Panel begins examining problems at VA hospital in N.H.

The Manchester VA Medical Center in New Hampshire.
The Manchester VA Medical Center in New Hampshire.

PEMBROKE, N.H. — Members of Congress Monday grilled the leaders of the Manchester VA Medical Center, asking why it took media reports and a congressional hearing to expose conditions that severely threaten the health and safety of veterans at the hospital.

“I am very concerned about leadership failures and deficiencies that have existed in Manchester and have been been allowed to compound for too many years,’’ said Representative Jack Bergman, a retired Marine Corps general and chairman of the House Veterans’ Affairs Oversight and Investigations subcommittee.

“But it’s also very clear there was no sense of urgency within the [Veterans Affairs New England office] to address these problems,” said Bergman, a Michigan Republican.


Bergman’s committee came to New Hampshire after the Globe Spotlight Team revealed a host of patient safety concerns at the state’s only veterans hospital, including flies in one operating room and neglect of spinal patients that may have led to permanent injury.

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After that report, Veterans Affairs Secretary David Shulkin immediately removed the hospital’s top three officials and launched a “top to bottom” review. Many of the 12 hospital staff members who raised the issues said hospital leadership had ignored their concerns and drove some to leave in disgust.

Dr. Ed Kois, one of the whistle-blowers, testified that the hospital’s chief of medicine, Dr. Stewart Levenson, who retired this year, was criticized and ostracized by Department of Veterans Affairs leaders for raising patient safety concerns. The doctors had been raising safety concerns at the hospital for at least a year before the Globe story was published.

“I know for a fact that Stewart Levenson sacrificed his career at the VA, giving negative feedback to the [regional VA leaders] only to be treated like he was some kind of village idiot,” said Kois, who identified more than 80 Manchester patients who suffered spine injuries that might have been prevented with better care.

At the hearing, members of the congressional panel focused on Dr. Michael Mayo-Smith, who oversees all of New England’s VA hospitals, asking him when he learned about the problems with patient care in Manchester.


Mayo-Smith said he was unaware of the some of the issues raised in the Globe report, even though several whistle-blowers, including Levenson, said they had brought their concerns directly to him.

He discussed at length the fly problem, reciting various efforts hospital officials had undertaken to get rid of the flies, so far unsuccessfully. But he said that he was unaware of other issues raised by the Spotlight report.

“We appreciate what the whistle-blowers brought us,” said Mayo-Smith. He and other officials said they have a plan to improve the quality of care at the medical center and to address management issues.

Outside the hearing room, Levenson, who retired in July, said Mayo-Smith was “very disingenuous” to welcome revelations from whistle-blowers when he repeatedly failed to respond to their concerns.

The head of the New Hampshire American Legion asked Shulkin to remove Mayo-Smith from a task force looking into how to improve the operations of the Manchester VA.


“He is the direct supervisor of the personnel who were released from the VAMC in Manchester,” wrote Dave Meaney Sr., commander of the New Hampshire American Legion. “In no case do we cast any aspersions on Dr. Mayo-Smith, but we feel that the mere perception of impropriety is not welcomed or should be entertained in the formation of this task force.”

Bergman said he sympathized with the frustration many of the doctors felt that VA leaders were not listening to them.

“The whistle-blowers tried to go through proper channels, but as we have seen happen over and over again at the VHA, their complaints were either ignored or were not addressed,” said Bergman.

Even with its problems, the VA rated the Manchester facility four stars out of a possible five.

“I have to question a rating system that gives out such a high scores while these and many other issues . . . were occurring during the same period of time,” Bergman said.

“It should not take a news report or a congressional hearing for you to respond to veterans’ and employees’ concerns,” Bergman said to Mayo-Smith. “As [New England] director your job is to lead proactively not reactively.”

Representative Annie Kuster of New Hampshire, the ranking Democrat on the committee, added that Shulkin “made the right decision” when he removed the hospital director, chief of staff, and head of nursing services at Manchester after the Globe article.

“VA leadership who knew about the reports of substandard care and failed to act should be held accountable,” she added.

Acting Manchester VA director Alfred Montoya and Dr. Carolyn Clancy, deputy undersecretary for health for organizational excellence, also appeared before the panel. They praised the whistle-blowers and insisted the agency would not retaliate against them for raising concerns.

But Dr. Kois, in his testimony, said the whistle-blowers at Manchester were so fearful of retaliation that they met in secret.

“The way I deal with it — I’m sitting here talking to you,” he said, describing the group of Manchester employees who came forward over several months, “almost like a secret society.”

Kois also said the problems in Manchester are part of something much bigger.

‘‘Unless we get a handle on really what’s happening in the VA system, this is going to continue,’’ Kois said. ‘‘We have really dedicated people who work in the system, but we have a bureaucracy that is so top heavy and so slow to react, it’s problematic.’’

David J. Kenney, chairman of the New Hampshire State Veterans Advisory Committee, testified that the revelations by the Globe were “appalling. I’m pleased the deficiencies have been uncovered. The need for whistle-blowers implies an underlying lack of accountability. If the system worked the way it should, there would be no need for whistle-blowers.”

Andrea Estes can be reached at