At a hearing today investigating a deadly Legionnaires' disease outbreak among patients of the VA Pittsburgh Healthcare System (VAPHS), Subcommittee on Oversight & Investigations (O&I) Chairman Rep. Mike Coffman (CO-06) blasted Department of Veterans Affairs officials for a culture of complacency that led to the deaths of five veterans.
"VA officials admitted under questioning that these deaths were preventable, and as testimony today from witnesses inside and outside VA made clear, it was a culture of complacency within VA at multiple levels that was the culprit," Coffman said.
Since January 2011, 26 VAPHS patients have contracted Legionnaires' disease, a type of pneumonia. Five of the cases were fatal and, according to a Centers for Disease Control investigation, likely resulted from infections contracted through contaminated water in the VAPHS. A months-long investigation by the O&I Subcommittee has revealed that VAPHS officials learned of problems with their water system as early as December 2011, yet waited nearly a year to disclose and address those issues. The subcommittee had requested that VAPHS officials who were directly involved in handling the Legionnaires' outbreak testify today, however, VA refused to make them available.
Dr. Janet Stout, a microbiologist who is the Director of the Special Pathogens Laboratory in Pittsburgh, testified that the lack of a coherent policy at VA and within VAPHS to address deteriorating water quality led to the outbreak and urged the subcommittee to seek accountability at the VA.
"You will hear excuses and diversions trying to shift responsibility to methodology, policies, public health authorities, and even blaming the disinfection technology that protected VA patients from 1994 to 2006. Don't be distracted," said Stout, who has spent more than 30 years conducting research in the field of Legionella bacteria and is widely considered one of the premier experts on the subject.
House Committee on Veterans' Affairs Chairman Jeff Miller (FL-01) expressed his disappointment with VA officials' response to the initial discovery of Legionella in the VAPHS water supply.
"When the VA discovered these issues, they had a responsibility to the veterans to notify the proper authorities and do everything in their power to make sure that this would not lead to an outbreak of Legionnaires' disease," Miller said. "Their response of sitting on this information and acting in a manner that demonstrates virtually no accountability is beyond unacceptable."
Coffman concluded the hearing by ordering the VA Central Office to strengthen the inherent weaknesses of its Infection Control Program Office, account for the failures identified as part of the O&I subcommittee's investigation and take steps to ensure VA employees know how to react to and prevent similar outbreaks in the future. Within the next 30 days, the VA is required to work with O&I subcommittee staff to develop a plan for achieving all of these directives. Additionally, VA will convene an internal working group responsible for strengthening agency protocols governing how similar incidents are handled in the future.