls to prevent such release were not properly

applied.

OIG Office of Healthcare

Inspections Released

Information to Hospital

Management

The Hospital Total Quality Improvement (TQI) Coordinator told us that on

January 11, 1995, prior to the Special Inquiry, the Assistant IG for

Healthcare Inspections telephoned her and requested information

concerning the Hospital’s original response to the unexplained deaths on

Ward 4 East. During the conversation, the TQI Coordinator asked about OIG

plans to investigate the complainant’s obstruction-of-justice allegation.

The Assistant IG acknowledged recent contact with the complainant and

stated that the OIG had no plans to investigate the allegations unless it was

forced to do so. The Special Inquiry did not identify this incident, which

involved the same Assistant IG who had released the complainant’s name

once before to the Central Region.

On the same day of this incident, the TQI Coordinator, at the request of the

Hospital Chief of Human Resources and the Associate Director, contacted

the FBI and the Kansas City OIG to determine if they had recently been in

contact with the complainant. The FBI referred her to the Kansas City OIG.

In contrast with the Assistant IG’s previously discussed answer

acknowledging contact with the complainant, the Kansas City OIG advised

that it would have to consult with OIG Counsel prior to any discussions

concerning the complainant. The Kansas City OIG later contacted the TQI

Coordinator and stated that OIG Counsel had advised that it could not

respond to the Hospital’s inquiry.

14The Assistant IG for Healthcare Inspections retired in June 1996.

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The Hospital Chief of Human Resources15 told us he was not sure why he

and the Associate Director had the TQI Coordinator make the inquiries

concerning contact with the complainant but thought it concerned a

March 9, 1994, letter from the Hospital Director advising the complainant

not to have any contact with the FBI or the OIG.

Revised Policies and

Procedures

Our review of the August 1995 revision of the OIG Policy and Procedure

Guide, Part I, Chapter 12 - Hotline, indicates that the OIG’s policies and

procedures concerning Protection of Complainants (Section 5) mirror

accepted standard hotline policies and procedures in federal agencies.

Consistent adherence to and ongoing awareness of these policies by OIG

personnel should result in effective protection of complainants.

OIG Comments and

Our Evaluation

The Department of Veterans Affairs’ Office of Inspector General provided

written comments on a draft of this report. The IG disagreed with our

report, stating that the OIG had found a number of errors in the findings

and conclusions presented in the report and in the analyses offered to

support the conclusions. The IG is of the opinion that there is no evidence

to support our overall conclusion that the OIG Special Inquiry report was

misleading.

Mainly, the IG disagrees with (1) our statement that the OIG did not

investigate the cover-up allegation, (2) one of the three statements in the

Special Inquiry report—an OIG conclusion—that we cite in our report as

being inaccurate and unsupported by evidence, and (3) the inclusion in

our report of a finding—based on an alleged violation of

confidentiality—that “lacks credibility.” Concerning the first point,

regardless of how the OIG characterizes its work, its review was not

planned or executed in a manner that would support its conclusions.

Neither did the OIG link or follow up on information it had available during

its review. Concerning the second point, as we have shown, no underlying

documentation supports the OIG’s conclusion that the complainant’s

communication with law enforcement entities had not been limited. With

regard to the third point, our discussion of an alleged breach of

confidentiality is based on substantive documentation and testimonial

evidence that the improper disclosure occurred. The fact that the media

had disclosed the complainant’s name did not relieve the OIG from its

15The Chief of Human Resources at the Hospital is the son of the Hospital Director, one of the subjects

of the allegations. The son was selected for the position in July 1994.

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responsibility to maintain confidentiality. The OIG had an obligation not to

release the complainant’s identity without his authorization.

An underlying theme of the IG’s comments is that we took individuals’

comments out of context or misrepresented facts. Also, according to his

comments, some of the individuals that we interviewed either denied or

did not recall discussing a particular matter with us. It is important to note

that our findings and conclusions are based on in-depth analyses of

documentation we obtained and interviews of witnesses that are

documented in our reports of interview. We have included additional

information in our report supporting our findings.

The IG objected to a proposed recommendation regarding the adequacy of

the OIG policies and procedures for protecting the privacy of complainants.

He stated that the issue is compliance and training, not formulating or

rewriting existing policy. We concur with the IG and have withdrawn the

proposed recommendation. The IG’s complete written comments, and our

evaluation, are presented in appendix II.

Scope and

Methodology

We conducted our review from April 1997 to March 1998 at the VA OIG

headquarters in Washington, D.C., and the Harry S Truman Memorial

Veterans Hospital in Columbia, Missouri. Initially, we reviewed the draft

and final OIG Special Inquiry reports and related files and workpapers. We

interviewed both current and former OIG officials and Hospital personnel

involved with the review of the suspicious deaths. We also reviewed (1) all

congressional testimony and related documents, (2) the OIG Investigative

Policy and Procedure Guide, and (3) all transcripts and tapes of the

recorded interviews conducted during the Special Inquiry. We transcribed

all tapes that had not been transcribed by the OIG. We reviewed available

files at the Hospital and documentation provided by individuals

interviewed. In conducting our review, we also assessed the OIG’s policies

and procedures concerning confidentiality.

As agreed with your office, unless you announce its contents earlier, we

plan no further distribution of this report until 30 days after the date of

this letter. At that time, we will send copies of the report to interested

congressional committees; the Secretary of Veterans Affairs; and the

Inspector General, Department of Veterans Affairs. We will also make

copies available to others on request. If you have any questions concerning

this report, please contact me at (202) 512-6722 or Assistant Director

Page 13 GAO/OSI-98-9 VA OIG’s Misleading Special Inquiry Report
B-279646 

Robert E. Lippencott at (312) 220-7600. Major contributors to this report

are listed in appendix III.

Sincerely yours,

Eljay B. Bowron

Assistant Comptroller General

 for Special Investigations

Page 14 GAO/OSI-98-9 VA OIG’s Misleading Special Inquiry Report
Page 15 GAO/OSI-98-9 VA OIG’s Misleading Special Inquiry Report
Contents

Letter 1

Appendix I 

Background

18

Appendix II 

Comments From the

Office of Inspector

General Department

of Veterans Affairs

20

Appendix III 

Major Contributors to

This Report

48

Abbreviations

FBI Federal Bureau of Investigation

GAO U.S. General Accounting Office

IG Inspector General

OIG Office of Inspector General

OSI Office of Special Investigations

TQI Total Quality Improvement

VA Department of Veterans Affairs

Page 16 GAO/OSI-98-9 VA OIG’s Misleading Special Inquiry Report
Page 17 GAO/OSI-98-9 VA OIG’s Misleading Special Inquiry Report
Appendix I 

Background

From March 8, 1992, through August 23, 1992, when a certain registered

nurse worked the night shift alone on Ward 4 East at the Harry S Truman

Memorial Veterans Hospital, the number of deaths on the ward increased,

with dramatic spikes in May, June, and July. The death rate returned to

normal when the nurse was assigned to another unit. A statistical analysis

conducted by a Hospital staff physician in September 1992 confirmed that

a statistically significant relationship existed between increased deaths on

Ward 4 East and the duty times of the nurse. The staff physician concluded

in his original statistical analysis that the probability that no relationship

existed between the deaths and the duty times of the nurse was less than 1

in 1,000 (in 1994, it was determined to be less than 1 in 1 million). The VA

Central Region Chief of Staff requested in October 1992 that the OIG Office

of Healthcare Inspections help resolve questions involved with the

Hospital staff physician’s study. The OIG Office of Healthcare Inspections

issued a report in September 1994, confirming the results of the initial

statistical study.

In October 1992, based on information provided by a Missouri state

legislator, the FBI and the OIG initiated a joint civil rights criminal

investigation concerning the suspicious deaths at the Hospital. On

February 2, 1998, the FBI issued a report to the Congress concluding that it

had conducted an extensive investigation and that the federal statute of

limitations had expired in August 1997 without any determination that a

crime had, in fact, been committed.

In a February 1993 letter, the staff physician who conducted the statistical

study at the Hospital alleged to the OIG that both the Hospital and VA

Central Region management had covered up the increase in patient deaths

on Ward 4 East. In the letter, the staff physician requested confidentiality.

The Inspector General referred the allegations of a cover-up to the OIG’s

Office of Investigations for investigation. The Office of Investigations

determined that due to the priority of the investigation of the suspicious

deaths, no immediate action would be taken on these allegations. The

letter was placed in the investigative file, and a copy was provided to the

FBI in March 1993.

In January 1995, after the complainant went to the media, the IG instructed

the Assistant IG for Departmental Reviews and Management Support to

conduct an administrative review (known as a Special Inquiry) of the

allegations that included a cover-up. In a series of letters that followed the

start of the Special Inquiry, the complainant reiterated his allegations of a

cover-up, not only by Hospital and VA management but by VA OIG as well.

Page 18 GAO/OSI-98-9 VA OIG’s Misleading Special Inquiry Report
Appendix I 

Background

He also alleged that the cover-up had continued even after the start of the

joint FBI/VA OIG investigation. In the Special Inquiry report issued in

September 1995, the OIG concluded that the evidence pointed to bad

management rather than to a deliberate plan to cover up or suppress

information.

A congressional hearing was held in October 1995, and VA healthcare and

OIG officials testified about the Special Inquiry and other matters. In their

testimony, VA and OIG officials agreed with the findings of VA OIG Special

Inquiry report and stated that no evidence of a cover-up by management

had been found. OIG officials admitted, however, that the OIG had taken too

long in dealing with the complainant’s allegations and attributed the 2-year

delay to other priorities and administrative error. OIG officials concluded

that even though no evidence of criminal misconduct had been found, they

did find “a dysfunctional management team . . . in place” that had made

significant judgmental errors in responding to the unexpected deaths. In

its prepared statement, the OIG expressed concerns about its shortcomings

in protecting the complainant’s identity and stated that it had issued a

written apology to the complainant.

Page 19 GAO/OSI-98-9 VA OIG’s Misleading Special Inquiry Report
Appendix II 

Comments From the Office of Inspector

General Department of Veterans Affairs

Note: GAO comments

supplementing those in the

report text appear at the

end of this appendix.

Page 20 GAO/OSI-98-9 VA OIG’s Misleading Special Inquiry Report
Appendix II 

Comments From the Office of Inspector

General Department of Veterans Affairs

Page 21 GAO/OSI-98-9 VA OIG’s Misleading Special Inquiry Report
Appendix II 

Comments From the Office of Inspector

General Department of Veterans Affairs

Now on pp. 3-6.

Now on p. 3.

See comment 1.

Page 22 GAO/OSI-98-9 VA OIG’s Misleading Special Inquiry Report
Appendix II 

Comments From the Office of Inspector

General Department of Veterans Affairs

Page 23 GAO/OSI-98-9 VA OIG’s Misleading Special Inquiry Report
Appendix II 

Comments From the Office of Inspector

General Department of Veterans Affairs

Now on p. 4.

Now on p. 4.

See comment 2.

Page 24 GAO/OSI-98-9 VA OIG’s Misleading Special Inquiry Report
Appendix II 

Comments From the Office of Inspector

General Department of Veterans Affairs

See comment 1.

Page 25 GAO/OSI-98-9 VA OIG’s Misleading Special Inquiry Report
Appendix II 

Comments From the Office of Inspector

General Department of Veterans Affairs

Now on p. 10.

Page 26 GAO/OSI-98-9 VA OIG’s Misleading Special Inquiry Report
Appendix II 

Comments From the Office of Inspector

General Department of Veterans Affairs

Now on p. 4.

See comment 2.

See comment 3.

See comment 4.

Page 27 GAO/OSI-98-9 VA OIG’s Misleading Special Inquiry Report
Appendix II 

Comments From the Office of Inspector

General Department of Veterans Affairs

Now on p. 4.

Now on p. 6.

See comment 5.

See comment 2.

See comment 2.

Page 28 GAO/OSI-98-9 VA OIG’s Misleading Special Inquiry Report
Appendix II 

Comments From the Office of Inspector

General Department of Veterans Affairs

See comment 2.

Now on pp. 6-8.

Page 29 GAO/OSI-98-9 VA OIG’s Misleading Special Inquiry Report
Appendix II 

Comments From the Office of Inspector

General Department of Veterans Affairs

Now on p. 6.

Page 30 GAO/OSI-98-9 VA OIG’s Misleading Special Inquiry Report
Appendix II 

Comments From the Office of Inspector

General Department of Veterans Affairs

Now on pp. 7-8.

Page 31 GAO/OSI-98-9 VA OIG’s Misleading Special Inquiry Report
Appendix II 

Comments From the Office of Inspector

General Department of Veterans Affairs

See comment 6.

Now on p. 8.

Now on p. 8.

Page 32 GAO/OSI-98-9 VA OIG’s Misleading Special Inquiry Report
Appendix II 

Comments From the Office of Inspector

General Department of Veterans Affairs

See comment 6.

Now on pp. 8-10.

Page 33 GAO/OSI-98-9 VA OIG’s Misleading Special Inquiry Report
Appendix II 

Comments From the Office of Inspector

General Department of Veterans Affairs

See comment 7.

Now on p. 9.

See comment 8.

Page 34 GAO/OSI-98-9 VA OIG’s Misleading Special Inquiry Report
Appendix II 

Comments From the Office of Inspector

General Department of Veterans Affairs

Now on pp. 10-12.

Now on pp. 10-11.

Page 35 GAO/OSI-98-9 VA OIG’s Misleading Special Inquiry Report
Appendix II 

Comments From the Office of Inspector

General Department of Veterans Affairs

Page 36 GAO/OSI-98-9 VA OIG’s Misleading Special Inquiry Report
Appendix II 

Comments From the Office of Inspector

General Department of Veterans Affairs

Now on p. 11.

See comment 9.

Now on p. 12.

Page 37 GAO/OSI-98-9 VA OIG’s Misleading Special Inquiry Report
Appendix II 

Comments From the Office of Inspector

General Department of Veterans Affairs

See comment 10.

See comment 11.

Now on pp. 3 and 12.

See comment 12.

Page 38 GAO/OSI-98-9 VA OIG’s Misleading Special Inquiry Report
Appendix II 

Comments From the Office of Inspector

General Department of Veterans Affairs

Page 39 GAO/OSI-98-9 VA OIG’s Misleading Special Inquiry Report
Appendix II 

Comments From the Office of Inspector

General Department of Veterans Affairs

See comment 13.

Page 40 GAO/OSI-98-9 VA OIG’s Misleading Special Inquiry Report
Appendix II 

Comments From the Office of Inspector

General Department of Veterans Affairs

Now on p. 3.

See comment 14.

Now on p. 1.

Page 41 GAO/OSI-98-9 VA OIG’s Misleading Special Inquiry Report
Appendix II 

Comments From the Office of Inspector

General Department of Veterans Affairs

Now on p. 18.

Now on p. 18.

Now on p. 18.

Page 42 GAO/OSI-98-9 VA OIG’s Misleading Special Inquiry Report
Appendix II 

Comments From the Office of Inspector

General Department of Veterans Affairs

Now on p. 9.

Now on pp. 6-7.

Now on p. 9.

Now on p. 13.

Now on p. 13.

Now on p. 18.

Page 43 GAO/OSI-98-9 VA OIG’s Misleading Special Inquiry Report
Appendix II 

Comments From the Office of Inspector

General Department of Veterans Affairs

Page 44 GAO/OSI-98-9 VA OIG’s Misleading Special Inquiry Report
Appendix II 

Comments From the Office of Inspector

General Department of Veterans Affairs

The following are GAO’s comments on the Department of Veterans Affairs

Office of Inspector General’s letter dated April 24, 1998.

GAO Comments 1.Despite how the OIG may characterize its work, we determined that its

review was not planned or executed in a manner that would support the

conclusion that it had found “no conclusive proof of an intentional

cover-up” by Hospital and Central Region officials and “no evidence of

criminal misconduct by top management.” The work done, as described by

those who did it and as reflected in the workpapers, did not include

collecting and analyzing evidence to identify intentional cover-up efforts.

2.In addition to in-depth analyses of pertinent documentation, our findings

and conclusions are based on extensive interviews of witnesses, including

the Assistant IG and lead analyst. Further, these interviews were

conducted without the presence of OIG management and the influence that

may result from such presence. Information contained in our report was

taken from documentation we examined and witnesses we interviewed.

To help refresh their recollections and focus them on the issues, we

provided the witnesses with copies of relevant sections of the OIG manual

and supporting documentation for the Special Inquiry. We have also

included additional information in our report to support our findings.

3.According to the VA OIG criminal investigator who conducted the criminal

investigation with the FBI, he never read the Special Inquiry report that was

issued in 1995. Further, he said he has no idea as to whether statements in

the report were true or accurate.

4.Section A of the Special Inquiry report is the Hospital and Central Region

management’s response to the unexplained deaths. That section concludes

that the OIG found “no conclusive proof of an intentional cover-up by

Medical Center and Region officials” and “no evidence of criminal conduct

by top management.” No attempt was made to formally reconcile the final

Special Inquiry report to the underlying evidence until we asked whether

such a reconciliation had been done. Further, following our request in

1997, the analyst who was responsible for referencing the report told us

that she was unable to reconcile some of the stated facts.

5. We have added to our report a discussion of the types of issues we

believe the OIG should have probed further and examples of instances in

which further probing could have elicited additional information.

Page 45 GAO/OSI-98-9 VA OIG’s Misleading Special Inquiry Report
Appendix II 

Comments From the Office of Inspector

General Department of Veterans Affairs

6.We disagree that a conclusion needs no supporting evidence. Since

conclusions represent review and analysis of evidence, it is essential to

include documentation and its analysis in the workpapers. But the OIG had

no evidence or analysis to support its conclusion. Further, contrary to the

OIG’s conclusion, documentation in the OIG file suggested that the Hospital

Director’s actions limited access. For example, according to a

memorandum for the record prepared by the lead analyst, the criminal

investigator told the analyst that he suspected that the Hospital Director

had told Hospital staff not to talk to investigators.

7.We have added a reference to our report about the OIG’s receipt of an

additional allegation from the complainant.

8.We have clarified our report to show the source of our statement about

the reason for the OIG’s delaying action on the complainant’s allegations.

9.While we did not interview the Assistant IG for Healthcare Inspections,

the IG is incorrect in his assumption that the facts as stated in our report

are based solely on the statements made to us by the TQI Coordinator.

Rather, the reason that we interviewed the TQI Coordinator was to

corroborate statements contained in a January 1995 contact memorandum

that she had prepared—immediately following the contact—to document

her telephone conversation with the Assistant IG.

10.We have revised our report to reflect that the TQI Coordinator contacted

the FBI at the request of the Associate Director and the Chief of Human

Resources.

11.The referenced footnote has nothing to do with the Hospital

management’s investigation of alleged nepotism concerning the

appointment of the Director’s son as Chief of Human Resources. Rather,

the purpose of the footnote is to inform the reader that the person who

requested the TQI Coordinator to make calls concerning the complainant is

the son of the individual on whom the complainant focused his allegations.

12.The IG’s characterization of its June 1993 Hotline policies as the most

recent is incorrect. The current policy was issued in August 1995 as

reflected in our report. The OIG’s May 1, 1998, acknowledgement of this

fact appears in the appended addendum.

13.We have withdrawn our proposed recommendation for revising the

OIG’s August 1995 policies and procedures for protecting the privacy of

Page 46 GAO/OSI-98-9 VA OIG’s Misleading Special Inquiry Report
Appendix II 

Comments From the Office of Inspector

General Department of Veterans Affairs

complainants. We concur with the IG that any corrective action would

require training and compliance with policy, not formulating or rewriting

policy. Accordingly, we have made the appropriate changes to our report.

14.We have considered these comments and made changes to the report

where appropriate.

Page 47 GAO/OSI-98-9 VA OIG’s Misleading Special Inquiry Report
Appendix III 

Major Contributors to This Report

Office of Special

Investigations,

Washington, D.C.

Jim Locraft, Special Agent

Barbara W. Alsip, Communications Analyst

Trudy Moreland, Project Manager

Thomas A. Luttrell, Senior Evaluator

Chicago Field Office Robert E. Lippencott, Assistant Director for Investigations

Office of the General

Counsel, Washington,

D.C.

Aldo A. Benejam, Senior Attorney

(600441) Page 48 GAO/OSI-98-9 VA OIG’s Misleading Special Inquiry Report
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