The former chief of the Bedford VA’s police force wrongly instructed officers to stay out of the building where a veteran went missing and was found dead a month later in a stairwell just 60 feet from his room, concludes a new report by the Department of Veterans Affairs Office of Inspector General.
By the time Tim White was found crumpled on the floor in June 2020, he had been dead for so long that the medical examiner couldn’t determine how he died. The Army veteran had been missing for a month, even though he never left the building where he lived on the US Department of Veterans Affairs campus in Bedford.
“Mr. White’s disappearance did not receive the attention it deserved from VA, an agency that is required by federal law to provide for the protection of all persons on its property,” wrote the assistant inspector general Katherine Smith in a 45-page report.
Investigators found that former VA police chief Shawn Kelley failed to order a significant search — he posted a photo of White on a department bulletin board and sent an e-mail to officers. He also waited nearly two weeks to respond to a request from the Bedford town police to search for White with police dogs. That search was never conducted.
Kelley resigned while the OIG investigation was under way. He cut short his interview with investigators and later quit, citing health issues, a person familiar with the situation said. Kelley could not be reached for comment.
Middlesex County District Attorney Marian Ryan conducted her own investigation into White’s death and, though she found egregious failures in the search for White, her December 2020 report did not recommend bringing criminal charges against anyone.
White, 62, was not a patient, but was living in a VA-owned building that had been converted to housing for homeless veterans by the nonprofit Caritas Communities. He had been living in the Bedford Veterans Quarters in Building 5, since early 2020, according to a Caritas spokesman.
As a resident, White was free to come and go, but Caritas staff kept an eye on the residents, many of whom suffered underlying health conditions and substance abuse issues. And the rarely used emergency stairwell where he was found would have been an unusual choice for exiting the building, since opening the door on the ground floor would have set off an alarm.
Another resident found White on June 12; he was wearing the same baseball cap, Red Sox jersey, and jeans he was last seen wearing in early May, when he was first reported missing.
VA police said they didn’t search for White because he was a resident, not a patient. But the inspector general said the VA is responsible for the safety of anyone at a VA campus. Its lease with Caritas also made clear that the stairwells were the VA’s responsibility, the OIG report said.
VA police officers had patrolled the building at least daily, but were ordered to stop by Kelly in February, three months before White disappeared. The OIG found that the police chief’s order conflicted with federal law and VA law enforcement policies, which require agency police to patrol VA property.
“Poor decision-making, misinformation, and lack of oversight also prevented anyone at VA from encountering Mr. White during the month after he was reported missing through routine patrols or cleaning of the emergency exit stairwell in which his body was found,” wrote Smith.
While VA officials in Washington agreed to implement the OIG’s recommended changes, the head of the VA in New England defended the agency’s response.
In comments appended to the report, Ryan Lilly, director of VA facilities in New England, said it is “unfortunate” that a search of the stairwell wasn’t conducted, but a “common sense reading of the situation” suggests the VA and the town police each believed that Caritas had searched the building.
People living in the building are akin to private citizens living in their own apartments so there is a “stark difference” in VA policing of the private spaces, he wrote.
In a written statement to the Globe, VA spokeswoman Maureen Heard said: “We are very saddened over the loss of Mr. Timothy White and extend our deepest condolences to his family.”
She said since White’s death the VA has put in place several changes -- including daily VA police patrols of Building 5 -- that will “prevent similar situations in the future.
“Massachusetts veterans deserve no less,” she said.
The OIG is not referring the case to criminal authorities, but its investigation has sparked national and local changes in the way the VA handles missing person cases as well as leases with private companies.
Local VA police chiefs can no longer decide which buildings they won’t patrol. They must search for any person missing from a VA facility.
VA facilities with leased space on their property must designate someone to monitor their leases to make sure responsibilities are clearly delineated.
The OIG launched the investigation last year at the request of Massachusetts’ congregational delegation including Representatives Seth Mouton, Lori Trahan, and Katherine Clark, and Senators Ed Markey and Elizabeth Warren.
Moulton, who receives his medical care at the Bedford VA, said: ”America’s veterans deserve the best health care in the world. Mr. White’s care didn’t come close. In the days ahead we must demand that the VA police department changes so that our country keeps its promises to those who have served.”
Trahan said the report “lays out in excruciating detail just how terribly Tim White was failed by this facility.
“We’ll never know if Mr. White could have been saved had he been found sooner, because violations of the law and proper protocol prevented us from ever finding out that answer, “ she wrote. “Mr. White deserved better.”
In an e-mailed statement, Warren added, “Our veterans deserve excellent care across the board, and the VA must implement the recommended changes at Bedford to keep our veterans safe.”
Markey said the report makes “clear that there are persistent and troubling issues at the Bedford VA that must be addressed thoroughly and quickly.”
Andrea Estes can be reached at firstname.lastname@example.org.