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87–677 2015

A CONTINUED ASSESSMENT OF DELAYS IN VA 

MEDICAL CARE AND PREVENTABLE VETERANS 

DEATHS 

HEARING 

BEFORE THE

COMMITTEE ON VETERANS’ AFFAIRS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED THIRTEENTH CONGRESS 

SECOND SESSION 

WEDNESDAY, APRIL 9, 2014 

Serial No. 113–64 

Printed for the use of the Committee on Veterans’ Affairs 

( 

Available via the World Wide Web: http://www.fdsys.gov 


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COMMITTEE ON VETERANS’ AFFAIRS 

JEFF MILLER, Florida, Chairman 

DOUG LAMBORN, Colorado 

GUS M. BILIRAKIS, Florida, Vice-Chairman 

DAVID P. ROE, Tennessee 

BILL FLORES, Texas 

JEFF DENHAM, California 

JON RUNYAN, New Jersey 

DAN BENISHEK, Michigan 

TIM HUELSKAMP, Kansas 

MIKE COFFMAN, Colorado 

BRAD R. WENSTRUP, Ohio 

PAUL COOK, California 

JACKIE WALORSKI, Indiana 

DAVID JOLLY, Florida 

MICHAEL H. MICHAUD, Maine, Ranking 

Minority Member 

CORRINE BROWN, Florida 

MARK TAKANO, California 

JULIA BROWNLEY, California 

DINA TITUS, Nevada 

ANN KIRKPATRICK, Arizona 

RAUL RUIZ, California 

GLORIA NEGRETE MCLEOD, California 

ANN M. KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

TIMOTHY J. WALZ, Minnesota 

JON TOWERS, Staff Director 

NANCY DOLAN, Democratic Staff Director 

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records 

of the Committee on Veterans’ Affairs are also published in electronic form. The printed 

hearing record remains the official version. Because electronic submissions are used to 

prepare both printed and electronic versions of the hearing record, the process of converting 

between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process 

is further refined. 


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C O N T E N T S 

Page 

Wednesday, April 9, 2014 

A Continued Assessment of Delays in VA Medical Care and Preventable 

Veterans Deaths ................................................................................................... 1 

OPENING STATEMENTS 

Hon. Jeff Miller, Chairman ..................................................................................... 1 

Prepared Statement ......................................................................................... 45 

Hon. Michael Michaud, Ranking Minority Member 

Prepared Statement ......................................................................................... 46 

Hon. Corrine Brown ................................................................................................ 3 

Prepared Statement ......................................................................................... 47 

Steve Cohen 

Prepared Statement ......................................................................................... 47 

WITNESSES 

Barry Coates, Veteran ............................................................................................. 4 

Prepared Statement ......................................................................................... 48 

Daniel M. Dellinger, National Commander, The American Legion .................... 6 

Prepared Statement ......................................................................................... 50 

Accompanied by: 

Edward Lilly, Senior Field Service Officer, The American Legion 

Thomas Lynch M.D., Assistant Deputy Under Secretary for Health for Clinical Operations, VHA, U.S. Department of Veterans Affairs ........................... 23 

Prepared Statement ......................................................................................... 61 

Accompanied by: 

Carolyn M. Clancy M.D., Assistant Deputy Under Secretary for Quality, Safety, and Value, VHA, U.S. Department of Veterans Affairs 

Debra A. Draper, Director, Health Care, GAO ..................................................... 36 

Prepared Statement ......................................................................................... 64 

John D. Daigh, Jr. M.D., Assistant Inspector General for Healthcare Inspections, Office of the Inspector General, U.S. Department of Veterans Affairs ....................................................................................................................... 38

Prepared Statement ......................................................................................... 82 

QUESTIONS FOR THE RECORD 

Questions From Chairman Miller to VA ............................................................... 90 


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A CONTINUED ASSESSMENT OF DELAYS IN 

VA MEDICAL CARE AND PREVENTABLE 

VETERANS DEATHS 

Wednesday, April 9, 2014 

U.S. HOUSE OF REPRESENTATIVES, 

COMMITTEE ON VETERANS’ AFFAIRS, 

Washington, D.C. 

The committee met, pursuant to notice, at 10:03 a.m., in Room 

334, Cannon House Office Building, Hon. Jeff Miller [chairman of 

the committee] presiding. 

Present: Representatives Miller, Bilirakis, Benishek, 

Huelskamp, Coffman, Cook, Walorski, Jolly, Brown, Brownley, 

Titus, Kirkpatrick, Negrete-McLeod, and O’Rourke. 

Also Present: Representative Cohen. 

OPENING STATEMENT OF CHAIRMAN JEFF MILLER 

The CHAIRMAN. The committee will come to order. Before we 

begin, I would like to ask unanimous consent that when he arrives, 

our colleague from Tennessee, Congressman Steve Cohen, be allowed to sit at the dais and participate in today’s proceedings. 

Hearing no objection, so ordered. 

Ladies and gentlemen, welcome to today’s full committee hearing, a Continued Assessment of Delays in VA Medical Care and 

Preventable Veteran Deaths. 

Today’s hearing is the fulfillment of a promise I made in early 

January to follow-up on delays in care at Veterans Affairs’ Medical 

Centers in Columbia, South Carolina and Augusta, Georgia that together resulted in nine preventable veteran deaths. 

I had hoped that during this hearing we could be discussing the 

concrete changes that VA had made, changes that would show beyond a doubt that VA had placed the care of our veterans first and 

that VA’s commitment to holding any employee who did not completely embody a commitment to excellence through actions appropriate to the employee’s failure to be held accountable. 

Instead today we are faced with even more questions and an 

ever-mounting list of evidence that despite the myriad of patient 

safety incidents that have occurred at VA medical facilities in recent memory, the status quo is firmly entrenched at the Department of Veterans Affairs. 

On Monday, shortly before this public hearing, VA provided evidence that a total of 23 veterans have died due to delays in care 

at VA medical centers. Even with this latest disclosure as to where 

the deaths occurred, our committee still does not know when they 


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may have happened beyond the statement that they most likely occurred between 2010 and 2012. 

These particular deaths resulted primarily from delays in gastrointestinal care. Information on other preventable deaths due to consult delays remains unavailable. 

Outside of the VA’s consult review, this committee has reviewed 

at least 18 preventable deaths that occurred because of mismanagement, improper infection control practices, and a whole 

host, of maladies that plague the VA healthcare system all across 

this great Nation, yet the department’s stone wall has only grown 

higher and more nonresponsive. 

There is no excuse for these incidents to have ever occurred. Congress has met every resource request that VA has made and I 

guarantee that if the department would have approached this committee at any time to tell us that help was needed to ensure that 

veterans received the care they required, every single possible action would have been taken to ensure that VA could, in fact, adequately care for our veterans. 

This is the third full committee hearing that I have held on patient safety. And I am going to save our VA witnesses a little bit 

of time this morning by telling you what I do not want to hear. 

I do not want to hear the rote repetition of, and I quote, ‘‘The 

department is committed to providing the highest quality care 

which our veterans have earned and that they deserve. When incidents occur, we identify, mitigate, and prevent additional risks. 

Prompt reviews prevent similar events in the future and hold those 

persons accountable,’’ end quote. 

Another thing I do not want to hear is again, and I quote from 

numerous VA statements including a recent press release, ‘‘While 

any adverse incident for a veteran within our care is one too 

many,’’ unquote, preventable deaths represent a small fraction of 

the veterans who seek care from VA every year. 

What our veterans have truly earned and deserve is not more 

platitudes and, yes, one adverse incident is one too many. Look, we 

all recognize that no medical system is infallible no matter how 

high the quality standards may be. But I think we also recognize 

that the VA healthcare system is unique because it has a unique, 

special obligation not only to its patients, the men and women who 

honorably serve our Nation in uniform, but also the hard-working 

taxpayers of the United States of America. 

When errors do occur, and they seem to be occurring with alarming frequency, what VA owes our veterans and our taxpayers in 

that order is a timely, transparent, accurate, and honest account 

about what mistakes happened, how those mistakes are being 

fixed, and what concrete actions are being taken to ensure accountability. 

It seems to me that my staff has been asking for further details 

on the deaths that occurred as a result of the delays in care at VA 

medical facilities now for months. And only two days before this 

hearing did VA provide any information that we have been asking 

for. Even then, that information is far from complete in what VA’s 

effort is to prevent future deaths. 

It concerns me even more than that at a briefing that VA provided on Monday and the testimony that is provided today, include 


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very few details about what, if any, specific actions have been 

taken to ensure accountability for 23 veterans who lost their lives 

and the many more who were harmed because they did not get the 

care they needed in a timely fashion. 

The VA witnesses’ testimony that is provided for today is ridiculous. It answers no questions. It provides no new information. And 

I am tired of begging the Department of Veterans Affairs to answer 

this committee’s questions. 

On our first panel today, we are going to hear from a veteran 

who sought care through the William Jennings Bryan Dorn VA 

Medical Center in Columbia, South Carolina, a facility that I visited earlier this year. 

That veteran, Mr. Barry Coates, is going to tell us that, and I 

quote, ‘‘The gross negligence and crippling backlog epidemic of the 

VA system has not only handed me a death sentence but ruined 

my quality of life.’’ 

Mr. Coates waited for almost a year and would have waited even 

longer had he not personally persistently insisted on receiving the 

colonoscopy that he and his doctors knew that they needed. That 

same colonoscopy revealed that Mr. Coates had stage IV colon cancer that has metastasized to his lungs and his liver. 

Maybe that is why VA does not want to define accountability in 

terms of employees who have been fired. The department is going 

to testify this morning that instead we should focus our accountability efforts on correcting system deficiencies in order to prevent 

adverse events from occurring again. 

There is nothing wrong with fixing the system, but Mr. Coates 

deserves better than that. His adverse event already has happened 

and for him, there is no going back. 

[THE PREPARED STATEMENT OF CHAIRMAN JEFF MILLER APPEARS

IN THE APPENDIX] 

With that, I yield to the ranking member, Ms. Brown, for her 

opening statement. 

OPENING STATEMENT OF HON. CORRINE BROWN 

Ms. BROWN. Thank you, Mr. Chairman, for calling this hearing 

today. 

We can all agree that veteran safety and quality of care issues 

at the VA health facilities are the utmost concern for this committee. However, it is unfortunate that we must continually call 

these hearings to make sure that our Nation’s veterans are receiving the care for which they have already paid dearly for on the battlefield and in service to protecting the freedom we all hold most 

dear. 

I also find it disturbing that just two days before this hearing, 

the VA has released findings that its healthcare personnel are not 

fully trained in the importance of timely consulting when treating 

a veteran. 

The definition defined a consultant as the act of seeking information or advice from someone with expertise in a particular area. 

The system the VA set up to make these consults easy obviously 

broke down and it is possible that at least five veterans died in 


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Florida because the right information was not shared with the 

right health professionals. 

I am concerned that in the five years after the colonoscopy debacle in the Miami VA nothing has changed. To refresh your memory, 

in 2009, staff members at a number of VA facilities noticed improper reprocessing of episcopes contrary to the manufacturing instructions. 

The VA properly ordered all facilities to step up and get retrained on the procedures. We want employees to feel free to report 

questionable issues and procedures without fear of retribution for 

trying to save lives. It seems that from the new consultant problems that the retraining stopped at this one procedure. 

The fact sheet your office put out regarding consults talks a lot 

about procedures and adverse events. However, I have heard that 

before and again our veterans are suffering. And I am looking forward to hearing the testimony today and explanations for this lack 

of proper care and accountability for these mistakes. 

I yield back the balance of my time. 

The CHAIRMAN. Thank you very much, Ms. Brown. 

[THE PREPARED STATEMENT OF CORRINE BROWN APPEARS IN THE

APPENDIX] 

Joining us today for our first panel is Mr. Barry Coates. Mr. 

Coates is a disabled veteran who served in the United States Army 

and currently resides in the Palmetto State. As I stated earlier, he 

is going to share his very personal story of attempting to receive 

needed care from the Department of Veterans Affairs. 

Also on the first panel is Daniel Dellinger, national commander 

of The American Legion. The commander is accompanied by Edward Lilly, senior field officer. 

Thank you all for your service both in and out of uniform. 

Thank you in particular, Mr. Coates, for being here today and for 

agreeing to share what I know is a very painful story. This committee is honored to have you here before us today, and you are 

recognized for your statement, Mr. Coates. 

STATEMENT OF BARRY COATES 

Mr. COATES. First of all, I would like to thank Chairman Mr. 

Miller, Ms. Brown, and other Members of the committee for the opportunity to be able to come in front of you today and give you my 

testimony. 

I would like to start, first of all, with the first part of my paragraph of my testimony, and I think each one of you all have that. 

My name is Barry Lynne Coates. And due to the inadequate and 

lack of follow-up care I received through the VA system, I stand 

here before you terminally ill today. 

I joined the army in February of 1991 anxious to serve my country. Near the end of basic training, an injury to my back derailed 

this plan and I was discharged around the 1st of May of the same 

year. 

After five years of fight to obtain service-connection status of my 

injury and treatment and pain management requirement as a result of it, I finally became eligible for medical treatment through 


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the VA system. That was the start of the long, painful, emotional, 

and unnecessary journey that brings me here to you today. 

First of all, I appreciate the opportunity to be able to stand here 

and testify in front of the committee, one for the veterans who have 

died because of this unnecessary tragedy that occurred that should 

not have ever occurred to start with. Also, for the families that 

have lost those veterans and for the veterans who have suffered 

and are still suffering because of this like myself and their families, 

I want to be a voice to them and an advocate to them. 

Hopefully this testimony will prove to the VA system the lack of 

knowledge or the lack of care that they gave to myself and to other 

veterans that need to be changed. Something needs to be created 

to change the policy of the way this is done. 

I talked to numerous veterans since all this occurred and a lot 

of them, I hear the same story like my story, you know, why didn’t 

we receive help, why didn’t I get care earlier, why didn’t it get 

outsourced. And outsourced is probably a good thing that needs to 

be put into policy if it is backed up to a part they cannot control. 

Another thing also that needs to be done for the veterans that 

are struggling, for the ones that have lost their husband or wife, 

it is hard to even get care and medical. 

Another thing, too, to look at, if I am serving in the military 

today and I look at what happened to veterans outside of the VA 

system and their care and I see what is going on there like what 

happened to myself and other veterans, what is a member of the 

military service going to think? They are going to think one thing. 

Well, they are not taking care of the veterans outside of this. Well, 

one day, I will be a veteran also. Are they going to be there to take 

care of myself, my family? 

And that is a big question that probably servicemen who are 

serving now, they are going to ask the question, why would I need 

to serve my country if they are not going to look at me and protect 

me after my service and become a veteran? 

And I think that is something we need to focus on because military service is really volunteer. If you look at time and history dating back to the Revolutionary War, it was all voluntary. And if it 

had not been for that voluntary service, we would not have what 

we got today in this country. And without that, we would not be 

here today and be able to talk to you all and deal with this matter. 

So something needs to be done. Someone needs to be held accountable for it. And I understand from other sources that no one 

has been held accountable for it. And I think someone should be 

held accountable for it, whether it be a director of the Dorn VA 

Hospital or it be the secretary of the Veterans Affairs or even the 

President of the United States. 

Thank you. 

[THE PREPARED STATEMENT OF BARRY COATES APPEARS IN THE

APPENDIX] 

The CHAIRMAN. Thank you, sir, for your testimony. 

And before we go to questions, I do want to ask Commander 

Dellinger if he would please proceed with his statement. 

You are recognized for five minutes. 


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STATEMENT OF DANIEL M. DELLINGER, NATIONAL COMMANDER, THE AMERICAN LEGION, ACCOMPANIED BY EDWARD LILLY, SENIOR FIELD SERVICE OFFICER, THE AMERICAN LEGION 

Mr. DELLINGER. Thank you. 

As the Nation’s largest wartime veteran service organization, 

The American Legion dedicates significant resources towards working with and observing the work of the VA. 

Through the Legion’s System, Worth Saving medical facility visits, Town hall meetings with veterans and the feedback we receive 

from the thousands of American Legion certified Veteran Service 

Officers across the Nation, we are able to provide you with the specific details in our written testimony that you have before you. I 

will highlight just a few of those details to you now. 

Chairman Miller and Members of the committee, on behalf of the 

two and a half million members of The American Legion, I want 

to thank you for inviting The American Legion to share our research and position on the important topics of delay in medical care 

and patient deaths. 

I am here today because The American Legion has no greater 

priority than ensuring that veterans receive timely and quality 

healthcare as a result of their service-connected illnesses. 

It seems a day cannot pass without a news report about the 

problems and challenges the VA faces with delays and quality of 

care issues. While we wait for things to get better, hundreds of 

thousands of veterans are waiting for their initial disability claim 

or appeal which prevents them from receiving VA healthcare. 

While we wait, transitioning servicemembers are falling through 

the cracks due to DoD and VA’s inability to create a single interoperable medical record. 

While we wait, officials in the VA central offices are preventing 

hospitals from being transparent during crisis. While we wait, veteran suicides continue to plague our Nation at 22 per day with no 

clear strategy from VA on addressing suicides proactively. 

And while we wait, veterans are being over-prescribed medications for pain, TBI, PTSD with reluctance toward looking at complementary and alternative medicine because giving out pills is 

faster than providing veterans the therapy sessions they need. 

In January, The American Legion went to Jackson, Mississippi 

where a veteran died as a result of when all the blood was drained 

from his body because he was not properly monitored during a 

medical procedure. 

When our task force members asked the facility director for a 

copy of the action plan they were using to address their problems, 

the director refused to give them a copy. 

Last November, we visited Pittsburgh. At that time, we believe 

the Legionnaire outbreak that left six dead and more than 20 sick 

was due to equipment failure. The neglect on the part of the VA 

to notify local health officials, veterans, and patients was bad 

enough, but then later, we learned that CBS news reported that 

senior officials at the Pittsburgh VA actually knew that human 

error was behind the outbreak and not equipment failures as officials had suggested to this committee. 


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Our System Worth Saving Task Force went to Atlanta in January where two veterans died of an overdose and one committed suicide which was attributed to mismanagement and an inability to 

get the mental healthcare they needed in a timely manner. 

Last night, there was a daughter that missed her dad saying 

goodnight. Today there is a wife who misses her husband. Tomorrow a father will still regret that he was able to outlive his son because someone at the VA did not do their job. 

Patient deaths are tragic. Preventable patient deaths are unacceptable. But failure to disclose safety information or worse, to 

cover up mistakes, is unforgivable and The American Legion will 

not sit quietly by while some VA employees cover up the truth and 

the VA should not either. 

We need to continue to ask the hard questions. What is VA doing 

to fix these problems and are they concerned about keeping me informed? How is VA holding their leaders accountable for these errors? And, finally, why is the VA reducing inpatient long-term care 

beds, ICU, emergency rooms, and closing hospitals such as Hot 

Springs, South Dakota? 

The American Legion will not stop asking the hard questions and 

we hope you won’t either. The American Legion looks forward to 

working with this committee as we work together with the VA to 

ensure that VA provides the best healthcare anywhere. 

Thank you. 

[THE PREPARED STATEMENT OF DANIEL M. DELLINGER APPEARS IN

THE APPENDIX] 

The CHAIRMAN. Thank you, Commander. 

Mr. Coates, in the more or less year that it took for you to receive a colonoscopy through the Department of Veterans Affairs, 

did anybody at any time ever tell you that you could be authorized 

to receive the procedure that you needed done through a private 

provider in the community enabling you to get a diagnosis sooner? 

Mr. COATES. No, sir. I never was advised during that time period. During that time period, I seen from January of 2011 when 

I first complained about it till the day of my colonoscopy which was 

December the 9th of 2011, I seen four different doctors that was 

in the VA system. 

One was Rock Hill Clinic outpatient, Dr. Verna. She was my outpatient clinic doctor I had in Rock Hill, South Carolina. I presently 

moved to the location I live now. I transferred. It takes roughly 

anywhere from four to six months to get a transfer to a different 

location for outpatient care which would have been the Florence 

Clinic. 

Upon that, I seen Dr. Verna on January, March, and I think May 

of that same year and each time, my problem got worse. And she 

made notes in her comments because I retrieved copies of those 

from the VA. And she made note of those saying may need 

colonoscopy. Never set a consult up for it. 

Upon getting transferred to the Florence Clinic in June of 2011, 

if I remember correctly, Dr. Naumann was my clinic doctor there. 

And being a new patient, he done a full exam, looked over information from Dr. Verna prior to treating me. And he kind of got upset 

because she did not have me on a certain prescription because of 


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taking pills for pain would cause certain problems and that I 

should have been on something already from that from being on 

those for quite a few years. 

But he immediately set me a consult up with a GI surgeon which 

I did not ever get an appointment with her until probably either 

around the eighth month, maybe the ninth month, if I remember 

correctly, Dr. Kim. 

And upon seeing her, I seen her twice, she delayed it another two 

to three months and I went back to her again around the tenth 

month. We did not have a good communication ability between 

each other because she kind of made me mad from my first appointment because of things that she could have done then that 

would have resulted earlier and set the consult up for a 

colonoscopy earlier if she would have done a couple other procedures other than a physical exam. 

I learned that she could have done a CT exam or a CT scan. She 

could have done a lithoscope exam which would have found the 

tumor that was only five inches in the area, in the lower rectum 

area. 

After that appointment with her on the 10th, she set me up for 

a consult for the colonoscopy to be done which I received the appointment in the mail two weeks later. And it was actually scheduled for April of the following year. We are talking six more 

months out and I had already been in pain for eight months already and suffering because of this. But I did not let that stand in 

front of me, so I called the department that scheduled that appointment and they told me that is the normal time is usually around 

six months before you can get a colonoscopy. There was nothing 

that she could do to get it done earlier, that the only way you could 

get it done earlier is request your physician to write the chief GI 

surgeon or either the gastroenterologist to get it done sooner or you 

could call each day and see if anyone dropped off from the appointment schedule. 

And I asked her could she write my name down and call me if 

someone dropped off. She said she could not do that. But, fortunately, due to the Lord’s grace, she called me the next morning at 

9:30 and asked me could I come to an appointment around 2:30 

that day which I did. And then that is when I was set up for the 

colonoscopy done at the Fort Jackson Military Hospital on December the 9th. 

So from January to December the 9th was a whole year. 

The CHAIRMAN. One other question. Do you know what an institutional disclosure is? Have you ever heard that term before? 

Mr. COATES. No, sir. 

The CHAIRMAN. It is where VA notifies a patient when there has 

been an adverse event such as a consult delay that ultimately resulted in the failure to diagnose an issue. 

So you are saying you never received an institutional notice? 

Mr. COATES. Not to my knowledge, no, sir. 

The CHAIRMAN. Ms. Brown. 

Ms. BROWN. Thank you. 

I think I will ask the first question to The American Legion, Mr. 

Dellinger. 


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During your System Worth Saving visits outlined in your testimony, did you encounter common themes throughout the VA medical center and how long have you all been doing this? 

Mr. COATES. We have been doing these System Worth Saving for 

the last ten years. 

Ms. BROWN. ten years? 

Mr. COATES. Yes, we have. 

Ms. BROWN. Yes, sir. 

Mr. COATES. And we go in. We do a town hall meeting the day 

before with the local veterans to learn their concerns and then we 

go into the hospitals and we review their procedures and do visit 

the hospital. 

Ms. BROWN. Since you have been doing it for ten years, and I 

have been on this committee for 22, have you seen any improvements over the last ten years in the system? 

Mr. COATES. I would say yes, we have seen improvements. There 

are still areas that need improving dramatically, but for the overall 

system, yes. 

I was actually in Salt Lake City a couple months ago and the director, first thing she had in her hand was a water quality test to 

show that she had done it. So they have started knowing when we 

are coming to be prepared and they do a better job. 

Ms. BROWN. Okay. Thank you very much. 

Mr. Coates, let me ask you a couple of questions. 

First of all, I want to thank you for your service. 

Mr. COATES. Thank you, ma’am. 

Ms. BROWN. And you are serving today being here. And I also 

want you to know that no one can determine when we are going 

to leave here. That is in the hands of the Lord. And they have a 

lot of new technology and equipment. And I know someone that 

they released him, said that you are going to die right away and 

four years later, they are still living. So we got to continue to work 

to make sure you get the best treatment that is needed. 

When you were going through this process, did you ever talk to 

any top officials? You were getting the runaround with the system 

it seems, but did you ever try to talk to the head of the VA at the 

particular hospital or anything like that? 

Mr. COATES. No, ma’am, I did not, which I probably should have 

been more aggressive like I was trying to get an earlier appointment. 

Ms. BROWN. Uh-huh. 

Mr. COATES. And not to discredit what you said, you should not 

have to do that. 

Ms. BROWN. No, you should not. But we do not want you to be 

a victim either. 

Mr. COATES. No, ma’am. 

Ms. BROWN. Yes, sir. 

Mr. COATES. No, ma’am. And nobody wants to be a victim and 

no one wants to be pointing a finger, too, but I should have but I 

did not. But a lot of times, you learn from hard things you do and 

mistakes that you make and give that advice to other vets and 

which I do. 

I represent a lot of other veterans around my community and my 

state that I help with VA compensation claims and also tort claims. 


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I help with them also and get them filed, how you file things, how 

you get things started because the VA system does not volunteer 

any information a lot of times. And a lot of times, you ask questions and you ask other veterans on how you get that. 

But to answer your question fully, no, ma’am, I did not ask anybody which I was, I guess, ignorant to that. 

Ms. BROWN. Let me just ask you one other question. You indicated that maybe the VA should not farm out, but you could go to 

outside—outside the system and that might be more efficient. 

Most of the times when we have testimony, let’s say women veterans, they say, well, we want to be served in the VA, but we do 

not like this and that. 

So do you think that we should consider maybe giving, particularly in some areas, an opportunity to go to the outside? I mean, 

I know you can, but making sure you know that you can. 

Mr. COATES. Yes, ma’am. I would say I think you should be able 

to give more opportunity. I think it should be put in a form or documentation when you are being treated, as common knowledge, 

same way as the handbook, the handout. I think that should be 

probably wrote in there somewhere you have options due to the VA 

system or you can request outsourced services. 

Presently now I have been dealing with the VA system for a little 

over two years now going to the oncology department at the Dorn 

VA. 

Ms. BROWN. Yes. 

Mr. COATES. I am well satisfied with my doctor I have and I give 

him credit. It is Dr. Babcock. He retired from private practice after 

30 years. And I guess he wanted to serve veterans or either work 

somewhere that dealt with veterans. And he goes three days at the 

Dorn VA and works there as oncology. 

When I first started, I actually got him the first week he came 

into the system which I think that was something the Lord had 

planned all together. And he is a real good Christian man. He said 

there is not a night that he does not go to bed at night and pray 

for me. 

But after all his works and what I have learned through the VA 

system medically, they have to request and get certain medication 

or certain different treatments to be done for cancer. I asked what 

he is doing. 

Recently I’m inquiring now after I have been there working for 

two years and now from my last scan I had a couple weeks ago 

spots on my lungs, liver, and a new spot has came up now in the 

abdominal area that they have grown and multiplied. 

And I am presently getting ready to go back on chemo in the 

next week, but I am looking for outside services now. I have acquired information now through the MSU—well, the MUSC out of 

Charleston which is another cancer research. They have ability to 

do—a lot more scientists to research different cancer and be able 

to offer more availability to treat me a lot better than what the VA 

has. 

And I have applied and checked on it and hopefully I can get 

payment due from the VA to be able to go to that hospital and try 

something new, you know, because I am talking about my life. 

Ms. BROWN. Yes. 


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Mr. COATES. And like you said, no one knows the exact moment 

that the Lord is going to call you home. 

Ms. BROWN. Uh-huh. 

Mr. COATES. But you also got sense enough to know that try your 

best while you are here and stay as long as you can. And I am at 

the process now where I am getting information together to them 

so they can look at my case and see what they can do. And it is 

always good to have another option because, you know, I am talking about myself and my life and my family. 

Ms. BROWN. Yes. 

Mr. COATES. And I am sure each one of you all here in this room 

now would do the same thing if it was you in my shoe. You would 

look for other things because I have been doing this for two years 

now and it has worked pretty good, but I think I am at the end 

of the line of where I am at now with the VA system. 

Ms. BROWN. Yes, sir. 

Mr. COATES. And I am having to go outside of that. 

Ms. BROWN. Thank you. 

My time is up, but let me just say I want to recommend a couple 

of the hospitals in my area. I have a couple of good ones. Shands 

and Mayo, they have some excellent work. So let me yield back the 

balance of my time, but I will make sure I get you that information. 

Mr. COATES. Yes, ma’am. 

Ms. BROWN. Thank you. 

Mr. COATES. Thank you. 

Ms. BROWN. Thank you, sir. 

The CHAIRMAN. Mr. Huelskamp, you are recognized for five minutes. 

Dr. HUELSKAMP. Thank you, Mr. Chairman. I appreciate the opportunity to participate in this hearing today. 

And, Mr. Coates, I would like to apologize on behalf of the failed 

system that has created such pain for you. And I know words probably do not mean much, but I mean that from the bottom of my 

heart. Thank you for coming here today. This probably was not 

easy. 

But in your testimony, I do note you do mention four different 

doctors, Dr. Verna, Dr. Naumann, Dr. Kim, and a Dr. Sarbah. 

Do you know if any of these doctors or related staff have faced 

any punishment or discipline for the failures in this situation? 

Mr. COATES. Thank you for the compliment. 

And as far as I know, there has not been any discipline. I would 

say out of two doctors in that four I mentioned would be one Dr. 

Verna. She had three occasions to set me up a consult, January, 

March, and May. 

Upon seeing Dr. Naumann my first time in that same year, he 

immediately looked over the information, set me a consult up with 

Dr. Kim, the GI surgeon, which I think he should have set me up 

with probably a different department that handled the 

colonoscopies. I know it is something to do with gastroenterology 

department, but he should have set me up with someone other 

than a GI surgeon. 

But he did make effort and I give him credit for that because he 

is the only one on the first initial meeting. 


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Dr. Kim was the GI surgeon I mentioned. She could have done 

a lot better than what she did if you missed my prior information 

about that as far as the procedure she could have done on my first 

visit with her and delayed it further. 

The last doctor was the one who actually done the colonoscopy 

and he done a real good job. And he was the chief doctor that done 

that and he was very sensitive to me and my family about that. 

And after that, he would see me in the hospital getting treatment 

and he would come up and talk to me and ask how everything is 

going, you know, everything. 

But now I have learned that he has left the system and they 

have lost a great man from that down at the VA, at Dorn. He 

called me a couple weeks before he left and he said, Barry, he said 

I just want to let you know that I am leaving the system here at 

the VA. He did not mention where he was going, but he asked me 

how I was doing which is very fortunate, you know, for a doctor 

to give a rapport like that, but—— 

Dr. HUELSKAMP. Mr. Coates, your interaction with other VA staff 

other than the doctors, can you describe that and was that simply 

taken up with the appointments or were there any visits with 

them, any attempts to help you move through the morass of bureaucracy and can you describe that as well for the committee? 

Mr. COATES. You are referring to appointments as far as what, 

set up the consults? 

Dr. HUELSKAMP. Well, any other staff. I mean, you have mentioned the doctors and those that really went above and beyond the 

call of duty and those that perhaps did not. 

What about other staff at this center? I mean, were they helpful? 

You had to fight your own way through the process? Can you describe that a little bit more? 

Mr. COATES. Well, I will say yes and no to that answer. There 

were ones who were helpful, but they only had a limited source. 

And the ones that was not trying to be helpful, they really did not 

care. And I can say that from knowledge of a record that I received 

from the VA upon the GI surgeon from filling her notes after she 

learned of the result from my colonoscopy. 

I had a meeting with her that same day at 1:00 or 1:30 and she 

came into the office. And that is the same woman that I had words 

with on the first initial meeting. And the only thing she could say 

was, Mr. Coates, I am so sorry, I did not expect that. I looked at 

her and I told her, I said, see there, I told you I was hurting. I said 

from now on, you need to start listening to your veterans and doing 

more for them on their first initial visit. 

And that way, you know, when you can look back and say I done 

the best thing I could do because I told her the same thing, that 

I looked up things that she could have done and she did not do it. 

And if she had done, it would have been a little sooner. And the 

only thing she could say I am sorry. Well, sorry does not change 

that. And nothing happened to her. No punishment came upon her. 

Learning from other surgeons in that same department, I cannot 

reveal their names, but because they work in that department and 

they told me that her policy changed after that to where now if any 

veteran comes in that has any bleeding or pain in the rectum area, 

that she immediately sets them up for consult for the colonoscopy. 


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So I am thankful that, I had to be the one to suffer to get that 

done, that other veterans that won’t suffer now. But she has been 

there. She was a seasoned doctor. And I think the lack of her ability, not her knowledge because she had the knowledge to know 

what was going on, but the lack of care it might be. I do not really 

know what it was, but there was a lot of things that she could have 

done more than what she did and she did not do it. 

Dr. HUELSKAMP. Thank you, Mr. Coates. I appreciate it. 

I yield back. 

The CHAIRMAN. Ms. Brownley, you are recognized for five minutes. 

Ms. BROWNLEY. Thank you, Mr. Chairman. And I really want to 

thank you for holding this hearing today. It is clearly a very important one. 

And, Mr. Coates, I want to thank you for your testimony this 

morning and truly on behalf of this committee and our Nation, I 

really want to apologize for the care that you received or the care 

that you did not receive. 

And clearly you agreed to serve our Nation and we agreed to 

take care of you when you came home, and we did not hold up our 

end of the bargain. And so I truly want to apologize to you. 

And I am the ranking member on the Health Subcommittee here 

for veterans. And when I learned of this, I actually wrote a letter 

to Dr. Benishek who chairs the Subcommittee on Health and was 

very obviously saddened by what I had learned about nineteen preventable deaths. 

And I even question nineteen preventable deaths. I mean, really, 

nineteen? I am sure I believe in my heart of hearts that there are 

probably more than nineteen, but nineteen that we know about. 

So I am, you know, very, very grateful that we are having this 

hearing today and it is incumbent on all of us here to make sure 

that the VA is held accountable for what has happened and is accountable to you, Mr. Coates, and to the other men and women 

who have served our country and who have not received the proper 

care. 

I just wanted to ask you, we have already asked a lot of questions around this, but during the time that you have gone through, 

were you aware of any recourse that you could take or did anyone 

suggest to you that there is someone in the VA that you could 

reach out to, a patient advocate, anything like that during the 

course of these delays? 

Mr. COATES. No, ma’am. 

Ms. BROWNLEY. And I know that you mentioned just in your last 

answer that Dr. Kim ultimately apologized to you for her lack of 

diagnosis and care. 

But have you had any formal apology from the VA? 

Mr. COATES. None. 

Ms. BROWNLEY. And in your experience, again, how would you 

describe, I guess I want to say sort of the bedside manner in terms 

of how you were treated? Clearly there were these delays, but did 

you experience from any VA employees or doctors that you encountered any sensitivity or concern about your frustration? 

Mr. COATES. Yes and no answer to that. No to a couple of the 

physicians that I had and yes to a couple of physicians that I had. 


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I mentioned, I think, briefly those ones that I mentioned. The lack 

of concern, I look at this way, and I have been going to the VA for 

quite a few years now since early 1990s, same hospital, and you 

see a lot of different things going there from different physicians 

and things like that. 

You got physicians that care about people and you got physicians 

that look at it as just a job to do. You got nurses and other officials 

there that look at it the same way. You got some that cares for the 

veteran themself and enjoy what they do. And then you got some 

that does it for a job. 

And I think that is what happened to a lot of people in America 

today. They do not look at the honor of having something and appreciate it anymore. I am not saying that anybody does not, but a 

lot of people do not. They come and go to work and go home. They 

want it for one thing and one thing only and they do it for their 

self. 

And I think if everybody worked together and do something for 

each other like it is supposed to and originally was set up, then we 

would probably be a lot greater Nation today. 

Ms. BROWNLEY. Thank you, Mr. Coates. And, again, I thank you 

for your testimony today and it means a great deal. And I hope 

that through your testimony today, it will pave the way for other 

men and women who serve our country, that they will not be treated as you were through this process. So I am very grateful to you. 

Thank you very much. 

Mr. COATES. Thank you, ma’am. 

Ms. BROWNLEY. I yield back, Mr. Chair. 

The CHAIRMAN. The gentle lady yields back. 

Mr. Cook, you are now recognized for five minutes. 

Mr. COOK. Thank you, Mr. Chair. 

Mr. Coates, thank you very much to come here. I know this is 

tough on you and your family and everything like this. 

Last year, I lost my sister with colon cancer and it is horrible for 

the family and everything else. She was much older than you are. 

Can I ask how old you are, sir? 

Mr. COATES. Forty-four. 

Mr. COOK. You do not have to tell me. 

Mr. COATES. Forty-four years young. 

Mr. COOK. Okay. And obviously you are expected to live much 

longer and that is why this is so tragic. 

I want to ask the commander, you know, Commander, you said 

that you think the VA has improved in certain areas, but the culture of the VA in terms of taking care of patients like Mr. Coates, 

it seems as though that is lacking. 

And do you share my concern about the culture, quite frankly, 

taking care of our veterans, taking care of the troops and that? 

And I am not trying to preach here and everything, but, you 

know, I spent a long time in the military. We have all had stories 

when people that where a grenade was thrown in there, somebody 

would land on a grenade, get killed, and save five, six people for 

the unit or going out on a battlefield and somebody was wounded 

and take them back under fire. 

And we have all heard these horror stories and very, very frustrating. And it seems as though the culture of the VA is such that 


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there is not a sense of urgency or, hey, we have got to take care 

of this veteran. You know, this is general orders. 

And if you could just comment. And maybe it is just me, but I 

have reached the breaking point on this where, you know, excuse 

after excuse after excuse after excuse. 

The gentlewoman from Texas talked about, I believe, or Julia 

talked about we expect more for somebody that has signed up to 

do their duty, the veterans, and return. That is what they are there 

for. That is their mission. 

So I finally got around to my question. Sorry. 

Mr. COATES. That is all right. 

You know, it is continuity. As I go around the country visiting 

these hospitals, you can tell the ones that are the caring ones just 

as Mr. Coates stated. You know, you have where they are there 

really for the patients and others are there to get a paycheck. And 

that is the difference. 

And I think it comes from the top down. VA needs to be accountable from the top down through the secretary, through the under 

secretary, all the way down to the directors and to the chief of 

staff. I have seen some great chiefs of staffs and other ones that 

are just there biding their time until they retire. 

Mr. COOK. You know, this is probably the most bipartisan committee, I think, in Congress. And I chaired the Veterans Committee 

in California and it was very bipartisan. And I do not think it is 

a democrat or republican. I really, really think it is culture that is 

not ingrained. You know, all talk is cheap. 

But in terms of actually talking about the suicides, we talked 

about all these, and we go on and on and on, and it is like business 

as usual and we cannot tolerate that. And maybe, you know, 

maybe we do have to fire people, but we certainly should not give 

them merit increases and all those things that go along with it, 

particularly in the IG investigations and everything else. 

If somebody is not doing what they are supposed to do in terms 

of, as I said earlier, taking care of our veterans, not just on the battlefield, but after they come back, then somebody deserves to be replaced or fired and have somebody in there that understands that 

is the primary mandate. 

If you could comment briefly. I know we have a lot of—— 

Mr. COATES. I agree. I mean, just as in the military, you disobey 

an order, you get court-martialed. 

Mr. COOK. That is right. 

Mr. COATES. Here we have seen instances where there have been 

some reprimands, but they are still on the job. 

Mr. COOK. That is right. 

Mr. COATES. And others are allowed to resign and then there is 

nothing. There is no—— 

Mr. COOK. That is right. You have a rank structure, but that 

rank structure, your primary responsibility is to take care of everyone under you. And if you do not, that is why you are the first one 

out the helicopter if you are in command. You are going to get 

drilled. That is just the way it is and I am afraid that it is not carried over. 

The CHAIRMAN. Thank you much, Mr. Cook. 

Mr. O’Rourke, you are recognized for five minutes. 


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Mr. O’ROURKE. Thank you, Mr. Chair. 

And for Mr. Coates, your testimony and the answers to the questions posed so far has been so powerful, so clear, so honest, really 

the questions that are left that I have are really for the VA, for 

ourselves, for this committee, for this country. 

What are we going to do now that we know the consequences of 

lack of access, delay, and ultimately denial really is what we are 

talking about in care and lack of accountability? 

So I just will use my time to personally and on behalf of the veterans that I have the honor of representing in El Paso thank you 

for your service, for your courage, for your testimony, and being 

here today and focusing our attention on something that we desperately need to fix. So thank you very much. 

Mr. Chair, I yield back. 

The CHAIRMAN. Thank you very much. 

Ms. Walorski, you are recognized for five minutes. 

Mrs. WALORSKI. Thank you, Mr. Chairman. 

And, Mr. Coates, I sit here and I think you are an example of 

the finest America has to offer. And it seems so petty to sit here 

and apologize on behalf of a bureaucratic system that is broken, 

but I do apologize. I am so sorry to you and your family sitting here 

of what you have gone through and that you are going to have to 

stand and be an advocate for the rest of these veterans. 

And I promised my veterans in my district when I ran for Congress that they answered the call, they did what this Nation asked 

them to do, and it was my turn to fight for them. That is what we 

do on this committee. We fight for the right of veterans to get the 

benefits they were promised, to be treated with the best care. 

I sit here as a freshman lawmaker so frustrated that there is a 

bureaucracy that is out of control. And if this happened in the civilian world where negligence was proven time and time again, we 

would be in the streets with signs saying shut them down. It is an 

outrage is what it is. This is an outrage. 

And so I just join the rest of my colleagues here. This is not a 

partisan issue. This is an American disaster that we have sat here 

and witnessed for me probably 16 months. And if I could change 

your circumstance, I would. I would do it in a heartbeat. 

Mr. COATES. Thank you. 

Mrs. WALORSKI. My dad was a veteran that died of colon cancer. 

This is so personal to me. And as a committee, I can tell you right 

now what the VA is going to say when they sit here. They are 

going to say what the chairman read in his opening remarks. They 

are going to give us long dramatic answers and nothing is going 

to change unless we in this Congress on the House and the Senate 

side decide to stand up and take on one of the biggest issues in this 

Nation which is this negligence toward taking care of the people 

that fight for freedom, fought for liberty, and allow us to sit and 

serve in a place called the U.S. Congress. 

And I just want to say today I hope that your testimony, I hope 

that your advocacy, and the truth of what you are saying changes 

the culture. It has changed the culture in this room. I can tell you 

that. But my prayer is for you and your family—— 

Mr. COATES. Thank you. 


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Mrs. WALORSKI [continuing]. And that together we can stand and 

change the culture in this country and say that today was a different day in the history of this VA. I do not know how they sleep 

at night, I really do not. But I can tell you that we are your brothers and sisters to stand and fight for you in every way that we possibly can. 

Mr. COATES. Appreciate it. Thank you. 

Mrs. WALORSKI. And to The American Legion, sir, you guys come 

in here faithfully every single time there are hearings, you and the 

many other advocacy organizations for the VA and for our veterans, and I just want to commend you for consistently coming, 

consistently telling the story, consistently being eyes and ears for 

all of us that have decisions to make and hopefully can improve a 

failed system. I so much appreciate what you do in your world and 

standing consistently for veterans. 

But, you know, this is so personal to me today because I had to 

advocate for my dad and I could and I did. And we did everything 

we could possibly do all the way down to the wire. And that is 

what I am going to do for you, Mr. Coates, and for the veterans 

in my district. I am going to stand here and continue to fight every 

day until we change a broken system. 

So God bless you. 

Mr. COATES. Thank you. 

Mrs. WALORSKI. And together, let’s change this system so no 

other veteran ever, ever has to do what you are going through and 

your family as well. And you are in our thoughts and prayers. We 

will stand with you through this as you continue to go through this 

process. But God bless you for being here today. 

Mr. COATES. Thank you, ma’am. 

The CHAIRMAN. The gentle lady yields back her time. 

Dr. Ruiz, you are recognized. 

Dr. RUIZ. Thank you very much, Mr. Chairman. 

First, Mr. Coates, I apologize again for the missed diagnoses that 

occurred in your case. Thank you for your strength. Thank you for 

your honor, your dignity. Thank you for being a voice for all those 

other missed diagnoses that has occurred. 

I am an emergency medicine doctor, and I see here that the ER 

doc recommended a colonoscopy. That was the right thing to do. It 

is unacceptable, and as someone who pursues excellence in medical 

care, it is very infuriating to know that a gentleman who comes in 

with rectal bleeding at any point did not have a rectal exam or an 

endoscopy or any other diagnostic study that would have detected 

your rectal nodules. 

I think that what we need to do now and, you know, I look at 

my colleagues, Mr. Cook and Ms. Walorski, and I thank you for 

your passion and I am sorry to hear about your father as well. And 

Mr. Cook, I can only imagine your memories of those soldiers who 

have given up themselves and their lives to protect others and I 

thank you for your service. It is very strong, coming from the heart. 

And I believe this to my—I say this to my colleagues, is that in 

this individual case we have missed a diagnoses and I hope that 

our committee does not miss the diagnoses that we must pursue in 

order to remedy this, to determine systematically whether or not 

we have more medical errors, more complaints from patient care 


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and more litigations that were found successful to the VA versus 

any private healthcare system that we would consider the gold 

standard because we not only expect the gold standard, we expect 

our VA system to be beyond the gold standard because our veterans are beyond the gold standards of our citizenry in our country. 

And so if there is a study or if there is a commission that we 

would be able to start as a committee to compare and contrast, to 

determine if there is a systematic increase of maltreatment, 

misdiagnoses, then I would be very much inclined to look at that 

diagnoses and take adequate treatment because we missed a diagnosis in this individual case. I want to make sure that the rectal 

nodule and cancer of our VA system gets removed as well. 

Thank you. I yield back my time. 

The CHAIRMAN. The gentleman yields back. 

Mr. Bilirakis, you are recognized for five minutes. 

Mr. BILIRAKIS. Thank you, Mr. Chairman. I appreciate it so very 

much. And sir, thank you very much for your service. You are an 

extraordinary individual. Thank you for coming today and sharing 

your story. 

I wanted to ask, sir, the VA has an ethical and legal obligation 

to disclose to patients adverse or potentially harmful events that 

have been sustained in the course of the patient’s VA care. I know 

the gentle lady touched on this and I want to ask once again, sir, 

were you notified and informed of your rights and recourse? 

Mr. COATES. To my knowledge, no, sir. 

Mr. BILIRAKIS. Say that again, sir. I am sorry. 

Mr. COATES. To my knowledge, no, sir. 

Mr. BILIRAKIS. No, sir, okay. And I know in your statement, in 

your testimony you may have mentioned this in your opening statement, and forgive me, I was a little late for the meeting, but you 

state and I quote, ‘‘The gross negligence of my ongoing problems 

and crippling backlog epidemic of the VA medical system has not 

only handed me a death sentence, but ruined by quality of life.’’ 

That is simply heartbreaking to hear. So would you like to elaborate some more? I want to give you the opportunity to, if you will. 

Mr. COATES. As far as ruining the quality of my life? 

Mr. BILIRAKIS. Quality of life, yes. 

Mr. COATES. Yes, sir. Thank you for the opportunity. Yes, it has 

dampered my quality of life to a great deal. Other than what I 

mentioned earlier about still having to go on with the chemo treatments and for now over two years now, and looking for other avenues but, you know, I have other family members other than myself to look at and like any one of us here, you know, you have children and you have grandchildren. I have children and I have 

grandchildren. 

The question is, and you don’t never know how much longer you 

have. You better enjoy them and them enjoy you. You take one day 

at a time. That is my philosophy. You live every day as it is going 

to be your last day. And once you do that, then the next day will 

come and you start again and you live that like it is your last day. 

And this has dampered a lot of what I can do, a lot of enjoyment. 

You know, I am 44 years old. I will be 45 in May of this year, but 

I am fairly young and a lot of things I can’t do. I can’t get out and 


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enjoy playing with my grandchildren. I can’t enjoy doing things 

that I could as a normal 45-year-old man. 

A lot of things has been taken from me because of that. I wanted 

to do things as far as—an example, if I want to get out there and 

play baseball with my grandchildren and do running or anything, 

I am not capable of doing that. I can’t lift but so much weight because I have a ostomy from that. 

If I decided I wanted to—at my age, you know, you probably look 

at me and say I am crazy—if I want to have another child, I can’t 

do that now. That option there is gone. And there are a lot of other 

things that, you know, I enjoy doing that I use to do that I can’t 

do now, and it has affected my life a lot and my family’s life a lot 

and now I look at what my children and my grandchildren look at 

me and they probably look and think, well, why can’t my—why 

doesn’t my dad, can’t enjoy himself. And my grandchildren say, 

well, why can’t you come out and play with me and do things like 

the other dads or other granddads do with them. And so that is 

something I am going to have to live with and deal with the rest 

of my life and hopefully my being here today, that maybe I am saving another father or another mother from having to go through 

the same tragedy that I went through and have a better quality of 

life for doing it. 

Mr. BILIRAKIS. I will tell you, sir, you are a tremendous role 

model for those children and grandchildren. I know they are very 

proud of you. 

I have one question for Mr. Dellinger, if I may, Mr. Chairman. 

I understand from your written testimony that The American Legion has been waiting for five months to receive a report from VA 

regarding the Jackson VA Medical Center. Is it common for your 

organization to experience lengthy wait times to get information 

from the Department? 

Mr. COATES. Yes, we do see lengthy delays with the fact that everything is centralized in Washington, D.C. They try to do everything out of Washington. We think it is very important that they 

empower the medical centers and the directors to be able to address crisis in a timely and quick manner. 

Mr. BILIRAKIS. Thank you very much. We got to do something 

about that, Mr. Chairman. 

Thank you very much for your testimony and I appreciate it. I 

yield back the balance of my time. 

The CHAIRMAN. Ms. Negrete-McLeod, you are recognized for five 

minutes. 

Dr. Benishek has not returned. 

Mr. Coffman, you are recognized for five minutes. 

Mr. COFFMAN. Mr. Coates, thank you so much for your service 

to our country. Which branch were you in again? 

Mr. COATES. Army. 

Mr. COFFMAN. Fantastic. And again, on behalf of the American 

people, I certainly apologize as so many other members of this committee have to you for the treatment that you got from the VA system. Let me ask you this question. Do you think, if you were given 

an option to be able to go outside the VA system and have it compensated through the VA for medical care, would you have taken 

that option? 


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Mr. COATES. Knowing what I know now, yes, I would. 

Mr. COFFMAN. Do you think other veterans ought to have that 

option that if there are such delays in the system, if they are unable to do proper diagnosis and something as simple as blood in the 

stools, that veterans ought to have choices? 

Mr. COATES. Yes, sir, I think they should and the reason for that 

is, if you get in a situation like that when you approach somebody’s 

health and their quality of life or life or death situation, and even 

under civilian medicals, you have a choice of what doctor you want 

to go to. And under the VA system, I think you should have the 

same opportunity there, what health care you want to use, what 

physician you want to use, what specialty physicians you want to 

use. And especially when you get in a situation where you have a 

backlog like there was and the bad and the sad part of it and I 

think this comes from Mr. Miller, I remember hearing, I think 

there was money allotted to the VA system at Dorn back in 2011 

and it was misused. 

The CHAIRMAN. It was over a million dollars. 

Mr. COATES. Correct. And no one has asked for that yet. I don’t 

know where it went. They say it was misappropriated. Well, what 

happened to it and who is responsible for that? Why didn’t it go 

where it went? We can’t answer that, but we can find out why and 

make sure it doesn’t happen again. 

Second of all, that was to help the backlog of those patients and 

the sad part of it is that was during the time I was going through 

that in 2011. 

The CHAIRMAN. Let me ask you this. The reality is you are the 

victim of the system that did not care as much as they should have 

about their patients. Do you think that culture or that system exists because of the fact that they don’t see themselves competing, 

that you are their only choice, that they don’t see themselves competing with anybody else, so that if you had an option to go outside 

the system and they would have to pay for that and that was your 

freedom to make that decision, do you think that they would have 

handled your case any differently? 

Mr. COATES. I think they probably would have. Any time it 

comes down to—and I am not the only one who probably knows 

this and anybody across America has known this—when it comes 

to spending government money, there are a lot of things that they 

like to spend it on and there are a lot of things that they pinch 

pennies about. If it is for national defense and it needs to be done, 

why, they jump on it. If it something saving somebody’s life, they 

get in a big debate about it, why does it need to be spent, where 

does it need to be spent at, and we have run across this and here 

recently in the past year, debates in the House and debates in the 

Senate, the debt ceiling being raised and allocated money for where 

it goes. 

But reality and you look into it, and you look at what we spend 

for different small items and you can probably request this information from somewhere, and I have heard this from other sources, 

what we pay for little small things like a hammer, a toilet seat, you 

know, $150, $350, when you can go to anywhere and buy it for $10, 

$12, we spend money where we think it needs to be at and where 

it not needs to go. 


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And the sad part of it is, we don’t get choices like that of knowing where it goes and where it doesn’t go. There are the people who 

have the authority to rest upon where it goes at. 

Mr. COFFMAN. Well, Mr. Coates, I again am sorry about your advanced rectal cancer as a result of substandard medical care by the 

VA, and I just want to say that they have received, the system has 

received a higher appropriation every single year. And so it is the 

question of how that money is utilized. 

And with that, Mr. Chairman, I yield back. 

The CHAIRMAN. I have a bunch of questions, but I am not going 

to ask them. You have given of your time today. Your story is more 

than compelling. I, like the other members of this panel, want to 

say thank you for your service in and out of uniform. 

Ms. BROWN. Thank you. My question is really for the commander. My question is, you know, I have been on this committee 

for 22 years as I have mentioned and you have been here, well, I 

believe, almost as long as—more than ten years. But my question, 

some of the members say that the VA system is broken. I don’t feel 

like it is broken. I feel like we need to do what we need to do to 

fix it. 

But I have traveled to, I can’t tell you how many hospitals. I was 

in one that’s going to be one soon yesterday, all day. But the point 

is, my feeling is that the VA people that I met with and talked to, 

I think they really care and it can’t be just my district. It can’t be 

just those areas in Florida or Tampa that I have been to or Jacksonville or Gainesville or Lake City. I mean, I have been to California and, you know, I have met with the people there and when 

I went out there I found out we had 400 units that just was sitting 

there and people could be using them. 

So the point is, on a one to ten, if you are going to evaluate the 

system, and I know we got problems. We are sitting here listening 

to the problems and I really think we need to be able to go outside 

the system to get certain services. 

How would you evaluate the system? 

Mr. COATES. It is a great question. I really believe I need to 

break that into two aspects. First, being the medical care that you 

receive at the medical centers and at the community-based outreach clinics. I think that is an eight to a nine because as you mentioned, they really do care. They really want to help. 

But what I think is broken is when you talk about the oversight 

and the works of the VA central offices and regional offices, I would 

rate that at about a five. They need a lot of improvement. Where 

we see most of our problems are at the regional and the central offices, not at the medical facilities themselves. 

Yes, there are instances just like Mr. Coates, but the overall system there, I think they are wanting to do better and just as a director tried to do, you know, wherever you see blood at this point, you 

get a colonoscopy. They are addressing these. 

Ms. BROWN. That is common sense. 

Mr. COATES. It is common sense. But when you have a failure 

at the—just like during the Legionella in Pittsburgh when they 

had a statement ready to go out and they had to send it back to 

Central Office so that they would evaluate the statement. It never 

got released. It is such a bureaucracy. 


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Ms. BROWN. Okay. So you are saying the part of the problem 

with the culture is that it is too—you don’t have enough responsibility on the regional level? 

Mr. COATES. I think regional, central area, yes, across the area. 

Ms. BROWN. Okay. Okay. But I really find that this, you know, 

maybe in this particular case, the person, it could have been cultural differences as far as—I mean I just can’t imagine somebody 

not caring. I mean, I serve on this committee because I care. And 

I think the people working in the VA, to just say that they work 

for a check is way beyond me because these people have served us, 

and what we are doing is giving back. This is the other opportunity 

to serve. 

Mr. COATES. Ms. Brown, I have with me Field Service Officer 

Lilly and he is out there every day. He goes to the System Worth 

Saving, he goes to the regional and central offices. I would like for 

him to make a comment on this also. 

Ms. BROWN. Thank you. Thank you. 

Mr. LILLY. Thank you, Commander, and thank you, Ms. Brown. 

I wanted to comment on what you said earlier about employees 

coming forward and trying to address the problem before it escalates and I completely agree with you there because what happens 

is there is this negative stigma of whistleblowers. That is what 

those employees become or they are former employees. 

So the local facilities on the local level need to be empowered to 

address crises when they happen, and that is not how it is right 

now and that is what our commander was referring to when he 

was saying that it takes a long time for these facilities to address 

what has happened because they have to get approval from Washington, DC. And that is what we have seen in Pittsburgh, Jackson, 

Atlanta, all these different trips. 

The veterans are scared. They are nervous. They are afraid to go 

to their own healthcare system because they just don’t know what 

steps the VA is taking to address the issue. 

Ms. BROWN. Well, thank you very much, and thanks again, 

thank all of you for your service. 

Thank you, Mr. Chairman. 

The CHAIRMAN. Thank you, Ms. Brown. Thank you, Members, for 

holding your questions until the next panel. 

And thank you very much, Mr. Coates, for being here. 

Commander, thank you and you are excused. 

Members, we are going to switch up the witnesses and we will 

take VA next instead of waiting until the third panel, so we will 

be preparing the table for the second panel. 

Members, joining us at the second panel is Dr. Thomas Lynch. 

He is the Assistant Deputy Under Secretary for Health for Clinical 

Operations and Management. 

Dr. Lynch is accompanied this morning by Dr. Carolyn Clancy. 

She is the Assistant Deputy Under Secretary for Quality, Safety 

and Value. 

Dr. Lynch, you are recognized for your testimony. 


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STATEMENT OF THOMAS LYNCH, M.D., ASSISTANT DEPUTY 

UNDER SECRETARY FOR HEALTH FOR CLINICAL OPERATIONS, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS, ACCOMPANIED BY 

CAROLYN M. CLANCY, M.D., ASSISTANT DEPUTY UNDER SECRETARY FOR QUALITY, SAFETY, AND VALUE, VETERANS 

HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS 

AFFAIRS 

STATEMENT OF THOMAS LYNCH 

Dr. LYNCH. Mr. Chairman, let me begin by saying that we have 

heard a compelling story. I need to recognize the fact that what we 

have heard is a sad story. 

Before I walked up here, I apologized to Mr. Coates. I told him 

that I am sorry for what happened. If he did not receive an institutional disclosure, I initiated that by extending my apology on behalf 

of VHA. 

I also commit that we will look into what happened so that we 

can understand and he can get a better explanation and the explanation that he deserves. 

I was looking around. It appears that he has left the room. I did 

and I want to publicly thank him for his service. I want to thank 

him for reminding us of what we are here for and for the people 

that we are serving through VHA and our healthcare system. 

I am going to go pretty much off script. I want to let you know 

that Dr. Clancy and I are here because I think we share a common 

value with you, sir, and with the committee, and that value is to 

provide quality care to our veterans. 

I would also suggest that we are here because we share common 

concerns and those are concerns regarding harm that has occurred 

to veterans in our healthcare system. 

I think it is good that we hear these stories, that we not ignore 

when harm has occurred. They are powerful. We need to learn from 

them and we need to do better. 

I think also I would like to acknowledge publicly that I think the 

relationship between VA and Congress has been a constructive relationship in the past. I think many good things have occurred in 

VHA healthcare because of the concerns you have expressed and 

because of the actions we have taken. 

In the late 1980s there were significant concerns about the quality of surgical care in the VA. The VA developed what was then 

called NSQIP, the National Surgical Quality Improvement Program. It is now called VASQIP. It gives us a risk adjusted model 

to assess outcomes in our surgical programs. 

It is so powerful, it has been adopted by the American College 

of Surgeons. It is now used to provide oversight and evidence to 

healthcare systems and to physicians to allow them to improve the 

services that they provide. 

In the mid-1990s, there were concerns expressed on behalf of 

Congress regarding the quality of our healthcare system. In response, the VA developed the electronic medical record. This is an 

advance that has now been adopted by the private sector. 

The VA has also moved towards looking at the way we deliver 

care and how we focus care with respect to prevention; preventing 


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illness, not necessarily treating illness. This means that we don’t 

necessarily have to put people into hospitals. We can treat them as 

outpatients. It is a model that is now being adopted in the private 

sector. 

I want to go back and make one point from what had been my 

prepared statement, Mr. Chairman, and that is that over a third 

of our employees are veterans and the fact that everyone in VA is 

constantly striving to eliminate the clinical and administrative errors that may occur. 

We strive, sir, to be transparent in disclosing what has happened. As a system, we have taken a lead in being transparent, we 

have taken a lead in clinical disclosure. We are not perfect, sir. We 

are a learning organization. 

When errors occur, we do try to express apologies to the involved 

patients and to their families. I think I will close with a statement 

from Ralph Gabarro. He is the former CEO of the Mayo Regional 

Hospital in Dover-Foxcroft, Maine. I think he has said it best, sir. 

To paraphrase, preventable patient deaths are a nightmare for 

our entire medical community, but our feelings, what we are going 

through, pales in relationship to what the families are dealing with 

and we understand that, sir. 

We are now prepared to take your questions. 

[THE PREPARED STATEMENT OF THOMAS LYNCH APPEARS IN THE

APPENDIX] 

The CHAIRMAN. Thank you, Dr. Lynch. Your recent National 

Consult Delay Review disclosed two deaths in Arizona, but committee investigation show that it appears that it could be much 

worse than you know or if you do know that it is worse than what 

the committee has been told, so I want to tell you about some information that we have received here in the committee as it relates 

to Phoenix. 

I have been made aware of internal emails from within the VA 

that suggest that Phoenix VA may have been using an unofficial 

electronic waiting list where veterans were placed on that unofficial list until an appointment became available. 

These lists were supposedly designed to give the appearance that 

veterans were only waiting for appointments for 24, 25 days or less 

and they potentially contain thousands of names. In cross referencing the two lists, it appears as though there could be as many 

as forty veterans whose deaths could be related to delays in care. 

Were you made aware of these unofficial lists in any part of your 

look back? 

Dr. LYNCH. Mr. Chairman, I was not. And Mr. Chairman, I 

would say that I have tried to work with your committee. I have 

visited with your staff. I was in Atlanta. I was in Columbia. I was 

in Augusta when you made those visits. I have tried to share the 

information that we have gained as we are obtaining it. I know it 

is not perfect information, sir, but I know there is a desire on your 

part to know that information as we obtain it. 

I am more than willing to meet with your staffers and take their 

information so that I can use it, sir. If I don’t have that information, I can’t act on it. 


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The CHAIRMAN. So your people had two lists and they kept it 

from your knowledge. So my question is, does that make you even 

internally question the validity of the information being utilized in 

your look back or your review? 

Dr. LYNCH. At the moment, sir, it does not, but I am open, I am 

happy to meet with your staffers, I am happy to look at the data 

so that we can understand it and see what the issues and the problems are. 

The CHAIRMAN. I want to provide you with a request for a preservation order for all potential evidence at Phoenix VAMC and I 

would also ask the Inspector General for Health care, Mr. Daigh, 

to look into this issue as soon as possible. I will be putting a letter 

to you quickly, but I make this as an official request on the record 

and we are ready to assist by providing our evidence and any assistance that Dr. Daigh may need as he goes forward. 

It has been mentioned a couple of times in here about Dorn being 

awarded a little over a million, 1.02 million or some number like 

that to help in the backlog of fee-basis colonoscopies and money 

was provided in September of 2011. I have still not been able to 

get a solid answer where that money went, so I am hoping that you 

might be able to provide an insight this afternoon. 

Dr. LYNCH. Mr. Chairman, I know that that information has 

passed through VHA. I took the opportunity to listen to the Deputy 

Secretary’s hearing the other day. I know he has committed to increasing the communication with Congress and with this committee, and I support his efforts and will do what I can to get you 

the information that you need, sir. 

The CHAIRMAN. So, again, another piece of information the committee awaits. I specifically asked for a complete accounting of 

those dollars when I was at Dorn earlier this year. 

On the 22nd of February in a Health Committee hearing, Dr. 

Benishek asked Dr. Petzel to provide a list of circumstances surrounding the removal of six SES employees over the last two years. 

Dr. Petzel promised at that hearing that he would provide that information at the end of that week. 

This is April 9th. It has been six weeks since the committee 

asked for the information. We have not received it. This information was referenced in a subcommittee on economic opportunity 

hearing that was chaired by Mr. Flores and, by the way, Mr. Flores 

is absent today because he is at the memorial for Fort Hood Texas, 

and the committee staff has made numerous requests. 

So I would also note that this statistic was also noted in your 

written statement for this hearing. So why is VA keeping this information from the committee when it was an entirely reasonable 

request? 

Dr. LYNCH. Sir, I wish I had an answer for you that you would 

find acceptable. I could only repeat that I support the Deputy Secretary’s efforts to get you the information. 

The CHAIRMAN. I have a bill right now, Dr. Lynch, that gives the 

secretary additional flexibility to fire SES employees. Out of the 

320,000 employees at the Department of Veterans Affairs, we are 

only talking about 450 individuals. The secretary is pushing back 

saying that he has the tools and that he has, in fact, taken the necessary steps and we are talking about six people and we have been 


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waiting months now to get that information, and I just—as the 

chairman and subcommittee chairman and the ranking members 

sit here just wondering why in the world it takes so long. 

In January, following my visit to Columbia and Augusta, which 

you were at, to follow up on the delays in care, I wrote a letter to 

the secretary asking for specific information regarding consult 

backlogs at those facilities and others in general. And though I requested a response be provided within thirty days, I have yet to receive a response, an answer from the department, so I ask you 

again, as somebody who should be intimately involved in the preparation of the secretary’s response, when can the committee expect 

to receive that information? 

Dr. LYNCH. I don’t want to sound like a broken record, sir. I realize that you take this seriously. I realize that your committee takes 

the responsibility seriously, and I accept the fact that there can be 

a constructive relationship between the committee and the VA, and 

I hope to be part of that solution, sir, and not the problem. 

The CHAIRMAN. Ms. Brownley, you are recognized. 

Ms. BROWNLEY. Thank you, Mr. Chair. And I wanted to ask, I 

know we skipped over a panel, but I wanted to refer back to some 

of the testimony that I reviewed from Dr. Daigh who spoke specifically around the problems in Columbia, around the consult backlog, 

and one of the indications that he gave was the availability of feebased care, that it had been reduced. 

I wanted to just hear your comments on that and why fee-based 

care was reduced in Columbia. 

Dr. LYNCH. I don’t have the full explanation for that, Congresswoman. I believe the facility felt at the time they had the resources 

to solve the problem. In retrospect, they did not. I think, however, 

Congresswoman, that in the process of looking back over what happened, we have developed a tool that gives the facility, that gives 

the network and it gives VA Central Office eyes on delays and 

helps us ask critical questions of a facility in terms of should they 

be using fee-basis care. 

We have improved our fee-basis process. We have implemented 

the PC3 process which helps us interact with the community to obtain services. I think we have the ability to identify where our demand exceeds our capacity, to understand why that may be occurring, and as we move forward, to effectively use fee basis. 

Ms. BROWNLEY. Thank you. And this tool that you are speaking 

of, can you give me some more details about what that is? What 

triggers you to begin to look at it? How long do the backlogs have 

to be before you begin to put your eyes on the problem and try to 

rectify it? 

Dr. LYNCH. I think, first of all, the answer is that it is individualized, but let me explain the tool to you. As we began to look back 

at our consults after the incidents in Columbia and Augusta, we 

observed that there were flaws in our consult process that allowed 

consults to remain open or unresolved. 

That put noise in our system and it prevented us from trying to 

identify those facilities where there was need for an alternative, 

such as fee-basis care. 

Over the past year, after the incidents in Columbia and Dorm, 

we went back. We examined over 250 million consults since 1999 


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in VA. We identified where there were delays. We had to resolve 

those consults and make sure that they were closed appropriately 

and that services were provided. And in the process of doing that, 

we implemented new business rules that helped us separate our 

clinical consults from what had become some administrative uses 

of that consult system. 

We are in the process of completing that review. It should be 

completed in the next month or two. With that and with new business rules, we will have the ability to look at a facility, to look at 

individual specialties within a facility, to take a look at trends in 

delays and to ask critical questions; whether the facility has the resources to address those delays, whether the facility thinks those 

delays are temporary, transient, or whether the trend is an indication of increasing delays, and to then work with the facility to decide do we need to add more staff or do we need to use fee-basis 

services. 

Ms. BROWNLEY. Thank you. Are you collecting any data as we 

speak, looking ahead—we talked a lot about looking to the past 

and what needs to be done for the future—but looking ahead, are 

you collecting data and benchmarks vis-a-vis consult backlogs 

throughout the VA. Obviously, we have determined there was some 

VISNs, there have been some real problems, but are we going to 

collect that data to understand the data that data gets shared with 

the committee and where are the trigger points that we can make 

an immediate fix to what potentially could be a very, very serious 

problem. 

Dr. LYNCH. I think the answer to that is yes, Congresswoman. 

In fact, about six months ago, using some initial data that we were 

beginning to collect, we sent over a $100 million out to the field for 

facilities to use to contract for fee-basis services. We reduced the 

wait time, the backlog at that point, by almost 50 percent or 50,000 

patients. 

So we have begun to use that tool. I think we can also begin to 

use that tool to look at what I think is the critical issue when we 

look at access, and that is delayed care. We focus on fourteen day 

access, but really, importantly, we need to look at where care is delayed. And we can set the filters on this system to look at delays 

at variable lengths of time, and as we get control of the system, 

slowly reduce backlog from ninety days to sixty days to thirty days 

based on the information that we will get. 

Ms. BROWNLEY. Thank you. I yield back. 

The CHAIRMAN. Mr. Huelskamp, you are recognized for five minutes. 

Dr. HUELSKAMP. Thank you, Mr. Chairman. Just a couple of follow questions if I might. First, in reference to our previous speaker, 

Mr. Coates, are you familiar with the specifics of his situation? 

Dr. LYNCH. I have not reviewed the specifics of his situation. I 

assure you, I will. 

Dr. HUELSKAMP. And Dr. Clancy, have you any familiarity with 

this situation? 

Ms. CLANCY. Not before what I heard this morning. Not before 

what I heard this morning. 

Dr. HUELSKAMP. Okay. I would ask if you could also follow up 

on the situation in prior discussions with Mr. Coates that currently 


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VA is requiring him to drive almost four hours for some follow-up 

treatments instead of being able to receive it right close to home. 

Would you please follow up on that and see if that is indeed that 

case? 

Ms. CLANCY. Absolutely. 

Dr. HUELSKAMP. Okay. Additionally, I would like to ask a couple 

of questions of Dr. Lynch. What specific person at the VA Medical 

Center level is responsible for ensuring timely care is delivered to 

veterans? 

Dr. LYNCH. Ultimately, it is the Medical Center director, sir, 

working with his quadrad, the director, the chief of staff, the chief 

of nursing and the associate director who often deals with engineering and environment of care. 

Dr. HUELSKAMP. And what specific person or position at the 

VISN is responsible for ensuring timely care? 

Dr. LYNCH. Ultimately, it is the network director, sir. He or she 

works with the chief medical officer and with the quality medical 

officer. 

Dr. HUELSKAMP. And then at the VA Central Office level, who is 

responsible for timely care? 

Dr. LYNCH. Ultimately, that would go to the office of the deputy 

under-secretary for operations and management and to Dr. Petzel. 

Dr. HUELSKAMP. And out of the people in positions you have just 

named and anywhere from twenty to forty deaths by delay of veterans, do you know if anybody at all has received any disciplinary 

action whatsoever? 

Dr. LYNCH. I believe that Dr. Petzel discussed disciplinary action 

the last time he was here. I believe we have identified two physicians in Memphis, which is another issue, where there was discipline. There was discipline in Augusta, as well as Columbia, and 

there was discipline in Atlanta. 

Dr. HUELSKAMP. And did anybody lose their job? 

Dr. LYNCH. I can’t answer that specifically, sir. 

Dr. HUELSKAMP. You don’t have the information or is it a refusal 

to—— 

Dr. LYNCH. No, I don’t have the information, sir. If I did, I would 

share it with you. I guess I would say, maybe in response—I understand your concern. I understand the chairman’s concern regarding 

accountability and I think that is important and I think VA has 

some very prescribed purposes for that. 

I am troubled a little bit by whether or not firing somebody is 

necessarily the answer. I think, as I mentioned earlier, almost a 

third of our employees are veterans. 

Dr. HUELSKAMP. Would you be opposed to taking away their 

bonus? 

Dr. LYNCH. Pardon? 

Dr. HUELSKAMP. Would you be opposed to taking away their 

bonus? 

Dr. LYNCH. Could I just continue for just a second? 

Dr. HUELSKAMP. I don’t have time for that answer. 

Dr. LYNCH. I think we need to be careful about punishing everybody for what may have occurred at one or two medical centers. I 

think by and large, sir, we have good people who care for veterans, 

who deliver quality care. And I think in those circumstances they 


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should be rewarded. I don’t think we should punish the system for 

what may be incidents that occurred in individual medical centers. 

Dr. HUELSKAMP. Lastly, Dr. Lynch, I am looking at your handbook that provides the procedures for disclosure of adverse events 

to patients. 

Dr. LYNCH. Yes, sir. 

Dr. HUELSKAMP. And it is pretty clear of the ethical requirements: ‘‘Unwavering ethical obligation to disclose to patients harmful adverse events that have been sustained in the course of their 

VA care.’’ Has this been disclosed to Mr. Coates? 

Dr. LYNCH. It would appear from his testimony that it hasn’t, sir. 

I think VA has taken a lead in this area. I don’t think we are perfect, but I think we have a good system and it can be better. 

Dr. HUELSKAMP. And if one failed to disclose this as apparently 

it is the case to Mr. Coates, what is the punishment? Who is punished for failure to meet an unwavering ethical obligation? 

Dr. LYNCH. Sir, at this point I don’t know. I need to understand 

the circumstances that occurred and I will be looking into that. 

Dr. HUELSKAMP. Yeah, I would appreciate the specifics on Mr. 

Coates, but the general question is who is responsible for meeting 

this unwavering, ethical obligation? 

Dr. LYNCH. The handbook would tell you that it is the executive 

team of the hospital. It is the director. It is the chief of staff. It 

is the chief of nursing. 

Dr. HUELSKAMP. Thank you, Mr. Chairman. Yield back. 

The CHAIRMAN. Mr. O’Rourke, five minutes. 

Mr. O’ROURKE. Thank you, Mr. Chair. 

Dr. LYNCH. Mr. Coates made a very powerful case that the delay 

of service to a veteran can effectively mean denial of life-saving 

care to a veteran, and I think you have made the commitment to 

look at his case specifically; find out what you can learn from that; 

apply those lessons to improving the VA, and specifically what happened with those specific doctors and he relayed an anecdote or 

anecdotes of poor performance on behalf of the doctor, but he also 

showed us that there are some truly terrific public servants working for the VA. He mentioned the doctor who retired from private 

practice and is spending time within the VA because he cares 

about veterans and he wants to make sure that they get the best 

care. 

I have found that to be the case in El Paso, that we have really 

wonderful doctors, terrific care for veterans who can get in my community, and far too often in other parts of the country is that it 

is very hard to get into the VA and get an appointment and see 

a doctor. Anecdotally, I have heard from veterans who served as 

back as World War II, who need simple procedures like cortisone 

treatment who have to, as Mr. Huelskamp just described, travel 

four or five hours to the nearest VA hospital in Albuquerque to get 

that care. They decide not to get the care and they end up either 

suffering, choosing an alternative or just going without. 

I have spoken to countless veterans who just delay or just do not 

receive appropriate treatment, procedures, or surgeries for the 

same reasons. That anecdotal information has been borne out by 

the recent SAIL report that the VA OIG recently produced that 

showed that El Paso is arranged 123 out of 128 VHA facilities for 


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access to care, and when we drilled down into the numbers a little 

bit further, we found that as recently as six months ago, only 18 

percent of veterans seeking to make an appointment were actually 

able to get an appointment within a reasonable period of time, a 

standard that you all set for yourselves. So for those 82 other out 

of every 100 veterans trying to make an appointment, they can’t 

get in and find care. 

So, you know, Mr. Huelskamp approached this, I think rightfully 

so from a perspective of accountability, and what do we do when 

people don’t perform, when veterans don’t get access and we have 

these poor outcomes? 

To look at the other side of the question: What are you missing 

in resources to be able to provide the access that we need to hire 

the very best doctors, or in El Paso’s case, enough doctors so that 

veterans can get in and get an appointment? What are we not providing to you and to the VA that you need to be able to turn this 

situation around? 

Dr. LYNCH. Dr. Clancy. 

Ms. CLANCY. So first, I want to say to you and your colleagues 

here that we very much appreciate the privilege and opportunity 

and honor of serving the men and women who have effectively 

written a blank check to this country; there is no higher calling, 

really, in medical care delivery. 

The issue of timely access is one that we take seriously, so to the 

extent that you have additional information that we haven’t seen, 

we would love to see and work on that with you. 

Mr. O’ROURKE. Here’s the thing—and I appreciate what you just 

said, but I have spoken to Dr. Petzel about this. You all had measured it and seen the outcomes and the lack of service. I am with 

Ms. Brownley and others who question whether the number of preventable deaths is really accurate. Who knows how many of those 

in El Paso who are not able to get an appointment or who were 

told they had to make a ten-hour roundtrip and those not to have 

the procedure, who knows who their outcomes were. I don’t know 

if we are effectively measuring that. 

What I want to know—and I have tried to do this in the most 

cooperative, polite, diplomatic fashion I can think of—what I want 

to know is what you are going to do to turn that situation around, 

and if you need something additional from me, as a Member of 

Congress, from us as a committee, from the House, the Senate, in 

terms of appropriating resources, what are you missing that is preventing you from delivering the standard of care that our veterans 

should be able to expect? 

Ms. CLANCY. What we are working on right now are new programs to improve our ability to schedule appointments in a timely 

fashion. In addition to that, particularly for folks who live in rural 

areas where traveling great distances often is a big challenge, we 

are looking into other options when it is feasible. Obviously, if you 

need an injection or a procedure, you can’t do that remotely, but 

we are looking at a variety of telehealth options sometimes for 

video consultation. It seems to be a very, very effective way to improve access for people who have mental health appointments, and 

other venues so that we can be able to get people in faster, and I 

will personally follow up with Dr. Petzel about your request. 


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I wanted to make one other comment, just about rankings. If you 

have 152 hospitals or centers in a system, there will be a number 

one and a number 152. I think the real question is: Is 123, how 

does that stack up against the private sector and what is the gap 

between best possible care and—— 

Mr. O’ROURKE. And use the other metric that I gave you, which 

is 82 out of every 100 veterans trying to make an appointment in 

El Paso cannot get in, in a reasonable amount of time, a standard 

in which you set. And I have asked Mr. Petzel publicly. We have 

talked to the office privately. 

When can we get something in writing that will tell us when you 

will be able to meet the standard of care that you, yourselves, have 

set for the veterans in El Paso, and the veterans all around this 

country, and I am still waiting for the reply. So I am going to ask 

you, again, publicly, to please work with Dr. Petzel and our office 

to get us that reply. 

Mr. Chair, thank you. 

Ms. CLANCY. I will do that. 

The CHAIRMAN. The gentleman’s time has expired. 

Dr. Benishek—— 

Dr. BENISHEK. Thank you. 

The CHAIRMAN [continuing]. Chairman of the health subcommittee, you are recognized for five minutes. 

Dr. BENISHEK. Thank you very much, Mr. Chairman. 

I thank both of you for being here this morning. Frankly, this 

makes me really angry, all right. I mean Mr. Coates is here testifying about this care at the VA where he has going to die and as 

far—I am a general surgeon. I do colonoscopies. I do colonoscopies 

at the VA. 

This man did not receive the standard of care and it is very frustrating for me to be here and have people calmly explain to me how 

they are working really hard to make things happen when there 

is not an emergency. This is an emergency. This gentleman did not 

receive the standard of care, all right. He did not receive an apology. 

It is hard for me to understand, you know, when I ask Dr. Petzel 

for what are you doing for this kind of stuff? 

And it was six people have been disciplined and then I can’t even 

get an answer from him as to which people and why. So how can 

I believe that the VA is serious about putting a stop to this stuff 

when I ask a simple question and I can’t even get an answer to 

it. It is very frustrating to me that we have to come up with some 

sort of legislative fix for how you people manage your department. 

I mean it should be a management decision that, you know, a 

physician who is not giving a colonoscopy when people have rectal 

bleeding or blood in the stool. This has been the standard of care 

for 30 years. And, you know, for not even getting a consultation for 

a colonoscopy for a year and then to get six months before he is— 

from what I can understand from the timing—six months. 

This is an emergency. If I see somebody in my office with rectal 

bleeding, they get a colonoscopy like the next day or within the 

week. And I don’t know—you know, I just get so frustrated by people like you that come here and calmly say we are going to fix it 

and it never gets fixed. 


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Dr. LYNCH. Congressman, I am a surgeon by training. I have 

spent the last 30 years working in the VA system working with 

veterans, training residents, working with medical school students. 

I am angry, as well, sir. I share your anger. 

I have been working for the last year since I have been here in 

central office to put together the tools that give us what we need 

to manage our system in a fashion so we can identify where there 

are delays and—— 

Dr. BENISHEK. No, I understand. 

See, you calmly answer me—— 

Dr. LYNCH. I am not calmly answering you, Congressman. I am 

angry like you are angry. 

Dr. BENISHEK. But I don’t see any progress, Dr. Lynch. I don’t 

see any progress. 

I mean all I asked of Dr. Petzel was for some things here. We 

don’t see where you are actually fixing it. All we get is calm responses from people that are assuring us that we are actually 

doing it, but we don’t see any progress and, you know, when I see 

a case like that case that was presented here earlier by Mr. Coates, 

I just can’t stand—what are you doing? I mean what mechanism 

do you have to find out about stuff like this? 

What happened to that doctor? Why wasn’t she working on—at 

the standard of care? I mean these are the kind of questions that 

we need answers to and we don’t ever get them, and so I am very 

disappointed with the quality and the management of the VA. I 

mean I worked at the VA for 20 years myself. I think that the VA 

has made tremendous improvements over the last 20 years, there 

is no doubt about it, and I applaud you for doing your career there, 

but, you know, coming from that system, where I worked as a physician, and I come here, and knowing, you know, how the bureaucrats work there, the physicians, to me, didn’t have enough input 

as to how things were done; it was the bureaucrats that decided 

about a lot of this stuff. 

So I would be happy to work with you to give you my insight as 

to how to do this better. You know—— 

Dr. LYNCH. Congressman—— 

Dr. BENISHEK [continuing]. Like I said, it is great—— 

Dr. LYNCH [continuing]. I would be happy to meet with you. 

Dr. BENISHEK. What is the second half of that? 

Dr. LYNCH. Dr. Clancy and I would both be happy to meet with 

you, sir. 

Dr. BENISHEK. I will yield back my time and hope—— 

Ms. CLANCY. And I do want to be clear that we both share your 

anger and are very, very upset and we know that we can’t take 

that back; it can’t be undone. So, a young man who will die prematurely, we get that. But what it inspires us to do is to work 

harder to make sure that we don’t do it again and we have a system in place to make it foolproof so that we don’t—— 

Dr. BENISHEK. Well, my frustration is how can I tell what is happening when I can’t even get a simple answer to a simple question 

from Dr. Petzel? Thank you. 

The CHAIRMAN. Ms. Titus, you are recognized for five minutes. 

Ms. TITUS. Thank you, Mr. Chairman. 


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I want to ask Dr. Lynch, I am sure you are aware that the IG 

is currently investigating the death of Sandi Niccum at the VA hospital out from Las Vegas. That investigation came at the request 

of the chairman and myself. It is taken awhile, and we hope to get 

the results soon, but just wonder when the results come to this investigation or any, what you do to follow up; how you assure us 

that you have made the changes; implemented the recommendations. 

Could you comment, maybe, specifically about the Las Vegas 

case or—and also generally? 

Dr. LYNCH. I can’t comment specifically about the Las Vegas 

case. I have not seen the OIG’s report yet. I can tell you that when 

those reports come in, I do read them. I do look at the recommendations and we do have a process for tracking to make sure 

that those recommendations are acted upon and closed. 

Ms. TITUS. Can you elaborate on that process for tracking them 

so that we can be sure that there is transparency and accountability and I can go back to my constituents and say this was the 

problem and this has happened to correct it. 

Dr. LYNCH. There is an office in VHA whose specific responsibility is to work with the OIG. They obtain those reports and they 

work with the OIG until such time as he accepts the actions that 

have been taken and closes the recommendation. 

Ms. TITUS. And that is public? 

Ms. CLANCY. Yes, that is public information in terms of what was 

the response of the VA Health System and the follow-up and so 

forth. So I think we can both commit to you that we will followup with you when that report is done. 

I want to stress, though, that we don’t wait for the Inspector 

General. The Inspector General is a very valuable resource and a 

source of information for us, but we have many internal processes. 

So our National Center for Patient Safety, for example, routinely 

is collecting information about adverse events and near misses; in 

other words, circumstances that set people up for errors. 

I have heard a lot of concern from all of you this morning, and 

we share that, about harms to patients and patient safety. And I 

would love to tell you that we can build an error-free system and 

that is not possible. 

What we can do, and are strongly committed to doing, is identifying things at the earliest possible phase so they can be fixed and 

the much longer-term consequences and more serious consequences 

can be prevented. So, we pay a lot of attention to the IG reports 

to reports by the GAO, but we also have our own internal processes 

where we are relying on every single employee who works at VA 

to let us know; it is called Stop the Lying. If you see something, 

say something. If you see something that could be unsafe, we need 

to hear about it and you need to let people know so that we can 

act on it, and together, across the system can learn about it. 

Ms. TITUS. Can you tell us then—and I appreciate that, I think 

that is a good thing that you have—but if something is being done 

to follow up on the Sandi Niccum case independent of the report 

that we are waiting on? 

Ms. CLANCY. I can get back to you with that. I am not familiar 

with the specifics of that, but we will definitely get back to you. 


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Ms. TITUS. Thank you very much. 

And I yield back, Mr. Chairman. 

The CHAIRMAN. Could you tell me why the video, the surveillance 

video that day in the hospital that showed Ms. Niccum, who was 

an elderly lady, was in severe pain and ended up dying, was 

erased, deleted, how did that occur? 

Dr. LYNCH. The only explanation I have heard is that after 30 

days, the videotapes are overwritten and we don’t have that information; and I understand that I don’t know the relationship between your request and when that tape was erased. 

I think from our standpoint, it is unfortunate; we would like to 

have seen what happened as well. 

The CHAIRMAN. Wouldn’t you think, though, as a matter of principle and good business practice, that if a death occurred in your 

facility and you had a video of that death—30 days—man, I can 

understand if it was 24 hours, maybe it got deleted—but 30 days 

before it got taped over? 

Dr. LYNCH. If I recall the case, which is now coming back, I don’t 

believe that Ms. Niccum died that day. I believe she died subsequently, following hospitalization. So I think the concern was that 

her care was delayed in the emergency department and there was 

a delay in her receiving radiology service. She went home and was 

subsequently admitted to another facility and died at that time. 

So it wasn’t that we had a death in the facility at that time, 

which I absolutely agree with you, Congressman, would have required that we review those videotapes and look at them. 

The CHAIRMAN. The GAO, in their written testimony for this 

morning’s hearing, alleges that oversight of the implementation of 

VHA’s business rules has been limited and has not included independent verification of VAMC actions. So my question to you is: 

Would the Department be willing to increase oversight of the new 

business rules and pursue independent verification of VA Medical 

Center implementation? 

Dr. LYNCH. I did read the GAO’s testimony, sir. I am not sure 

that we agree that there is value to auditing of the facilities. We 

think that we have provided adequate training. We think that we 

have provided the education that the facilities need to implement 

those. We know that the facilities have begun to implement and 

use consult management teams. We feel very strongly that the consult tool that is resulting from this review will give us that individual oversight by facility and by specialty. 

The CHAIRMAN. And they also allege in their statement that the 

Department did not require medical centers to document how they 

address unresolved consults that were opened greater than 90 

days; is that true? 

Dr. LYNCH. That is true, sir. 

But we felt we had a process defined that identified which 

consults could be closed. When there were individual patient 

consults which remained unresolved that resulted—that related to 

clinical care, that we had a process and an expectation of our medical centers, that those would be reviewed individually. 

The CHAIRMAN. In their written statement this morning, GAO 

references one VA Medical Center where specialty care providers 

have allegedly been instructed to discontinue consults for appointVerDate Aug 31 2005 09:44 Aug 21, 2015 Jkt 000000 PO 00000 Frm 00038 Fmt 6633 Sfmt 6633 Y:\87-677.TXT PAT

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ments that are not needed within 90 days and to track these 

consults outside the consult system and to resubmit them closer to 

the date that they are needed. 

Is this an acceptable practice? 

Dr. LYNCH. We have a process, as we implement new business 

rules that will identify consults for what we term ‘‘future care.’’ Future care would be somebody who perhaps had an endoscopy—— 

The CHAIRMAN. So the answer to that question is: Yes, it is an 

acceptable practice? 

Dr. LYNCH. The answer to that is: Yes, we have a process in 

place to be able to identify those and be sure that we have eyes 

on those future care consults, sir. 

The CHAIRMAN. So we have a dual track list? 

Dr. LYNCH. No, sir. We have an electronic process that follows 

those and kicks them out at the appropriate time back into our system so that we are aware that an endoscopy or a consult needs to 

be scheduled at the appropriate time. 

The CHAIRMAN. Can you respond to the comment made in the 

IG’s written statement that there seems to be a lack of focus on 

healthcare delivery as priority one at VA medical facilities, as evidenced by the length of time that it takes to fill a vacant position. 

I think that any one of us that goes to a VA Medical Center for 

a visit are often not surprised anymore by the number of people 

that have the word ‘‘acting’’ before their name or that there are positions that are important that are vacant. 

Can you respond to those comments? 

Dr. LYNCH. Yes, sir. 

First of all, I think if we look back through VHA, the system that 

we currently have was initially developed around 1940 by Omar 

Bradley, and by Dr. Paul Holly. It focused on clinical care. It focused on academic affiliation and the education of medical school 

students and residents, and it focused on the value of research. 

I realize that healthcare has changed. I respect the IG’s recommendations and thoughts. I think we do need to re-examine our 

system, but I would disagree that I think we are ignoring clinical 

care in favor of research or education. I think they are both critical 

components of what we do in VHA. The research that we have done 

has helped to improve patient care and the care that we deliver. 

I can give you two recent examples. 

There was VHA research on the treatment of PTSD that has resulted in new treatments for patients with PTSD, as well as tools 

for identifying TBI. There was a study on the use of the drug 

Prazosin and its value in patients with PTSD that has been implemented, not only in VA, but also in the private sector. I think that 

research plays a critical role in helping us assure that we have 

quality care for our veterans. 

The CHAIRMAN. Final question from me: Does the VA have every 

legal authority it needs to pay for a veteran’s care whose care is 

delayed, to receive care outside of the VA system? 

Dr. LYNCH. To my knowledge, sir, yes. 

The CHAIRMAN. So, would it be correct to say that failure to deliver care in a timely fashion is simply a question of poor leadership at VA? 


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Dr. LYNCH. I think that would be a stretch, sir. I think that our 

system strives to treat patients within VHA because we think we 

do provide good care. We think we provide quality care. I hope that 

we can identify those circumstances where it may be necessary to 

send somebody into the private sector. I think we have to use all 

the resources that we have, sir. 

The CHAIRMAN. Ms. Brownley. any further questions? 

Ms. BROWNLEY. I don’t have any further questions, but I do have 

a comment that I would like to make, and to say, I, too, share the 

frustration of the committee that we are not able to get the answers that we want. 

And I think, you know, we are looking for specifics, data, metrics, 

et cetera, and, feel—I always feel as though we never get them. We 

get answers like ‘‘We have a system that provides eyes on the process’’; ‘‘We have tools.’’ But we are really looking for the specifics. 

Our staffs assure us that you know the questions that we are 

going to ask and what we are interested in knowing through these 

hearings and it is just my feeling and my only conclusion that I can 

come to, if you are not willing to reveal the facts, that there is 

something that you don’t want the public to hear, and I just want 

to make that statement. I don’t know what else to conclude when 

we don’t get the facts and the information that we are specifically 

asking for. 

Dr. LYNCH. Congresswoman, I would point out that, in fact, one 

of your staff members of the HVAC did meet with Dr. Mike Davies 

of our staff and did go over the consult tool that we are developing 

and was shown how it works. 

The CHAIRMAN. Mr. O’Rourke or Ms. Titus, any further questions? 

Thank you very much for being here with us, and the second 

panel is dismissed. 

Members, joining us on the third and final panel—and thank you 

very much for your indulgence in allowing VA to give their testimony before you—is Deborah Draper, Director of Healthcare for 

the Government Accountability Office, and, Dr. John Daigh, Assistant Inspector General for Healthcare Inspections for the VA Office 

of the Inspector General. The committee appreciates both of you for 

being here today and thank you for your hard work and advocacy 

on behalf of America’s veterans. 

Ms. Draper, we will begin with you, you are recognized for five 

minutes for your opening testimony. 

STATEMENT OF DEBRA A. DRAPER 

Ms. DRAPER. Chairman Miller and Members of the Committee, 

I am pleased to be here today to discuss access problems in VA 

that may delay needed medical care for veterans. GAO and others, 

including VA’s Inspector General, have continued to report that VA 

medical centers do not always provide timely care, and in some 

cases, these delays have resulted in harm to veterans. 

My statement today covers two access-to-care concerns. First, I 

will highlight preliminary observations from our on-going work related to VHA’s management of outpatient specialty care consults. 

Second, I will discuss concerns regarding VHA’s medical appointment wait times, and scheduling, including progress VHA has reVerDate Aug 31 2005 09:44 Aug 21, 2015 Jkt 000000 PO 00000 Frm 00040 Fmt 6633 Sfmt 6633 Y:\87-677.TXT PAT

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ported making in implementing our December 2012 recommendations. 

VHA providers request and manage consults for specialty care 

using VHA’s clinical consult process, which is supported by an electronic system. Clinical consults include both clinical consultations, 

such as an evaluation of a patient’s clinical concern, as well as specialty procedures, such as a colonoscopy. The specialty care provider who receives the consult request is to review it within 7 days 

of it being sent to determine whether it is needed and appropriate. 

VHA’s guideline is for consults to be completed within 90 days. 

In 2012, VHA created a database to capture all consults systemwide; however, the data were deemed inadequate for monitoring 

purposes. One issue was the lack of standard processes and uses 

of the electronic consult system. For example, in addition to requesting consults for clinical concerns, the system was also being 

used to request a variety of administrative tasks, such as requesting veterans’ travel to appointments. Additionally, VHA could not 

accurately determine whether veterans actually received the care 

requested or received it in a timely manner. At the time the database was created, there were approximately two million consults 

open for more than 90 days. 

In May 2013, VHA began an initiative to standardize aspects of 

the consults process with the goal of developing consistent and reliable systemwide consult information. Among other tasks, VA medical centers were to complete a clinical review as warranted, and 

as appropriate, close all consults open for more than 90 days. 

Through our on-going work on outpatient specialty care consults, 

we found examples of delays in care at each of the VA medical centers included in our review. For example: For three of ten gastroenterology consults reviewed in one facility, up to 210 days elapsed 

from the dates the consults were requested to when they were completed. 

In another facility, for three of ten physical therapy consults reviewed, more than 100 days elapsed with no apparent actions 

taken to schedule appointment. These consults were eventually 

sent back to the requesting providers without the veterans involved 

receiving the requested care. According to the patients’ files, no 

non-service connected evaluations were being accepted due to resource constraints. 

We also found variation in how VHA’s consult initiative is playing out at the local level. For example: VA medical centers have developed different strategies for clinical consults that are needed beyond the 90-day completion guideline. Some facilities are managing 

these future-care consults outside of the electronic system, and consequently, these consults do not appear in VHA’s systemwide data. 

VA medical centers are also not required to document how they 

address consults open for more than 90 days. None of the facilities 

in our review were able to provide us specific documentation in this 

regard. VHA officials estimated that as of April 2014, of the two 

million open consults that existed when the systemwide database 

was created in 2012, 450,000 remained unresolved. 

Additionally, oversight of VHA’s consult initiative has been limited, and has not included independent verification of VHA medical 

centers’ actions. Without this verification, VHA cannot be assured 


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that the actions have been implemented correctly. Furthermore, 

VHA’s consult data may not accurately reflect whether veterans received the care needed, or if they received it in a timely manner. 

The second access-to-care concern that I wanted to highlight 

today relates to our December 2012 report and subsequent Congressional testimony. We reported that VHA’s outpatient medical 

appointment wait times were unreliable, and that there were problems in the implementation of VHA’s scheduling policy. We recommended VA take actions to: Improve the reliability of medical 

appointment wait time measures, Ensure the consistent implementation of a scheduling policy, Allocate scheduling resources based 

on needs and Improve telephone access for medical appointments. 

VA concurred with our recommendations and has reported continued actions to address them. For example, VHA officials told us 

they have implemented new wait time measures, which they say 

are more reliable. We believe that work needs to continue to fully 

implement our recommendations. It is essential that VHA also assess the actions taken to ensure that they are achieving the intended improvements. 

Mr. Chairman, this concludes my opening remarks, I am happy 

to answer any questions. 

[THE PREPARED STATEMENT OF DEBRA DRAPER APPEARS IN THE

APPENDIX] 

The CHAIRMAN. Thank you very much. 

Dr. Daigh, you are recognized for five minutes. 

STATEMENT OF JOHN D. DAIGH, JR., M.D. 

Dr. DAIGH. Chairman Miller, Members of the Committee, it is an 

honor to be able to testify before you here today. I would like to 

recognize the courage of Mr. Coates for his testimony this morning. 

It was extremely important to hear and I think very sad. 

My staff works tirelessly to try to ensure that these events don’t 

occur and this is a failure for us to see a story like this. I believe 

the VA has lost its focus on the importance of providing quality 

medical care as its primary mission. In the day-to-day decisions 

that managers at all levels make, that they take for granted often 

times, and assume that quality medical care will be provided. 

When addressing the competing demands to provide medical education, research, support to our nation in time of national disaster, 

comp and pen exams, the fight against homelessness, managers 

have lost focus on the importance of making quality medical care 

delivery their number one priority. 

In my written statement, I addressed three events that we have 

recently published that have occurred at more than two institutions. One is the colon cancer issue that we discussed here previously, the second would be veterans at Miami and Atlanta who 

died in VA hospitals from overdoses of street drugs, and in both 

cases, basic policies were not followed. 

In Buffalo and Salisbury, North Carolina, insulin pens designed 

to be used for one patient to take multiple doses were, instead, 

used on the ward for multiple patients, putting hundreds of veterans at risk for the risk of blood-borne viral infections. There is 

no good explanation for these events. They are not consistent with 


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good medical practice. They are not consistent with common sense, 

and they are not consistent with VA policies that exist. 

The most important factor in preventing these events, in my 

view, is excellent leadership that instills a culture of safety and accountability. In addition, I believe that a review of VHA’s organization and business rules is appropriate to determine if there are 

changes that would support the singular importance of quality of 

care and improve the ability of leadership to deliver that high quality medical care across the system. 

For example, one might identify positions within the medical center that are deemed essential for the delivery of medical care, and 

should one of those positions become vacant, for instance, the nurse 

in the colonoscopy suite or the GI nurse, that job would automatically be refilled. It wouldn’t have to compete for being refilled within the administration for medical education or a technician who 

might want to be hired for research. So, again, a way to try to focus 

the budget and resources on healthcare. 

In addition, VISN and hospital instructions are not standardized. 

It is not possible to look at—the position descriptions are not the 

same. The areas of responsibility are not the same. So if you ask 

the simple question: Who owns the operating room? You are not 

really sure if it is the chief of surgery; is it the chief of anesthesia; 

is it the chief of surgical care line; is it the head nurse? 

So I believe that these rules that currently exist which—and I 

will be the first to admit that the VISN system and the mantra 

that all healthcare is local has served the VA very well. I believe 

that these systems ought to be looked at to see if it is time to 

change some of these rules. 

With that, I will end this portion of my testimony and be pleased 

to take questions. 

[THE PREPARED STATEMENT OF JOHN DAIGH, JR. APPEARS IN THE

APPENDIX] 

The CHAIRMAN. Thank you, both. 

I was looking at the written statement for the GAO and you 

talked about, and the IG talks about it, too, that VA experienced 

difficulty in hiring and retaining specialists for gastroenterology 

and physical therapy. And the question is: Did you find any reason 

for that? 

Dr. DAIGH. I guess—— 

The CHAIRMAN. Either can answer on it. 

Ms. DRAPER. Yeah, I think what we heard in some locations was 

that for some high volume specialities, there is a national shortage 

of some specialists, so it is difficult to hire. I think we heard, generally, that there was an increased volume of requests for certain 

specialty services which is complicating providing care. So, you 

know, if you have a shortage of providers, you can’t backfill and, 

you know, increase the capacity that you have within the specialty 

clinics, so we did hear some of that. 

The CHAIRMAN. I would suspect that if you had a shortage of providers or you had vacancies that you couldn’t fill, then the obvious 

thing would be a fee-for-service if possible, and then the question 

begs to be answered: Do you think VA makes adequate or even 


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maximum use of fee-bases resources when those specialists are not 

available? 

Ms. DRAPER. We have not looked at this in any great detail. I 

mean it varies considerably from facility to facility. And at one facility, for example, they fee-based two to three hundred GI consults 

a month. In other facilities, they do very little. It is hard to understand what the variation is, but it does vary considerably from one 

facility to another. 

Dr. DAIGH. I would say, sir, that this is not a new problem. We 

published, you know, a similar report in 2006 that outlined the difficulty that VA had in following up on patients who were being 

screened for colonoscopy and needed tests to look for the presence 

of colon cancer on a regular basis. And so I think, A, you have to 

have a system in place, but, B, you are just talking about a procedure and the procedure can be done by a variety of people trained 

to do that procedure. 

So the question is: If you need a colonoscopy done, well, maybe 

a PA could do that or maybe a nurse could do that—to have the 

training and to assist the physicians and other staff to make sure 

that this simple procedure got done adequately, and where a physician needed to impart additional insight into what one should do, 

you could schedule visits for that. So I think this is just not a new 

problem. 

The other point I would make is that many VAs, probably 100 

of them, are affiliated with medical schools, so you have right there 

a whole set of physicians that are in the community that are available, so that if you could work with that group of patients, a group 

of facilities, one could probably construct solutions that would be 

worthwhile. 

So, I think fee-basis consults, creative uses and training of your 

resources and your people to plan for what you know are going to 

be on-going problems; they are all parts of the solution here. 

The CHAIRMAN. Ms. Draper, have you ever seen an instance or 

instances where a VISN director or a medical center director restricted the use of fee-basis care funds or diverted those funds to 

be used in other programs? 

Ms. DRAPER. I have not, but for this work we have not looked at 

that in any great detail. 

But I do want to say one thing about fee-basis, as well, is that 

these are not tracked the same way, so you don’t know what the 

wait times are. So when you fee-base something out there, you lose 

that tracking ability to see, so you may not really be accomplishing 

something—you may not be getting the care in a timely way, it is 

just that VA doesn’t—they don’t really track that. 

The CHAIRMAN. And, again, they should. 

Ms. DRAPER. They should, and we pointed that out in our previous report. 

The CHAIRMAN. We found this issue in Atlanta, in particular, 

where mental health care was an issue where basically once VA 

fees something out, it appeared that they just dropped off the radar 

screen and they weren’t watching it or tracking it again. 

Just because they are not getting care in a VA facility doesn’t 

mean that they are not VA’s patient or America’s patient and VA 

had darn sure better—— 


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Ms. DRAPER. Right. And VA is paying the bill, so—I mean that 

was one of the issues that we pointed out in our 2012 report is that 

is was not tracked. 

The CHAIRMAN. Actually, a grateful American taxpayer is paying 

the bill and I think VA forgets that sometimes; it is the taxpayers’ 

funds, not theirs. 

Ms. Brown. 

Ms. Titus. 

Ms. TITUS. We have been here a long time. Thank you, Mr. 

Chairman. 

I just keep hearing a theme over and over that these things seem 

to vary have facility to facility, and I understand perhaps the need 

for some flexibility because some hospitals may be associated with 

the medical school, different demographics, different geography, 

and all of that. But it seems to me there is some need for some 

kind of standardized policy to some extent. 

I know at the Las Vegas hospital, they are flying in emergency 

room doctors from all over the country on contract for a few day 

schedules. That doesn’t seem very practical to me. I mean there 

must be all of the Las Vegas Valley, some emergency room doctors 

who could do that. It seems like you would save money and get 

more of a buy in from the medical community than these kind of 

flying in doctors. 

I would like that addressed, but I also would like to go back to 

the Sandi Niccum case. Dr. Lynch kind of got his memory back in 

the course of answering that question, but I would like to ask ya’ll 

if you can give us some kind of progress report so we can find out 

if that is moving and when we are able to get some results. 

Dr. DAIGH. Yes, the research on that has been done. The report 

has been written. It is in draft phase, and it will be out within a 

couple—three or four weeks. So we are—we will be ready. 

In the normal process, I would like to clarify a little bit what was 

said previous. We would write a report and lay out the facts as we 

see them. We would then send a report to VHA at multiple levels, 

including the hospital in Las Vegas, ask them to read the report 

and verify they think the facts are correct. We would then make 

recommendations in the report and ask them to respond to the recommendations and they would, in writing, respond to those recommendations. 

At that point, we would offer the Committee and you a briefing 

on the findings and we would publish the report to the web where 

it would be public, that would be our report, plus their response. 

The response sometimes takes awhile for VA to follow back up 

on, so we then have a part of our office that does follow-up. Usually, it is that we ask for records to prove that X and Y were done, 

and if they provide records that X and Y were done, then we usually close it. 

Occasionally, we say this is so important an issue that we personally will go back and re-visit the facility and try to do a followup. The follow-up documents, though, are not made public unless 

they are requested, so they are internal to us. I see them, you ask 

for them, you can get them. We do provide a list to Congress multiple times a year of those recommendations that have not been 

filled within a year. 


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So where we have not been unable to close a recommendation on 

one of our reports within a year, we make that available to you as 

an item and we are happy to talk about those. 

Ms. TITUS. Okay. So when you say the report will be finished 

within three weeks or so, is that the stage in which you send it to 

the hospital or—— 

Dr. DAIGH. No, I think this should be publishable within three 

weeks or so, three to four weeks. 

Ms. TITUS. Well, I will look forward to getting that. 

And it seems to me that sometimes these reports that focus on 

a specific problem in a specific hospital are used to address just 

that and not taken in the broader, I don’t know, perspective, so 

that they can be used to solve problems at other facilities. 

Dr. DAIGH. Well, I think in terms of just producing a report and 

making sure it is accurate, I have to narrow the scope often times 

to what I can be accurate about. 

Ms. TITUS. Uh-huh. 

Dr. DAIGH. But if one looks at the reports that we put out or you 

ask us to talk about it—I am familiar with the reports that we put 

out—we are happy to try and talk about patterns that we see. 

Certainly, VHA gets the reports and they can look for patterns 

and we are aware of patterns, so I think you are right; there is a 

difficulty in that they don’t all talk to the universe, but I can’t do 

that and get it out timely. 

Ms. TITUS. I understand that. 

Mr. Chairman, thank you. I yield back. 

The CHAIRMAN. Mr. O’Rourke. 

Mr. O’ROURKE. Thank you, Mr. Chair. 

Dr. Daigh, a couple things that you said really struck home in 

terms of trying to figure out what is going wrong and how we fix 

it. You said it was a question of leadership and you also said it is 

a question of having a culture that prioritizes safety and accountability. And those issues are so big and so tough to address in a 

five-minute question and response. 

But I will just tell you that I have had the chance to meet Secretary Shinseki. I have heard him testify here. I have no question 

whatsoever that he has the highest and deepest commitment to improving the service of the VA—and if he were here, I am sure that 

he would agree and share everyone’s frustration—and say that the 

results that we described today are unacceptable, and I also have 

no doubt about Dr. Lynch and Dr. Clancy and their commitment. 

The people that I meet within the VA are good people who are 

trying, and yet, the awful numbers that I gave for El Paso earlier 

are not new. In 2008 we had the worst access not country to be 

able to get in to see a doctor and it has improved only marginally 

since then. So, despite good people doing good work and assuring 

us of their efforts, it is not getting better—certainly not quickly 

enough for the veterans who need to see care. 

Let me ask you this: In assessing the job that I am doing and 

the job that Congress and this Committee is doing, you know, the 

primary responsibility for these veterans is within the VA. The ultimate responsibility is within Congress. We have the power and 

responsibility of authorizing, appropriating, and oversight, and so 

I will ask you the question that I asked Dr. Lynch: What could we 


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be doing that we are not doing now to change the outcome and to 

get veterans the care that is being delayed and ultimately denied, 

as we heard with Mr. Coates and as I see every single day in El 

Paso? 

Dr. DAIGH. I have watched this system for awhile; I would agree 

that the people who work in it are excellent. They are committed. 

Many of them are veterans and they are of the highest quality 

when you sit and talk with them. That is why I expressed the frustration over the events that I talked about when you say ‘‘Well, 

what really happened?’’ 

And often, I think—so let me go to your point. I think that serious thought needs to go into the business model that VA uses now 

to deliver care. So if you are in the middle of Manhattan and you 

have multiple medical schools and many hospitals, you have a different group of folks to deal with in terms of trying to resource and 

provide care. You would make different decisions about how you 

provided care. You may decide that cardiac surgery is so great at 

this hospital that why shouldn’t I get into that business, why 

wouldn’t it use it all the time. 

And if you are a different facility someplace, you have entirely 

different business needs, and I think that the VA structure has not 

morphed over the last number of years, as I think it should. In the 

past, I think most veterans lived in the shadow of the hospital. If 

they drove and could get there, they were enrolled in that facility. 

If the goal is deliver one standard of care to all veterans who are 

eligible for that particular piece of care, the ones that live on the 

other side of the mountain and across the river, I think you have 

to rethink a little bit how you are doing that. And so I would take 

a serious look at, given that the information flow has changed; data 

requirements have changed; data is available—the capabilities of 

computing are different. I think it is time to take a look and fix 

what needs to be fixed bureaucratically to drive efficiency and drive 

standardization, but try very hard to preserve the mantra that all 

healthcare is local, so that local folks can make important local decisions. 

Mr. O’ROURKE. And I appreciate the fact that representatives 

from the VA are here listening to this, and I am sure at headquarters, they are listening as well, and to a certain degree, they 

can choose to adopt these recommendations administratively, but 

just to put a finer point on the question that I am asking: Are you 

suggesting that, again, despite the best efforts within the VA and 

current leadership, we are not seeing the kind of change that we 

need? That the recommendation that you are making needs to 

come in the form of a legislative proposal, a bill that would force 

the VA to change how it delivers cares? 

Dr. DAIGH. So how change occurs, I am not quite the expert on, 

whether it needed to be law or discussion. But, certainly, if you 

were to change business structure, I am assuming that you would 

need to change some law. 

But what I am pointing to is in a GI clinic where you are scheduling colonoscopies and you have people who need colonoscopies, 

you know what the demand is. If you lose a critical player in that 

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fore. So the people in that clinic, the doctors, the nurses, everybody, 

needs to have an easy conduit to drive change and make it happen. 

If the complaint is that at the local level within a hospital, they 

can’t get the positions filled, they need filled to ensure that what 

gets done gets done, and those people who are not bureaucratically 

responsible for the delivery of care are somehow able to drive resources outside of the delivery of primary care, I think that needs 

to be fixed. 

I think there ought to be a study. I think there ought to be a 

good look at how VA is currently set up and see if there are not 

better ways to manage this system in 2014 and forward. 

Mr. O’ROURKE. Thank you, Dr. Daigh, and, Ms. Draper, I thank 

you for your answers. 

Mr. Chair, I yield back. 

The CHAIRMAN. The gentleman yields back. 

Ms. Titus, do you have a request? 

Ms. TITUS. I do, Mr. Chairman, thank you. 

I would like to submit Mr. Michaud’s written statement for the 

record because he couldn’t be here. 

The CHAIRMAN. Without objection. 

The CHAIRMAN. Being no further questions from the Committee, 

we will be submitting some questions for the record. We would appreciate a timely response from all the witnesses today. 

I do ask unanimous consent that all members would have five 

legislative days with which to revise and extend or add extraneous 

material to their remarks. 

Without objection, so ordered. 

And, once again, thank you to all of the witnesses for being here 

today. 

This hearing is adjourned. 

[Whereupon, at 12:41 p.m., the Committee was adjourned.] 


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APPENDIX 

PREPARED STATEMENT OF CHAIRMAN JEFF MILLER

Good morning. 

The committee will come to order. 

Before we begin I’d like to ask unanimous consent for our colleague from Tennessee, Congressman Steve Cohen to sit at the dais and participate in today’s proceedings. 

Hearing no objection, so ordered. 

Welcome to today’s full committee oversight hearing, ‘‘a continued assessment of 

delays in VA medical care and preventable veteran deaths.’’ 

Today’s hearing is the fulfillment of a promise I made in early January to followup on delays in care at department of veterans affairs (VA) medical centers in Columbia, South Carolina, and Augusta, Georgia, that, together, resulted in nine preventable veteran deaths. 

I had hoped that during this hearing, we would be discussing the concrete 

changes VA had made—changes that would show beyond a doubt that VA had 

placed the care our veterans receive first and that VA’s commitment to holding any 

employee who did not completely embody a commitment to excellence through actions appropriate to the employee’s failure accountable. 

Instead, today we are faced with even with more questions and ever mounting evidence that despite the myriad of patient safety incidents that have occurred at VA 

medical facilities in recent memory, the status quo is still firmly entrenched at VA. 

On Monday—shortly before this public hearing—VA provided evidence that a total 

of twenty-three veterans have died due to delays in care at VA medical facilities. 

Even with this latest disclosure as to where the deaths occurred, we still don’t know 

when they may have happened beyond VA’s stated ‘‘most likely between 2010 and 

2012.’’ These particular deaths resulted primarily from delays in gastrointestinal 

care. Information on other preventable deaths due to consult delays is still unavailable. 

Outside of the VA’s consult review, this committee has reviewed at least eighteen 

preventable deaths that occurred because of mismanagement, improper infection 

control practices, and a host of other maladies plaguing the VA health care system 

nationwide. Yet, the department’s stonewall has only grown higher and non-responsive. 

There is no excuse for these incidents to have occurred. 

Congress has met every resource request that VA has made and I guarantee that 

if the department would have approached this committee at any time to tell us that 

help was needed to ensure that veterans received the care they required, every possible action would have been taken to ensure that VA could adequately care for 

those veterans. This is the third full committee patient safety hearing we have held 

since I have been chairman and I am going to save our VA witnesses some time 

by telling them what I don’t want to hear from the department this morning. 

I don’t want to hear the rote repetition of—and I quote from several prior VA 

statements, including the written testimony that was provided for this hearing— 

‘‘the department is committed to providing the highest quality care, which our veterans have earned and deserve. When incidents occur, we identify, mitigate, and 

prevent additional risks. Prompt reviews prevent similar events in the future and 

hold those responsible accountable.’’ 

Another thing I don’t want to hear is—and, again, I quote from numerous VA 

statements, including a recent press statement—‘‘while any adverse incident for a 

veteran within our care is one too many,’’ preventable deaths represent a small fraction of the veterans who seek care from VA every year. 

What our veterans have truly ‘‘earned and deserve’’ is not more platitudes and, 

yes, one adverse incident is indeed one too many. We all recognize that no medical 

system is infallible, no matter how high the quality standards might be. But I think 

we all also recognize that the VA health care system is unique because it has a special obligation not only to its patients—the men and women who honorably serve 

our nation in uniform—but also to its financers—the hard-working American taxpayers. 

When errors do occur—and they seem to be occurring with alarming frequency— 

what VA owes our veterans and our taxpayers, in that order, is a timely, transparent, accurate, and honest account about what mistakes happened, how they are 

being fixed, and what concrete actions are being taken to ensure accountability. 

It concerns me that my staff has been asking for further details on the deaths 

that occurred as a result of delays in care at VA medical facilities for months and 

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ing for. Even then that information is far from a complete description of the problem 

and VA’s efforts to prevent future deaths. 

It concerns me even more that VA’s briefing Monday and testimony today include 

very few details about what, if any, specific actions have been taken to ensure accountability for the twenty-three veterans who lost their lives and the many more 

who were harmed because they didn’t get the care they needed in a timely manner. 

On our first panel today, we are going to hear from a veteran who sought care 

through the William Jennings Bryan Dorn VA medical center in Columbia, South 

Carolina. That veteran—Mr. Barry Coates—is going to tell us that, and I quote, ‘‘ 

. . . the gross negligence . . . and crippling backlog epidemic of the VA [health 

care] system has not only handed me a death sentence but ruined my quality of life 

. . . ’’ 

Mr. Coates waited for almost a year and would have waited even longer had he 

not actively, persistently insisted on receiving the colonoscopy that he and his doctors knew he needed. That same colonoscopy revealed that Mr. Coates had stage 

four colon cancer that had metastasized to his lungs and his liver. Maybe that is 

why VA does not want to define accountability in terms of employees who have been 

fired. 

The department is going to testify this morning that, instead, we should focus our 

accountability efforts on correcting systems deficiencies in order to prevent adverse 

events from occurring again. 

There is nothing wrong with fixing systems. But Mr. Coates deserves better than 

that. His adverse event already happened and, for him, there is no going back. With 

that, I now yield to acting ranking member Brown for any opening statement she 

may have. 

f 

PREPARED STATEMENT OF MICHAEL MICHAUD, RANKING MEMBER

Thank you, Mr. Chairman, for holding this hearing today. We all agree that patient safety and quality of care issues remain top priorities for this Committee. 

I read with concern the testimony provided by our first two panels. All too often, 

members of this Committee hear the same issues raised again and again in reports 

by agencies such as the Government Accountability Office and the VA’s Office of Inspector General. 

Findings such as inadequate training, improper oversight, lack of guidance, no accountability, and failing to follow proper procedures already in place, are too common. 

Mr. Chairman, I understand that the Department is a very large agency and not 

without its challenges. I also understand that mistakes are going to be made. I also 

believe no matter how transparent the Department is, something clearly has to 

change. 

My frustration lies in the fact that findings are made and plans are implemented, 

but the situation does not seem to get better. Veterans, like Mr. Coates from our 

first panel, have suffered terribly from these ongoing mistakes. As Mr. Coates states 

in his testimony: 

‘‘I am not here today for me. I am here to speak for those to come, so that they 

might be spared the pain I have already endured and know that I have yet to face.’’ 

Mr. Chairman, we owe it to the veterans of this nation to do everything we possibly can to improve the processes that will help prevent such incidents’ happening 

in the future, and ensure proper accountability for those who are responsible. 

Veterans are not statistics, a number or a column on a spreadsheet. They are people who have fought for the freedoms we so enjoy today. We need to remember that 

and the Department needs to make much stronger efforts to turn this issue around. 

In today’s day of advanced systems and rapid technology development, there is 

no excuse for ‘‘losing track’’ of vital consults and appointments. Ensuring proper 

tracking and timely appointments is critical. 

Mr. Chairman, I do not want to revisit this issue in six months. It is time to stem 

the tide of rationalizations and excuses. Let’s get this done. 

I look forward to hearing from our panelists today and want to thank everyone 

for being here. 

Mr. Chairman I yield back the balance of my time. 


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PREPARED STATEMENT OF HON. CORRINE BROWN

Thank you, Mr. Chairman, for calling this hearing today. We can all agree that 

veteran safety and quality of care issues at the VA health facilities are of utmost 

concern for this Committee. 

However, It is unfortunate that we must continually call these hearings to make 

sure that our nation’s veterans are receiving the care for which they have already 

paid dearly for on the battlefields and in service to protect the freedoms we all hold 

most dear. 

I find it disturbing that just two days before this hearing, the VA has releases 

findings that its healthcare personnel are not fully trained in the importance of 

timely consults when treating a veteran. 

The dictionary defines a consult as the act of seeking information or advice from 

someone with expertise in a particular area. 

The system the VA set up to make these consults easier obviously broke down 

and it is possible that at least ficve veterans died in Florida because the right information was not shared with the right health professionals. 

I am concerned that in the five years after the colonoscopy debacle at the Miami 

VA, nothing has changed. 

To refresh your memory, in 2009, staff members at a number of VA facilities noticed improper reprocessing of endoscopes contrary to the manufacturer’s instructions. The VA properly ordered all facilities to Step-Up and get retrained on the procedures. We want employees to feel free to report questionable issue and procedures 

without fear of retribution for trying to save lives. 

It seems that from this new consult problem that the retraining stopped at that 

one procedure. 

The fact sheet your office put out regarding the consults talks a lot about procedure and adverse events. However, I have heard that before and again our veterans 

are suffering. 

I look forward to hearing the testimony today and explanations for this lack of 

proper care and accountability for these mistakes. 

VA we have appropriated much money over the years to overhaul your computer 

system, and yet, you could not separate that heart consults are of a higher priority 

than a ride across town? 

What kind of training did employees get before and how is the training different 

now? 

f 

PREPARED STATEMENT OF HON. STEVE COHEN (TN 9) 

Thank you, Chairman Miller, for allowing me to submit a statement into the 

record for today’s hearing on preventable veteran deaths. While I do not sit on the 

VA Committee, today’s hearing touches on an issue that unfortunately has affected 

veterans and their families in my home of Memphis, Tennessee. I appreciate the 

Committee for accepting my statement. 

In October 2013, the VA Office of Inspector General released a concerning report 

regarding three deaths at the Memphis VA Medical Center Emergency Department. 

The report, which was based on a May 29–31, 2013 site visit, found that certain 

actions and inactions taken by physicians at the VA may have contributed to the 

death of the veterans mentioned in the report. I do not dispute the report’s findings 

but instead am interested in learning what Congress and our VA medical centers 

can do to help prevent incidents like these from reoccurring in my home and at VA 

medical centers across America. 

As soon as this report was released, I sent a letter to VA Secretary Eric Shinseki 

raising my concerns about its findings as well as those of my constituents. In the 

same spirit of learning what can be done to prevent avoidable deaths at VA medical 

centers, in my letter I also invited the Secretary to visit the Memphis facility to 

meet with Memphis veterans and hospital staff. I asked that he offer any suggestions that would improve care at the Memphis VA center—whether it be increased 

funding, personnel, technology or equipment. 

While I am waiting to hear back from the Secretary’s office regarding my invitation, I hope that the witnesses present at this hearing will offer corrective actions 

that can be taken to improve care at VA medical centers. I am also interested in 

their suggestions for incorporating standards of care at these facilities so that preventable deaths do not occur in the future. 

I have been in close contact with Director C. Diane Knight at the Memphis VA 

Medical Center, who was appointed in July 2013. While the deaths and the IG site 


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visit occurred prior to her leadership, I am confident that the reforms she has put 

into place since becoming director and in light of the report will greatly improve patient care at the facility. I hope that the witnesses’ testimonies will reflect this and 

again, offer constructive suggestions for how we all can work to improve conditions 

at the VA medical center in Memphis and across America. Our veterans bravely 

risked their lives for us and we owe them the very best care we can offer. 

Mr. Chairman, again, thank you for accepting my statement and I look forward 

to reviewing the testimonies. 

f 

PREPARED STATEMENT OF BARRY L. COATES

My name is Barry Lynn Coates and due to the inadequate and lack of follow up 

care I received through the VA system, I stand before you terminally ill today. I 

joined the Army in February of 1991 anxious to serve my country. Near the end 

of basic training an injury to my back derailed those plans and I was discharged 

around the first of May that same year. 

After a five year fight to obtain service connection status for my injury and the 

treatment and pain management required as a result of it, I finally became eligible 

for medical treatment through the VA system. That was the start of the long, painful, emotional, and unnecessary journey that brings me to you. 

On November 22, 2010 severe abdominal pain sent me to Carolina Pines Regional 

Medical Center in Hartsville SC, where a spinal CT showed that my lungs were 

clear and my liver were normal however, there was blood seen in the stool so a follow-up was recommended and consideration of a colonoscopy was suggested. That 

follow-up recommendation was completed at the Rock Hill Clinic with Dr. Anuradha 

Verma on January 20, 2011. No rectal exam was done, I was basically told to continue taking my medications previously prescribed and to come back if things did 

not improve or things got worse. 

Due to increased pain and constipation, on February 25, 2011 I requested to be 

seen by a doctor or to be referred to a GI Specialist. I saw Dr. Verma again on 

March 3, 2011 because of increased pain and rectal bleeding. I reminded her of the 

suggestion made by the ER doctor that a colonoscopy might be needed. I was sent 

home with hemorrhoidal suppositories and the promise that a colonoscopy might be 

done at some point. I was not seen until May of 2011 and the results were the same. 

I had relocated in October 2010 but had to continued to be seen at the Rock Hill, 

SC Clinic due to the back log at the Florence, SC Clinic. I was first seen by Dr. 

Eric Naumann at the Florence Clinic in June 2011. He started by putting me on 

100 mg of the stool softener ‘‘Docusate’’ in order to counteract the constipation 

caused by narcotics necessary to treat the ongoing back pain to my previous injury. 

He also expressed dismay that this had not be done previously. Most importantly, 

he agreed that a colonoscopy needed to be done. 

However my first GI consult did not occur until August 2011 with Dr. Sylvia Kim. 

I informed Dr. Kim of the ongoing pain, constipation, and bloody stools that I had 

been dealing with for over a year only to repeatedly have it dismissed as hemorrhoids. I was simply told to return in two months, still no referral for colonoscopy 

despite my request. In a conversation with Andy Pigge, Rn at the Florence Clinic, 

I made it known that my requests were being ignored and I felt it was jeopardizing 

my health. 

On September 1, 2011 after ample time on the Docusate I sent Dr. Naumann a 

message via my healthyvet.com informing him that I was still bleeding every bowel 

movement and still experiencing pain. As of September 15, 2011 I began having 

trouble urinating in addition to the other problems and only found some relief sitting in warm water. Dr. Naumann was informed of these new symptoms at this 

time. He stated that I may need to see a surgeon and may need to be considered 

for a colonoscopy. Dr. Naumann requested for the second time a colonoscopy October 

4, 2011. 

I saw Dr. Kim October 12, 2011 and told her that the pain was now constant as 

well as the rectal bleeding and that my stools have become smaller and bright red 

in color. I was finally scheduled to have a colonoscopy consultation in April of 2012, 

which would be approximately a year and a half after the beginning of this journey. 

Tired of living in constant pain and knowing that my problems were bigger than 

hemorrhoids, I persistently called on the chance that there might be an earlier opening or cancellation. I was able to secure an opening for consultation appointment 

for November 30, 2011 and finally had the colonoscopy done December 9, 2011. The 

procedure was done at the Fort Jackson Hospital by Dr. Steedman Sarbah which 

found that I had a 5.5 mm nodule located six to eight centimeters from the anal 


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verge with almost total luminal obstruction. I was diagnosed with stage four colon 

rectal cancer. Further tests revealed metastatic nodules on the right lung in the 

upper lobe along with liver lesions. It was stated that because of the post proximity 

of the nodules to anal verge a proper rectal exam would have easily found it and 

prompted treatment sooner. 

I saw Dr. Kim days later on the 14 of December 2012 and expressed to her sentiments of the doctor that performed the colonoscopy along with my own that a doctor 

should take time to listen to her patients as they know their bodies and can often 

sense when something is wrong. After ‘‘supposedly’’ not being able to feel the tumor 

during prior exam after seeing the images she was suddenly able to locate it easily. 

I had surgery on December 16, 2012 for a post diverting loop colostomy and started chemotherapy in January of 2012 followed by 26 radiation treatments. The tumor 

was removed July 22, 2012 with a total anal recession. I have since had to endure 

a permanent colostomy which requires multiple bag changes per day along with 

catherization several times daily because of the bladder nerves being severed in 

order to remove the tumor. I am totally and permanently impotent as well as incontinent. The extensive chemotherapy has resulted in permanent neuropathy in both 

my hands and feet causing constant discomfort and pain. 

A follow up exam on April 2, 2014 has shown even further spreading of cancer 

with new lesions on my liver, multiple new lesions on both lungs, plus growth of 

the existing lesions and a referral for a MRI as the doctor fears it may have spread 

to my brain. Another round of Chemotherapy would have been started immediately 

but was postponed so I would be able to come and speak to all of you. 

It is likely too late for me, the gross negligence of my ongoing problems and crippling backlog epidemic of the VA medical system has not only handed me a death 

sentence but ruined the quality of my life I have for the meantime. I am not here 

today for me, I am here to speak for those to come so that they might be spared 

the pain I have already endured and know that I have yet to face. 

My situation is made even more unnecessary knowing that a 1.2 million dollar 

grant was given to the Dorn VA Center to reduce backlog and improve care and 

treatment of veterans only to learn that the money was misallocated by diverting 

it to other uses instead of using it for the intended purpose. Only 1/3 of those funds 

were used properly. 

Men and women across this country volunteer every day to serve in the armed 

forces. The fact that our military stays well-manned and strong solely on the willingness of those volunteers to risk their lives for the protection of the nation as a 

whole is truly awe-inspiring. Other nations have to force service in order to maintain a strong military. The very least this country should do is to ensure that those 

volunteers are taken care of after they have made sacrifices to take care of our country. I am not a unique case in the VA health care system as 19 others have already 

died and 60 more are in the same terminal status. I am here because proper care 

was not given exams were not performed properly, and diagnostic tests were either 

postponed or not done at all. 

In the civilian world, these doctors would face malpractice suits and medical review boards. As the saying goes ‘‘heads would roll.’’ In the VA system oversight is 

not as clear cut and complaints are often either lost or covered up by bureaucracy. 

So I ask you today, how many more vets will be allowed to suffer and die before 

someone is held accountable? 

Thank you for your time, 

Barry Coates 


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VACREP180 with DISTILLERInsert offset folio 15 here 87677.015
68 


VACREP180 with DISTILLERInsert offset folio 16 here 87677.016
69 


VACREP180 with DISTILLERInsert offset folio 17 here 87677.017
70 


VACREP180 with DISTILLERInsert offset folio 18 here 87677.018
71 


VACREP180 with DISTILLERInsert offset folio 19 here 87677.019
72 


VACREP180 with DISTILLERInsert offset folio 20 here 87677.020
73 


VACREP180 with DISTILLERInsert offset folio 21 here 87677.021
74 


VACREP180 with DISTILLERInsert offset folio 22 here 87677.022
75 


VACREP180 with DISTILLERInsert offset folio 23 here 87677.023
76 


VACREP180 with DISTILLERInsert offset folio 24 here 87677.024
77 


VACREP180 with DISTILLERInsert offset folio 25 here 87677.025
78 


VACREP180 with DISTILLERInsert offset folio 26 here 87677.026
79 


VACREP180 with DISTILLERInsert offset folio 27 here 87677.027
80 


VACREP180 with DISTILLERInsert offset folio 28 here 87677.028
81 


VACREP180 with DISTILLERInsert offset folio 29 here 87677.029
82 


VACREP180 with DISTILLERInsert offset folio 30 here 87677.030
83 


VACREP180 with DISTILLERInsert offset folio 31 here 87677.031
84 


VACREP180 with DISTILLERInsert offset folio 32 here 87677.032
85 


VACREP180 with DISTILLERInsert offset folio 33 here 87677.033
86 


VACREP180 with DISTILLERInsert offset folio 34 here 87677.034
87 


VACREP180 with DISTILLERInsert offset folio 35 here 87677.035
88 


VACREP180 with DISTILLERInsert offset folio 36 here 87677.036
89 


VACREP180 with DISTILLERInsert offset folio 37 here 87677.037
90 


VACREP180 with DISTILLERInsert offset folio 41 here 87677.041
91 


VACREP180 with DISTILLERInsert offset folio 42 here 87677.042
92 


VACREP180 with DISTILLERInsert offset folio 43 here 87677.043
93 


VACREP180 with DISTILLERInsert offset folio 44 here 87677.044
94 


VACREP180 with DISTILLERInsert offset folio 45 here 87677.045
95 


VACREP180 with DISTILLERInsert offset folio 46 here 87677.046
96 


VACREP180 with DISTILLERInsert offset folio 47 here 87677.047
97 


VACREP180 with DISTILLERInsert offset folio 48 here 87677.048
98 

Æ 


VACREP180 with DISTILLERInsert offset folio 49 here 87677.049