Staff at the San Diego VA hospital failed to follow rules and guidelines that might have prevented the death of a 68-year-old quadriplegic veteran last summer, according to a report released last week by federal investigators.

A team of investigators from the VA’s Office of Inspector General visited the hospital in February to examine the cause of the veteran’s unexpected death. They uncovered widespread problems affecting the hospital and the care of its patients, including inadequate staff training, outdated equipment, poor patient supervision, incomplete reporting of safety concerns and improper testing of emergency alarm systems.

Why this matters

Quality of care issues have plagued the Department of Veterans Affairs’ healthcare system for years, most notably the 2014 cover-up of long wait times veterans endured to get appointments.

The VA San Diego Healthcare System serves the nearly quarter-million veterans in San Diego and Imperial counties. Those veterans rely on the San Diego VA to provide them with high quality health care and to protect them from harm if possible.

“This is a tragic case that should have been avoided,” said Congressman Mike Levin, whose district stretches from Del Mar to Dana Point, in a statement. Levin, a Democrat, is a member of the House Committee on Veterans’ Affairs and its subcommittee on veterans health.

“We have a responsibility to provide our nation’s heroes with the best possible health care services, and we must do more to consistently meet that responsibility,” Levin said.

The veteran — whose name was concealed in the report — died when his breathing and speaking devices malfunctioned. Investigators found that hospital employees failed to closely monitor the patient, even though they had seen his equipment malfunction before.

And staff had never reported the safety problem as required by hospital policy, the report says.

“The facility did not have measures in place to mitigate that risk, which may have contributed to the patient’s death,” concludes the report, issued last Tuesday.

The San Diego VA hospital provides care to more than 80,000 patients a year, and it has 30 beds in the spinal cord injury unit, where the veteran who died was staying. The hospital provides specialized care to spinal cord patients and treats people from Southern California, Arizona and Nevada.

The veteran, who lived in San Diego with his wife, fell while trimming a tree in American Samoa in 2017, which resulted in paralysis in his arms and legs. He needed a ventilator to breathe and a feeding tube to eat, and he also suffered from high blood pressure, difficulty swallowing and a deep ulcer. After repeated bouts of pneumonia and a lung collapse, he was transferred from a nursing home to the VA hospital.

Risky Research

inewsource has reported on dangerous medical research at the San Diego VA as part of its ongoing Risky Research series, finding that doctors had taken liver samples from sick veterans without their consent.

Read the series here.

Hospital police immediately reported his death to the Inspector General’s Office to investigate, which is required in cases of suspicious deaths on VA property. A spokesperson told inewsource the office rarely receives these kinds of reports, and when it does, the deaths are usually caused by suicide or drug overdose.

The Inspector General’s Office conducts audits, reviews and investigations of the Department of Veterans Affairs.

A team from Washington, D.C., spent four days interviewing doctors, nurses and other employees at the San Diego VA hospital, as well as reading through medical records and speaking with the veteran’s family. Investigators carefully documented the events leading up to the patient’s death in their report.

The morning before he died, a respiratory therapist had used a device called a PMV to help him speak with family and hospital staff. The device was connected to the patient’s ventilator, which helped him breathe. Because of the way the eating and breathing equipment was configured together, the ventilator’s emergency alarm — which was meant to warn nurses of breathing problems — was going off continuously. The therapist decided to turn down the volume on some of the patient’s alarms but couldn’t remember which ones had been adjusted when talking to investigators.

A sign outside the San Diego VA Medical Center directs visitors to the spinal cord injury center, May 1, 2019. (Brandon Quester/inewsource)

Hours after the therapist left the veteran, his ventilator disconnected. Nobody was with him when that happened, and no alarms went off to warn his caregivers of the problem, the report says.

The patient, who was found unresponsive in bed, had signed an order preventing staff from attempting CPR on him. He was pronounced dead shortly after noon on June 19, 2018.

“Patient A’s death was a traumatic event for many employees,” the report says, “and the facility conducted multiple staff debriefings on the incident and offered mental health/emotional support to staff.”

According to the report, the patient’s alarms should have “remain(ed) active to alert caregivers to disconnects, patient fatigue, or other clinical issues.” The report also said the patient should not have been left alone, and changes to the alarm settings should have been documented.

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Investigators found that none of the respiratory therapy staff had been trained to use the patient’s PMV device. Plus, the alarms in the spinal cord injury unit were supposed to be tested annually, but the inspector general’s office couldn’t find testing results for 2017 or 2018.

And investigators discovered another key piece of information during their interviews — the patient’s ventilator had disconnected multiple times previously, but his nurses had never reported the incidents as required.

“This failure resulted in the patient safety staff being unable to evaluate the incidents to determine if further investigation was needed,” the report says. “As a result, the facility missed an opportunity to implement corrective action.”

Though it wasn’t mandatory to use at the time, a piece of equipment called an “anti-disconnect device” could have prevented the ventilator from malfunctioning. None of the hospital staff were using or had been trained to use the device when the patient died, the report says.

“It was a tragic event,” said Suzanne Gordon, who has been writing about health care issues for more than three decades. “These kinds of things happen in large healthcare systems. It’s a terrible thing.”

Hospital performance data from the Department of Veterans Affairs shows that in early 2018, San Diego VA patients had more serious in-hospital complications than the facility expected from its care. That includes the development of infections, pneumonia, cardiac arrest or other problems that could have been prevented if health care had been delivered properly.

Infections resulting from ventilators also peaked at the hospital in early 2018, the data show.


Throughout that year, the San Diego VA had high rates of catheter infections, accidental cuts and tears from medical care and collapsed lungs from treatment compared to other VA hospitals around the country.

After the veteran died, the spinal cord injury unit immediately stopped accepting new patients on ventilators for about 10 days until the unit’s leaders made changes to ensure patient safety, according to the report. They trained staff, began using anti-disconnect devices and created a process for respiratory therapists and nurses to communicate about equipment use.

The Inspector General’s Office determined that the hospital’s response to the veteran’s death was appropriate.

Gordon agreed. She said the hospital’s swift action could help prevent future problems. She also pointed out that similar mistakes happen often in private hospitals, too, but they seem more common at VA facilities because they are public entities. That means it’s easier to access information about VA hospitals when things go wrong, like published reports following suspicious death investigations.

Suzanne Gordon, a healthcare author, is shown in this undated photo. (Credit: Courtesy of Suzanne Gordon)

“We have a public report about it that we can learn from,” she said. “And this is completely different than in the private sector.”

San Diego VA spokesperson Cindy Butler said, “We appreciate the inspector general’s oversight, which in this case highlights events that occurred more than a year ago. VA San Diego appreciates the IG’s determination that the facility responded promptly and appropriately.”

The report recommended 10 changes at the VA hospital and said they are in the process of being implemented. The hospital has trained staff on reporting safety issues and using ventilator and PMV devices, and said it would review its alarm systems annually, according to the report.

The Inspector General’s Office also told the San Diego VA to work with the National Center for Patient Safety to determine whether a National Patient Safety Advisory should be issued about the “deficit in training” for staff caring for ventilated patients. Butler did not say whether that safety advisory had been issued.

inewsource intern Lauren J. Mapp contributed to this story.

Jill Castellano is an investigative data reporter for inewsource. When she's not deep in a spreadsheet or holed up reporting and writing her next story, she's probably hiking, running or rock climbing. She also loves playing board games and discussing the latest chapters with her book club. Jill...