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Spotlight Follow-up

Veterans Affairs secretary promises ‘brand new’ review of Manchester hospital

A fly zapper stood in operating room 2 of the Manchester VA Medical Center this spring.handout

An internal investigation of problems at New Hampshire’s only hospital for veterans recently found “no substantial or specific danger to public health” even though 11 members of the medical staff alleged a wide range of problems, from flies in an operating room to veterans permanently disabled due to neglect.

But the top official at the VA on Wednesday pledged to disregard the June report’s conclusions and conduct a new “top-to-bottom review” of conditions at the Manchester VA Medical Center following a Globe Spotlight report describing the whistle-blowers’ charges.

“Secretary (David) Shulkin has been clear that the top-to-bottom review he ordered following The Boston Globe article will be comprehensive, transparent, and brand new,” said Curt Cashour, spokesman for the US Department of Veterans Affairs. “The undersecretary for health will personally supervise the review, and we’re also identifying a third-party panel of medical experts to be named shortly who will review the final report and provide input to the VA.”

“Manchester veterans deserve no less,” said Cashour.


The attorney for the whistle-blowers expressed relief that Shulkin’s office is going to disregard the findings of the Office of the Medical Inspector, which the doctors labeled a whitewash, saying investigators barely talked to them before exonerating the hospital.

“I’m happy to hear the undersecretary (Steve Young) whom I met with this morning has agreed to our proposal to have an independent medical review,” said Andrea Amodeo-Vickery, who represents 11 doctors and medical staffers who contacted a federal whistle-blower agency and the Globe to say the facility is endangering patients. “We just think the whole investigation should be independent.”

Within hours after the Globe report on Sunday describing the whistle-blowers’ concerns, Shulkin removed the two top officials at the hospital and sent in two teams to interview staffers and begin the review.

Shulkin, who came to the VA in 2015 under President Obama before being named to the top job by President Trump, has spoken bluntly about the problems with veterans’ health care, saying the VA is “in critical condition and requires intensive care.”


And Shulkin is known for taking swift action when he sees problems. In April, Shulkin replaced the director of the a VA hospital in Washington, D.C., after the Office of Inspector General, an independent agency that oversees the VA, cited the facility for mismanagement of medical equipment, supplies, and staffing.

But, in Manchester, Shulkin’s intervention drew criticism from the whistle-blowers because one of the investigative teams he sent to New Hampshire came from the Office of the Medical Inspector, whose earlier report failed to substantiate most of the complaints.

“We found violations of (Veterans Health Administration) policy, but no substantial or specific danger to public health exists at the Medical Center,” concluded the 25-page report, which is dated June 9 but never released publicly.

But VA spokesman Cashour said the office’s “conclusions will have no bearing on the current brand-new review.”

The controversy in Manchester began more than a year ago when eight doctors and three other medical staff members reported a host of problems to the whistle-blower agency, the Office of Special Counsel. The agency, which is separate from the VA, ultimately focused on three allegations: that there were flies in an operating room, that a doctor cut and pasted patients medical records without updating their condition, and that scores of Manchester patients were suffering from debilitating spinal problems that might have been prevented.


Earlier this year, the Office of Special Counsel found a “substantial likelihood” the allegations were true and ordered the VA’s Office of Medical Inspector to launch an investigation, which began in January.

But the medical inspector report did not find significant harm from various mistakes in Manchester.

And the investigators could not substantiate the most serious allegation — that the severe spine problems of dozens of patients were caused by “clinical neglect” as alleged by the head of the VA’s spinal cord clinic, Dr. William “Ed” Kois. The investigators said they reviewed the medical records of 94 patients and found most of them were treated appropriately and “without delay.”

In a six-page letter, the whistle-blowers’ lawyer, Amodeo-Vickery, assailed the Office of Medical Inspector’s investigation as “substandard” and “overall unsatisfactory.”

The investigators, she alleged, asked administrators of the Manchester VA whom they should interview, and the officials then “cherry-picked” witnesses who were not impartial.

They did not seek to interview Kois, who had compiled the list of patients with spinal problems that he alleged were allowed to worsen at the Manchester VA.

“All in all,” she wrote, “the behavior of the so-called independent reviewing committee was far from neutral or independent. . . . It is clear that they had no interest in a fair and impartial and complete investigation into the systemic problems that directly impacted patient care in Manchester.”

Shulkin’s spokesman said the secretary did not know the details of the whistle-blowers’ allegations until he read the Globe story, and he reacted immediately.


Shulkin removed hospital director Danielle Ocker and chief of staff Dr. James Schlosser, appointing Alfred Montoya, the current director at the White River Junction VA in Vermont, as Ocker’s replacement.

“These are serious allegations, and while we cannot comment on the specifics due to patient privacy issues, rest assured that we will look into them right away,” promised Cashour, the VA press secretary.

But the new investigation in Manchester got off to a rocky start when investigators from the Office of the Medical Inspector Wednesday asked the whistle-blowers to sign a statement promising to keep the details of the probe secret. They refused.

“If you sign it, you can’t talk about anything pertaining to the problems here. And I want to talk about the problems here,” said Kois.

Cashour, the VA spokesman, said the document the whistle-blowers were asked to sign are “simply a reminder of the legal protections and requirements that apply in the investigation process.”

Now, top VA officials are looking for ways to make sure the new review is both thorough and fair. VA officials suggested in a meeting with Manchester doctors on Wednesday that private doctors from the Dartmouth-Hitchcock health care system could help with the review to guarantee its independence.

Amodeo-Vickery urged Shulkin’s investigators to also look at “operational issues” at the Manchester VA. Why for example is the hospital managed by a group of four officials, only one of whom is a doctor, some have asked.


Andrea Estes can be reached at andrea.estes@globe.com.