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. 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. 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. 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. The OIG’s Special Inquiry report issued in September 1995, attributed the delay to administrative error. The Special Inquiry review looked at whether the OIG protected the complainant’s right to confidentiality. OIG Comments and Our Evaluation

The Department of Veterans Affairs’ Office of Inspector General provided written comments on a draft of this report. 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. 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. 5.
Why GAO Did This Study

Pursuant to a congressional request, GAO reviewed the Department of Veterans Affairs (VA) Office of Inspector General's (OIG) Special Inquiry into the alleged cover-up of an unexplained increase in deaths at the Harry S Truman Memorial Veterans Medical Center, Columbia, Missouri, focusing on: (1) whether the Special Inquiry report represents the results of OIG's review; (2) whether OIG complied with its policies in conducting the Special Inquiry; (3) why a delay occurred between receipt of the cover-up allegations in February 1993 and the beginning of the Special Inquiry in January 1995; (4) whether OIG protected the confidentiality of the staff physician who made the allegations of a cover-up; and (5) if OIG processes and procedures are adequate for ensuring confidentiality.

What GAO Found

GAO noted that: (1) the VA OIG conducted the Special Inquiry as a management review to determine how hospital and VA Central Region management had responded to an out-of-norm situation regarding unexplained deaths at the Hospital; (2) GAO determined that OIG did not collect or analyze evidence in a manner that would identify intentional cover-up efforts; (3) thus, the Special Inquiry's conclusion that no evidence of an intentional cover-up had been found was not consistent with the inquiry conducted and was misleading; (4) OIG failed to comply with its own reporting policies concerning completeness and accuracy by presenting statements that were not supported by the evidence contained in OIG files, including reference to a discussion that the Special Inquiry never verified; (5) OIG attributed the delay in acting upon the cover-up allegations received in February 1993 to administrative error; (6) the confidentiality of the staff physician who had made the allegations of a cover-up was breached on at least three occasions; and (7) OIG's current policies and procedures on confidentiality are adequate.