Senator Elizabeth Warren on Friday demanded that the Veterans Affairs secretary send a special team to Bedford VA Medical Center to investigate the death of a Vietnam veteran who went into cardiac arrest while a nurse’s aide reportedly was playing games on her computer.
In a letter to Veterans Affairs Secretary David Shulkin, Warren also called on the VA inspector general to speed up a criminal investigation already underway and said that anyone implicated in the death of veteran William Nutter last year should be fired.
“Patients at the Bedford VA Medical Center are not serial numbers in a file,” Warren wrote to Shulkin. “They are heroes who deserve the highest-quality care. It is beyond outrageous that someone in the care of the VA died because an employee was apparently more interested in playing a video game than checking on him.”
On Friday, a spokesman said Shulkin is sending an investigative team from the VA’s newly created Office of Accountability and Whistleblower Protection to the Bedford VA next week. It was unclear whether his action was in direct response to Warren’s call.
The 2016 death of Nutter, a retired police detective and former helicopter gunner in Vietnam, has drawn widespread condemnation since the Globe Spotlight Team revealed this week that, on the night Nutter died, a nurse’s aide failed to conduct hourly checks on him to make sure he did not go into cardiac arrest. The nurse’s aide admitted she had been playing video games on her computer, according to someone with firsthand knowledge.
Also on Friday, three Massachusetts members of Congress — Seth Moulton, Niki Tsongas, and Katherine Clark — asked the House Veterans Affairs Committee to hold a hearing at the Bedford VA to look at Nutter’s death as well as broader patient safety issues at the sprawling suburban medical center.
“This is a terrible tragedy,” said Moulton, a Salem Democrat and former Marine who served four tours of duty in Iraq. “But the most important question now is, ‘What can we do to prevent it from happening again?’ What bothers me most about the situation is not just the mistakes that were made, but that the Bedford VA leadership appears to have made no effort to determine if this is a pervasive problem, or limited to one individual.”
“I’m glad this is getting this high level of visibility and someone is trying to get answers for us,” said Brigitte Darton, Nutter’s daughter, who received a call from Warren. “I hope justice is done.”
Shulkin has already said he will visit Bedford to meet with employees, leaders, elected officials, and whistle-blowers, though he hasn’t set a date yet. Shulkin has also said that he plans to seek the permanent termination of the aide, Patricia Waible, who was transferred to the Bedford VA cafeteria after Nutter’s death on July 3, 2016.
“We are proceeding to propose removing the employee,” said Curt Cashour, press secretary for the Department of Veterans Affairs.
Reached by phone Friday, Waible angrily asked, “Who gave you the right to put my name in the paper?” She then hung up.
Nutter had multiple medical problems, including diabetes, which his doctors said were caused by exposure to the defoliant Agent Orange.
He had just had a second leg amputated, but he also suffered from a condition that could cause his heart to stop beating without warning.
A few days after his death, a Bedford VA doctor told his wife, Carol, that a staff member on the night shift had failed to check on him hourly, as she was supposed to. But the doctor didn’t tell her that the nurse’s aide was playing games on her computer and didn’t check on Nutter at all.
“These veterans deserve the best care,” said Carol Nutter. “They need more compassion and people who care.”
Nutter, who has consulted a lawyer and is considering a lawsuit against the VA, said last week that she hopes that by speaking out she can prevent other veterans from being neglected or subjected to sub-par care.
The Bedford VA Medical Center, rated by the VA as one of its best hospitals, now faces a growing number of questions about its quality of care. The inspector general already is working with the FBI and the US attorney’s office to determine what systemic failures led to the lapse in care and whether there were criminal violations.
In their letter to Shulkin, the three members of Congress said there is a second criminal investigation by the inspector general concerning drug dealing at the Bedford campus.
In addition, whistle-blowers and families of veterans have claimed that relatively healthy patients deteriorate within months after being admitted to the Bedford VA. Others say that veterans living in long-term-care buildings on the campus sometimes go without food for many hours, or they’re left in soiled clothes or bed linens. And buildings are laced with asbestos, a Bedford electrician charges, exposing everyone to the cancer-causing material.
In written responses to some of the whistle-blowers’ complaints and other outside reviews, the Bedford VA leaders acknowledged some of the problems but said they are working to improve conditions where improvement is warranted.
But VA Secretary Shulkin has already demonstrated a willingness to take harsh actions when he sees problems. After the Spotlight Team revealed serious problems with patient care at another VA hospital, Shulkin removed the Manchester VA Medical Center’s three top administrators.
In her letter to Shulkin, Warren said she would support firing anyone, including senior administrators, at the Bedford VA who may have contributed to Nutter’s death.
“While the majority of our VA employees are hard-working and dedicated to patient care, any failure of care is unacceptable,” wrote Warren, “and VA employees must be held accountable when they cut corners in the delivery of care to our veterans.”Andrea Estes can be reached at firstname.lastname@example.org.