Inspectors General: Veterans Affairs Special Inquiry Report Was Misleading
Released: 1998-05-14T00:00:00

Letter

Background

An unexplained increase in patient deaths occurred in one ward at the Harry S Truman Memorial Veterans Hospital (hereinafter referred to as Hospital) in Columbia, Missouri, during the spring and summer of 1992. In October 1992, based on information provided by a Missouri state legislator, the Federal Bureau of Investigation (FBI) and the VA OIG initiated a joint criminal investigation into the suspicious deaths. In February 1993, the OIG received specific allegations that the Hospital Director and the VA Central Region Chief of Staff had attempted to cover up the unexplained increase in patient deaths, including by not referring the matter to law enforcement authorities.

In January 1995, the OIG initiated an administrative investigation (known as a Special Inquiry), which focused on management’s response to the patient deaths. Subsequent to the start of the Special Inquiry, the VA OIG received a series of additional letters from the complainant alleging that the cover-up (1) involved not only Hospital and VA management but the VA OIG as well and (2) had continued even after the October 1992 start of the joint FBI and VA OIG investigation. The OIG issued the Special Inquiry report in September 1995. In its report, the OIG analyzed and criticized Hospital and VA management’s response to the increase in deaths and noted that it had “found a dysfunctional top management team . . . in place.” The OIG reported that while the evidence might indicate to some individuals that at least the appearance of a cover-up existed, management’s actions could be attributed instead to bad judgment. The OIG further reported that it had found no conclusive proof of an intentional cover-up by Hospital and Central Region officials and no evidence of criminal conduct by top managers. As to its own role, the OIG stated that it had made mistakes but avowed that it had not participated in a cover-up. (A more extensive background is provided in app. I.)

VA OIG’s Conclusion Regarding Alleged Cover-Up Is Misleading

The title and text of the Special Inquiry report suggest that allegations of a cover-up had been investigated. We determined that the OIG did not plan or conduct its review or analysis in a way that could determine if a cover-up had occurred. Had the OIG conducted such a review, its documentation would have included an effort to link individual pieces of evidence that together suggest additional lines of inquiry—including elements of a cover-up. Further, both the Assistant IG and the analyst responsible for the Special Inquiry told us that the OIG did not review or investigate the allegations of cover-up. The Assistant IG told us that the Special Inquiry report overstates its conclusion regarding no evidence of a cover-up. Therefore, the Special Inquiry’s conclusion was not supported by work done or evidence collected and is misleading.

Misrepresentation of Facts and Misleading Report Language

In the Special Inquiry report, the OIG represents that its review included the allegation of a cover-up on the part of the Hospital Director and the Central Region Chief of Staff. However, according to the lead analyst who conducted the review and the Assistant IG who wrote the final report, the issue of cover-up was “off the table” because, in their view, their “charge” from OIG management did not include looking at cover-up allegations. They defined cover-up as being related to criminal issues and added that neither of them was a criminal investigator.

Prior to his retirement, the lead analyst responsible for the Special Inquiry completed the interviews and field work and wrote a draft report entitled Special Inquiry: Management Response to Unexplained Patient Deaths, Harry S. Truman VA Medical Center, Columbia, Missouri. The body of that draft report made no reference to allegations of a cover-up by the Hospital Director and Central Region Chief of Staff. In the draft report, only one issue was addressed—whether management officials complied with VA policy when responding to the revelation of the unexplained deaths.

According to the Assistant IG who prepared the final report, he did not review the underlying evidence while preparing the final report, nor did he reconcile the stated facts in the report with the underlying evidence prior to issuing the report. He stated that in writing the final Special Inquiry report, he changed the original title and edited the report in an attempt to tie the text to the complainant’s allegations. He characterized this as wordsmithing and added that he had no intent to mislead. He concluded that in hindsight he probably should not have changed the title and that the report probably overstated its case concerning no evidence of a cover-up, as the OIG did not investigate the cover-up allegations.

Although the Assistant IG stated that there was no intent to mislead, the report title—Special Inquiry: Alleged Cover-up of an Unexplained Increase in Deaths, Harry S. Truman Memorial VA Medical Center, Columbia, Missouri—and two of the report’s three major sections—“Alleged Cover-up by Medical Center and Central Region Officials Subsequent to the Criminal Investigation” and “Alleged Cover-up by the Office of Inspector General”—specifically refer to the cover-up allegations. Further, the OIG reported that it had found “no conclusive proof of an intentional cover-up by Medical Center and Central Region officials” and “no evidence of criminal conduct by top management.” This language is misleading, because the OIG did not conduct its Special Inquiry so as to support its conclusion concerning an intentional cover-up. Instead, it addressed whether management had complied with VA and Hospital policy and procedures in its response to the increase in deaths.

The then IG told us that he had intended for the Special Inquiry to investigate allegations of a cover-up and that, based on his reading of the report, it appeared that it had. He added that if the review did not include an investigation of the cover-up allegations, he believes that the report, as written, is misleading.

Review Planned and Executed From a Management Perspective

We determined that the OIG did not plan or conduct its Special Inquiry in a manner to determine if improper acts pertaining to a cover-up had occurred. According to the Assistant IG, in preparing the report, he examined components of the complainant’s allegation separately, rather than linking or relating the information gathered. He added that had the inquiry included investigation of a crime, it would have been appropriate to show whether a pattern of conduct existed. One method of establishing such a pattern, as is required by the OIG’s Investigative Policy and Procedure Guide for special inquiries, is to create a chronology of events and actions. The OIG did not do this.

Frequently a single act, taken by itself, is not sufficient to establish that the act was done willfully and intentionally with improper purpose. However, a series of acts considered collectively may suggest a pattern of conduct indicative of intentional impropriety rather than accident or error. For example, the following actions or alleged actions concerning the Hospital Director were not linked or followed up on by the OIG. If the OIG had done so, the linkage would have suggested a pattern of conduct requiring additional investigation and lines of inquiry by the OIG.

The Hospital Director did not notify law enforcement authorities of the unexplained deaths despite the District Counsel’s recommendation that he do so.

The Hospital Director did not notify law enforcement authorities of a statistical relationship between a nurse and the unexplained deaths despite telling the staff physician who had developed the analysis that he would do so.

The Hospital Director, after learning that a staff physician had accused the nurse in question of killing his patients, did not refer the matter to the OIG.

The Hospital Director demoted the Hospital’s Chief of Police reportedly because of the Chief’s efforts to obtain information about the Hospital’s response to the unexplained deaths.

The Hospital Director did not provide the Peer Review Board examining the unexplained deaths with the statistical analysis that established a relationship between a nurse and the deaths.

The Hospital Director’s initial reaction to the FBI investigation was to attempt to obtain confidential information provided to the FBI, potentially to identify the source of that information.

The Hospital Director, in an apparent attempt to impede an investigation, instructed the staff physician who prepared the statistical analysis to have no further contact with the FBI.

The Hospital Director’s son—the Chief of Human Resources at the Hospital—instructed the TQI Coordinator to determine from the FBI and the OIG whether they had had recent contact with the complainant.

Our review of the OIG case files, interviews with individuals involved with the Special Inquiry, and statements from knowledgeable Hospital employees reflected that potential lines of inquiry were not pursued. For example, in the incident of a conference call between the VA Central Region Chief of Staff, the Hospital Director, the Hospital pathologist, and the TQI Coordinator, it was alleged that the Central Region Chief of Staff, in response to the issue of notifying law enforcement, stated that the last time law enforcement authorities had been called in, both the Chief of Staff and the Hospital Director were fired. The Special Inquiry analysts interviewed the pathologist and the TQI Coordinator. One individual recalled the statement being made; the other did not. However, the analysts never interviewed the Hospital Director or the Central Region Chief of Staff about this issue. Because of this, it was never verified that the conversation had taken place as alleged; and the OIG never attempted to resolve the conflicting testimony by questioning the person who had allegedly made the statement or the person to whom the statement had allegedly been made.

Based on our review of relevant memorandums and tape recordings of interviews, we determined that the analysts questioned the Hospital Director and the Central Region Chief of Staff about compliance with VA policies. The analysts told us they accepted “I don’t know” answers instead of asking follow-up questions. For example, the analysts accepted, without probing further, the Hospital Director’s response that he did not recall the District Counsel’s advice in August 1992 that he notify the FBI or OIG about the unexplained deaths. In another instance, the Hospital Director responded to the analysts that he could not recall the actions he had taken to monitor Hospital management’s investigation of the deaths. At a minimum, the analysts should have provided the Hospital Director available information to refresh his recollection.

OIG Noncompliance With Policies, Report Inaccuracies, and Unsupported Statements

In conducting the Special Inquiry, the OIG failed to follow its own policies concerning completeness and accuracy of its reports. As a result, the OIG’s Special Inquiry report contained statements that were either inconsistent with or unsupported by the evidence contained in the OIG’s files. We noted inaccuracies in the way the OIG (1) reported the Hospital Director’s failure to notify law enforcement of the possible association of a particular nurse to an unexplained increase in deaths, (2) attributed remarks to the Hospital Director and the Central Region Chief of Staff about withholding statistical analysis information from a Peer Review Board, and (3) assessed the Hospital Director’s instructions to the complainant that he refrain from making further contacts with the FBI and the OIG about the case.

Failure to Inform Law Enforcement

The Special Inquiry report stated that the Hospital Director had asked the Central Region Chief of Staff for his opinion on whether to report to authorities the unexplained deaths and the possible relationship of a particular nurse to the deaths. According to the report, the Central Region Chief of Staff responded that he “thought the situation warranted far more review before either relieved of patient care duties or notified law enforcement authorities advised the Hospital Director not to notify law enforcement authorities until the reviews were completed.” The OIG report concluded that “[the Hospital Director] followed the advice of the Central Region Chief of Staff and did not report the issue to law enforcement.”

As written, the report leads one to believe that the Hospital Director followed the advice of the Central Region Chief of Staff not to report the situation to law enforcement authorities. However, we found insufficient documentation to support the OIG report’s conclusion that the Central Region Chief of Staff had told the Hospital Director not to report the issue to law enforcement authorities. Our review of memorandums of interview and transcripts of recorded interviews found inconclusive evidence that the Central Region Chief of Staff and the Hospital Director discussed whether to report the issue. Further, when asked to do so, the OIG was unable to cite the evidence supporting its conclusion.

Misinformation About Withholding the Complainant’s Statistical Analysis

On September 3, 1992, a Hospital Peer Review Board was convened to evaluate five August deaths on Ward 4 East at the Hospital; but the Board was not provided with a staff physician’s statistical analysis that had reported a statistical relationship between the increase in deaths and a particular nurse. The Special Inquiry report concludes that “The Peer Review Board was not a ’sham’ as alleged by the complainant, but was limited in scope and did not consider the statistics developed by [the staff physician].” According to the report, the Central Region Chief of Staff and the Hospital Director stated that they had withheld the statistical analysis from the Board members to allow them to take an objective look at the cases.

However, documentation shows that the Central Region Chief of Staff told the OIG that he had never issued instructions to deny the Peer Review Board access to the data. According to the memorandum of interview prepared by the OIG, the Hospital Director told the OIG that he recalled no one asking him whether the Peer Review Board could look at the statistical data and that it did not occur to him to let the Board members have the data.

Limitations on Complainant’s Communications With Law Enforcement

“By making such a requirement, management is in effect stifling an employee’s ability to discuss matters openly and freely with the investigators. The Director’s action can be viewed as an effort to impede an official investigation by intimidating employees, and is clearly improper. However, from a practical standpoint, action to the best of our knowledge did not limit the OIG or the FBI in obtaining appropriate information from or other employees.” (Emphasis added.)

We found no documentation to support the Special Inquiry report’s conclusion that the Hospital Director’s action did not limit the OIG or the FBI in obtaining information from the complainant or other Hospital employees. Except for an OIG memorandum of interview with the Hospital Director, we found no evidence of an investigative effort in support of the report’s conclusion. At a minimum, one would expect to find documentation that the OIG had talked to the complainant and the cognizant FBI and OIG criminal investigators before arriving at such a conclusion.

Circumstances Surrounding Special Inquiry’s 2-Year Delay

The OIG received the complainant’s allegations of a cover-up of patient deaths in February 1993, immediately acknowledged its receipt, provided a copy of the letter to the FBI in March 1993, and filed the complainant’s letter without investigating the allegations. The OIG did not begin its inquiry until after the complainant discussed the allegations with the media in January 1995. The OIG’s Special Inquiry report issued in September 1995, attributed the delay to administrative error.

Complainant’s Allegation Letter Filed Without Investigation

In February 1993, when the OIG received the complainant’s allegations of a cover-up of patient deaths, it referred the allegations to its Office of Investigations. The OIG investigator told us that he had contacted the complainant to acknowledge receipt of the allegations and had advised him that all his assets were being expended on other matters. Further, he told us that in addition to a murder investigation, he was investigating a death threat and a sexual assault. Although the OIG criminal investigator and the Assistant IG for Investigations did not recall if they had sent a copy of the allegation letter to the FBI, we learned that a copy of the letter containing the allegations had been provided to the FBI in March 1993. The original letter was filed in the OIG’s field office in Kansas City, Missouri; and no follow-up action was initiated.

The Assistant IG for Investigations told us that when his office received the complainant’s letter in February 1993, the criminal investigation with the FBI was ongoing and all resources were being devoted to that investigation. He said that it was a “collective decision” on the part of the Office of Investigations that no further investigation was necessary. Further, according to the Assistant IG, the FBI and OIG criminal investigation had not disclosed any evidence that VA officials were involved in a cover-up, and the complainant’s letter contained no new information. He stated that the OIG’s failure to follow up on the allegations was a failure of its process.

The former IG told us that he was upset in January 1995 when he became aware, as a result of media inquiries, that the complainant’s allegations had not yet been investigated. He further stated that when the OIG received the allegations in February 1993, the most important thing in his mind was the unexplained deaths.

FBI Perceived Allegations to Be Administrative

In response to our inquiries, the FBI told us that because the complainant’s February 1993 letter primarily concerned “the issue of the administrative response” of VA managers, the allegations were not within the investigative jurisdiction of the FBI. Also, because the FBI found no evidence of criminal activity in connection with the unexplained deaths, the FBI criminal investigation did not inquire into the allegations of a cover-up on the part of VA management. Further, according to the FBI, had the FBI investigation developed evidence of criminal activity at the VA, it would have explored the potential culpability of any person—whether management, employee, or staff—before, during, and after the deaths, to include deliberate attempts to cover up.

OIG Attributed Delay to Administrative Error

The Special Inquiry report stated that, due to administrative error, the OIG had waited too long to initiate the Special Inquiry. During the interval (February 1993 to January 1995), the Hospital Director retired and the Central Region Chief of Staff resigned from the VA.

VA OIG Failed to Protect Complainant’s Confidentiality

When the complainant sent his February 1993 letter to the OIG alleging cover-up by the Hospital Director and the Central Region Chief of Staff, he requested confidentiality. The Special Inquiry review looked at whether the OIG protected the complainant’s right to confidentiality. In the Special Inquiry report, two instances were discussed in which the OIG had disclosed its contacts with the complainant to the Central Region and, ultimately, to the Hospital Director. The OIG report concluded that the OIG should have been more careful in protecting the complainant’s confidentiality, and it attributed one of the confidentiality disclosures to an “error” and the other to an “honest mistake.” We found a third instance in which the complainant’s contact with the OIG was provided to Hospital management. All three disclosures were related to the March 1994 Hospital Director’s letter to the complainant advising him not to have contact with the FBI or OIG.

OIG Office of Investigations Gave Complainant’s Documents to District Counsel

In March 1994, the OIG Office of Investigations received documents from the FBI that had been prepared by the complainant. In turn, the Office of Investigations passed the information to the District Counsel, who forwarded it to the Central Region and the Hospital Director. The complainant alleged that the ultimate disclosure to the Central Region indicates that the OIG was participating with the Central Region to suppress an inquiry of a cover-up. The Special Inquiry report, however, characterized what happened as an error, stating that the OIG had provided the documents to the Office of the District Counsel, which represents both the Hospital and the Central Region, without any restrictions on their dissemination.

OIG Office of Healthcare Inspections Released Information to VA Central Region

The complainant alleged that in March 1994, the Assistant IG for Healthcare Inspections gave Central Region officials a report of contact with the complainant as part of an OIG effort to suppress information about actions by Hospital and Central Region officials. The Special Inquiry report stated that (1) in this instance the OIG had an obligation not to release the complainant’s identity to other VA officials without the complainant’s consent and (2) controls to prevent such release were not properly applied.

OIG Office of Healthcare Inspections Released Information to Hospital Management

The Hospital Total Quality Improvement (TQI) Coordinator told us that on January 11, 1995, prior to the Special Inquiry, the Assistant IG for Healthcare Inspections telephoned her and requested information concerning the Hospital’s original response to the unexplained deaths on Ward 4 East. During the conversation, the TQI Coordinator asked about OIG plans to investigate the complainant’s obstruction-of-justice allegation. The Assistant IG acknowledged recent contact with the complainant and stated that the OIG had no plans to investigate the allegations unless it was forced to do so. The Special Inquiry did not identify this incident, which involved the same Assistant IG who had released the complainant’s name once before to the Central Region.

On the same day of this incident, the TQI Coordinator, at the request of the Hospital Chief of Human Resources and the Associate Director, contacted the FBI and the Kansas City OIG to determine if they had recently been in contact with the complainant. The FBI referred her to the Kansas City OIG. In contrast with the Assistant IG’s previously discussed answer acknowledging contact with the complainant, the Kansas City OIG advised that it would have to consult with OIG Counsel prior to any discussions concerning the complainant. The Kansas City OIG later contacted the TQI Coordinator and stated that OIG Counsel had advised that it could not respond to the Hospital’s inquiry.

The Hospital Chief of Human Resources told us he was not sure why he and the Associate Director had the TQI Coordinator make the inquiries concerning contact with the complainant but thought it concerned a March 9, 1994, letter from the Hospital Director advising the complainant not to have any contact with the FBI or the OIG.

Revised Policies and Procedures

Our review of the August 1995 revision of the OIG Policy and Procedure Guide, Part I, Chapter 12 - Hotline, indicates that the OIG’s policies and procedures concerning Protection of Complainants (Section 5) mirror accepted standard hotline policies and procedures in federal agencies. Consistent adherence to and ongoing awareness of these policies by OIG personnel should result in effective protection of complainants.

OIG Comments and Our Evaluation

The Department of Veterans Affairs’ Office of Inspector General provided written comments on a draft of this report. The IG disagreed with our report, stating that the OIG had found a number of errors in the findings and conclusions presented in the report and in the analyses offered to support the conclusions. The IG is of the opinion that there is no evidence to support our overall conclusion that the OIG Special Inquiry report was misleading.

Mainly, the IG disagrees with (1) our statement that the OIG did not investigate the cover-up allegation, (2) one of the three statements in the Special Inquiry report—an OIG conclusion—that we cite in our report as being inaccurate and unsupported by evidence, and (3) the inclusion in our report of a finding—based on an alleged violation of confidentiality—that “lacks credibility.” Concerning the first point, regardless of how the OIG characterizes its work, its review was not planned or executed in a manner that would support its conclusions. Neither did the OIG link or follow up on information it had available during its review. Concerning the second point, as we have shown, no underlying documentation supports the OIG’s conclusion that the complainant’s communication with law enforcement entities had not been limited. With regard to the third point, our discussion of an alleged breach of confidentiality is based on substantive documentation and testimonial evidence that the improper disclosure occurred. The fact that the media had disclosed the complainant’s name did not relieve the OIG from its responsibility to maintain confidentiality. The OIG had an obligation not to release the complainant’s identity without his authorization.

An underlying theme of the IG’s comments is that we took individuals’ comments out of context or misrepresented facts. Also, according to his comments, some of the individuals that we interviewed either denied or did not recall discussing a particular matter with us. It is important to note that our findings and conclusions are based on in-depth analyses of documentation we obtained and interviews of witnesses that are documented in our reports of interview. We have included additional information in our report supporting our findings.

The IG objected to a proposed recommendation regarding the adequacy of the OIG policies and procedures for protecting the privacy of complainants. He stated that the issue is compliance and training, not formulating or rewriting existing policy. We concur with the IG and have withdrawn the proposed recommendation. The IG’s complete written comments, and our evaluation, are presented in appendix II.

Scope and Methodology

We conducted our review from April 1997 to March 1998 at the VA OIG headquarters in Washington, D.C., and the Harry S Truman Memorial Veterans Hospital in Columbia, Missouri. Initially, we reviewed the draft and final OIG Special Inquiry reports and related files and workpapers. We interviewed both current and former OIG officials and Hospital personnel involved with the review of the suspicious deaths. We also reviewed (1) all congressional testimony and related documents, (2) the OIG Investigative Policy and Procedure Guide, and (3) all transcripts and tapes of the recorded interviews conducted during the Special Inquiry. We transcribed all tapes that had not been transcribed by the OIG. We reviewed available files at the Hospital and documentation provided by individuals interviewed. In conducting our review, we also assessed the OIG’s policies and procedures concerning confidentiality.

As agreed with your office, unless you announce its contents earlier, we plan no further distribution of this report until 30 days after the date of this letter. At that time, we will send copies of the report to interested congressional committees; the Secretary of Veterans Affairs; and the Inspector General, Department of Veterans Affairs. We will also make copies available to others on request. If you have any questions concerning this report, please contact me at (202) 512-6722 or Assistant Director Robert E. Lippencott at (312) 220-7600. Major contributors to this report are listed in appendix III.

Background

From March 8, 1992, through August 23, 1992, when a certain registered nurse worked the night shift alone on Ward 4 East at the Harry S Truman Memorial Veterans Hospital, the number of deaths on the ward increased, with dramatic spikes in May, June, and July. The death rate returned to normal when the nurse was assigned to another unit. A statistical analysis conducted by a Hospital staff physician in September 1992 confirmed that a statistically significant relationship existed between increased deaths on Ward 4 East and the duty times of the nurse. The staff physician concluded in his original statistical analysis that the probability that no relationship existed between the deaths and the duty times of the nurse was less than 1 in 1,000 (in 1994, it was determined to be less than 1 in 1 million). The VA Central Region Chief of Staff requested in October 1992 that the OIG Office of Healthcare Inspections help resolve questions involved with the Hospital staff physician’s study. The OIG Office of Healthcare Inspections issued a report in September 1994, confirming the results of the initial statistical study.

In October 1992, based on information provided by a Missouri state legislator, the FBI and the OIG initiated a joint civil rights criminal investigation concerning the suspicious deaths at the Hospital. On February 2, 1998, the FBI issued a report to the Congress concluding that it had conducted an extensive investigation and that the federal statute of limitations had expired in August 1997 without any determination that a crime had, in fact, been committed.

In a February 1993 letter, the staff physician who conducted the statistical study at the Hospital alleged to the OIG that both the Hospital and VA Central Region management had covered up the increase in patient deaths on Ward 4 East. In the letter, the staff physician requested confidentiality. The Inspector General referred the allegations of a cover-up to the OIG’s Office of Investigations for investigation. The Office of Investigations determined that due to the priority of the investigation of the suspicious deaths, no immediate action would be taken on these allegations. The letter was placed in the investigative file, and a copy was provided to the FBI in March 1993.

In January 1995, after the complainant went to the media, the IG instructed the Assistant IG for Departmental Reviews and Management Support to conduct an administrative review (known as a Special Inquiry) of the allegations that included a cover-up. In a series of letters that followed the start of the Special Inquiry, the complainant reiterated his allegations of a cover-up, not only by Hospital and VA management but by VA OIG as well.

He also alleged that the cover-up had continued even after the start of the joint FBI/VA OIG investigation. In the Special Inquiry report issued in September 1995, the OIG concluded that the evidence pointed to bad management rather than to a deliberate plan to cover up or suppress information.

A congressional hearing was held in October 1995, and VA healthcare and OIG officials testified about the Special Inquiry and other matters. In their testimony, VA and OIG officials agreed with the findings of VA OIG Special Inquiry report and stated that no evidence of a cover-up by management had been found. OIG officials admitted, however, that the OIG had taken too long in dealing with the complainant’s allegations and attributed the 2-year delay to other priorities and administrative error. OIG officials concluded that even though no evidence of criminal misconduct had been found, they did find “a dysfunctional management team . . . in place” that had made significant judgmental errors in responding to the unexpected deaths. In its prepared statement, the OIG expressed concerns about its shortcomings in protecting the complainant’s identity and stated that it had issued a written apology to the complainant.

Comments From the Office of Inspector General Department of Veterans Affairs

The following are GAO’s comments on the Department of Veterans Affairs Office of Inspector General’s letter dated April 24, 1998.

GAO Comments

1.Despite how the OIG may characterize its work, we determined that its review was not planned or executed in a manner that would support the conclusion that it had found “no conclusive proof of an intentional cover-up” by Hospital and Central Region officials and “no evidence of criminal misconduct by top management.” The work done, as described by those who did it and as reflected in the workpapers, did not include collecting and analyzing evidence to identify intentional cover-up efforts. 2.In addition to in-depth analyses of pertinent documentation, our findings and conclusions are based on extensive interviews of witnesses, including the Assistant IG and lead analyst. Further, these interviews were conducted without the presence of OIG management and the influence that may result from such presence. Information contained in our report was taken from documentation we examined and witnesses we interviewed. To help refresh their recollections and focus them on the issues, we provided the witnesses with copies of relevant sections of the OIG manual and supporting documentation for the Special Inquiry. We have also included additional information in our report to support our findings. 3.According to the VA OIG criminal investigator who conducted the criminal investigation with the FBI, he never read the Special Inquiry report that was issued in 1995. Further, he said he has no idea as to whether statements in the report were true or accurate. 4.Section A of the Special Inquiry report is the Hospital and Central Region management’s response to the unexplained deaths. That section concludes that the OIG found “no conclusive proof of an intentional cover-up by Medical Center and Region officials” and “no evidence of criminal conduct by top management.” No attempt was made to formally reconcile the final Special Inquiry report to the underlying evidence until we asked whether such a reconciliation had been done. Further, following our request in 1997, the analyst who was responsible for referencing the report told us that she was unable to reconcile some of the stated facts. 5. We have added to our report a discussion of the types of issues we believe the OIG should have probed further and examples of instances in which further probing could have elicited additional information. 6.We disagree that a conclusion needs no supporting evidence. Since conclusions represent review and analysis of evidence, it is essential to include documentation and its analysis in the workpapers. But the OIG had no evidence or analysis to support its conclusion. Further, contrary to the OIG’s conclusion, documentation in the OIG file suggested that the Hospital Director’s actions limited access. For example, according to a memorandum for the record prepared by the lead analyst, the criminal investigator told the analyst that he suspected that the Hospital Director had told Hospital staff not to talk to investigators. 7.We have added a reference to our report about the OIG’s receipt of an additional allegation from the complainant. 8.We have clarified our report to show the source of our statement about the reason for the OIG’s delaying action on the complainant’s allegations. 9.While we did not interview the Assistant IG for Healthcare Inspections, the IG is incorrect in his assumption that the facts as stated in our report are based solely on the statements made to us by the TQI Coordinator. Rather, the reason that we interviewed the TQI Coordinator was to corroborate statements contained in a January 1995 contact memorandum that she had prepared—immediately following the contact—to document her telephone conversation with the Assistant IG. 10.We have revised our report to reflect that the TQI Coordinator contacted the FBI at the request of the Associate Director and the Chief of Human Resources. 11.The referenced footnote has nothing to do with the Hospital management’s investigation of alleged nepotism concerning the appointment of the Director’s son as Chief of Human Resources. Rather, the purpose of the footnote is to inform the reader that the person who requested the TQI Coordinator to make calls concerning the complainant is the son of the individual on whom the complainant focused his allegations. 12.The IG’s characterization of its June 1993 Hotline policies as the most recent is incorrect. The current policy was issued in August 1995 as reflected in our report. The OIG’s May 1, 1998, acknowledgement of this fact appears in the appended addendum. 13.We have withdrawn our proposed recommendation for revising the OIG’s August 1995 policies and procedures for protecting the privacy of complainants. We concur with the IG that any corrective action would require training and compliance with policy, not formulating or rewriting policy. Accordingly, we have made the appropriate changes to our report. 14.We have considered these comments and made changes to the report where appropriate.

Major Contributors to This Report

Office of Special Investigations, Washington, D.C.

Chicago Field Office

Office of the General Counsel, Washington, D.C.

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