A fatal wait: Veterans languish and die on a VA hospital’s secret list

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Teddy Barnes-Breen (right) says his father was so proud of his military service that he would go nowhere but the VA for treatment. On September 28, 2013, with blood in his urine and a history of cancer, Teddy and his wife, Sally (left), rushed his father to the Phoenix VA emergency room, where he was examined and sent home to wait.

(CNN) — At least 40 U.S. veterans died waiting for appointments at the Phoenix Veterans Affairs Health Care system, many of whom were placed on a secret waiting list.

The secret list was part of an elaborate scheme designed by Veterans Affairs managers in Phoenix who were trying to hide that 1,400 to 1,600 sick veterans were forced to wait months to see a doctor, according to a recently retired top VA doctor and several high-level sources.

For six months, CNN has been reporting on extended delays in health care appointments suffered by veterans across the country and who died while waiting for appointments and care. But the new revelations about the Phoenix VA are perhaps the most disturbing and striking to come to light thus far.

Internal e-mails obtained by CNN show that top management at the VA hospital in Arizona knew about the practice and even defended it.

Dr. Sam Foote just retired after spending 24 years with the VA system in Phoenix. The veteran doctor told CNN in an exclusive interview that the Phoenix VA works off two lists for patient appointments:

There’s an “official” list that’s shared with officials in Washington and shows the VA has been providing timely appointments, which Foote calls a sham list. And then there’s the real list that’s hidden from outsiders, where wait times can last more than a year.

Deliberate scheme, shredded evidence

“The scheme was deliberately put in place to avoid the VA’s own internal rules,” said Foote in Phoenix. “They developed the secret waiting list,” said Foote, a respected local physician.

The VA requires its hospitals to provide care to patients in a timely manner, typically within 14 to 30 days, Foote said.

According to Foote, the elaborate scheme in Phoenix involved shredding evidence to hide the long list of veterans waiting for appointments and care. Officials at the VA, Foote says, instructed their staff to not actually make doctor’s appointments for veterans within the computer system.

Instead, Foote says, when a veteran comes in seeking an appointment, “they enter information into the computer and do a screen capture hard copy printout. They then do not save what was put into the computer so there’s no record that you were ever here,” he said.

According to Foote, the information was gathered on the secret electronic list and then the information that would show when veterans first began waiting for an appointment was actually destroyed.

“That hard copy, if you will, that has the patient demographic information is then taken and placed onto a secret electronic waiting list, and then the data that is on that paper is shredded,” Foote said.

“So the only record that you have ever been there requesting care was on that secret list,” he said. “And they wouldn’t take you off that secret list until you had an appointment time that was less than 14 days so it would give the appearance that they were improving greatly the waiting times, when in fact they were not.”

Foote estimates right now the number of veterans waiting on the “secret list” to see a primary care physician is somewhere between 1,400 and 1,600.

Doctor: It’s a ‘frustrated’ staff

“I feel very sorry for the people who work at the Phoenix VA,” said Foote. “They’re all frustrated. They’re all upset. They all wish they could leave ’cause they know what they’re doing is wrong.

“But they have families, they have mortgages and if they speak out or say anything to anybody about it, they will be fired and they know that.”

Several other high-level VA staff confirmed Foote’s description to CNN and confirmed this is exactly how the secret list works in Phoenix.

Foote says the Phoenix wait times reported back to Washington were entirely fictitious. “So then when they did that, they would report to Washington, ‘Oh yeah. We’re makin’ our appointments within — within 10 days, within the 14-day frame,’ when in reality it had been six, nine, in some cases 21 months,” he said.

In the case of 71-year-old Navy veteran Thomas Breen, the wait on the secret list ended much sooner.

“We had noticed that he started to have bleeding in his urine,” said Teddy Barnes-Breen, his son. “So I was like, ‘Listen, we gotta get you to the doctor.’ ”

Teddy says his Brooklyn-raised father was so proud of his military service that he would go nowhere but the VA for treatment. On September 28, 2013, with blood in his urine and a history of cancer, Teddy and his wife, Sally, rushed his father to the Phoenix VA emergency room, where he was examined and sent home to wait.

“They wrote on his chart that it was urgent,” said Sally, her father-in-law’s main caretaker. The family has obtained the chart from the VA that clearly states the “urgency” as “one week” for Breen to see a primary care doctor or at least a urologist, for the concerns about the blood in the urine.

“And they sent him home,” says Teddy, incredulously.

Sally and Teddy say Thomas Breen was given an appointment with a rheumatologist to look at his prosthetic leg but was given no appointment for the main reason he went in.

The Breens wait … and wait … and wait …

No one called from the VA with a primary care appointment. Sally says she and her father-in-law called “numerous times” in an effort to try to get an urgent appointment for him. She says the response they got was less than helpful.

“Well, you know, we have other patients that are critical as well,” Sally says she was told. “It’s a seven-month waiting list. And you’re gonna have to have patience.”

Sally says she kept calling, day after day, from late September to October. She kept up the calls through November. But then she no longer had reason to call.

Thomas Breen died on November 30. The death certificate shows that he died from Stage 4 bladder cancer. Months after the initial visit, Sally says she finally did get a call.

“They called me December 6. He’s dead already.”

Sally says the VA official told her, “We finally have that appointment. We have a primary for him.’ I said, ‘Really, you’re a little too late, sweetheart.’ ”

Sally says her father-in-law realized toward the end he was not getting the care he needed.

“At the end is when he suffered. He screamed. He cried. And that’s somethin’ I’d never seen him do before, was cry. Never. Never. He cried in the kitchen right here. ‘Don’t let me die.’ ”

Teddy added his father said: “Why is this happening to me? Why won’t anybody help me?”

Teddy added: “They didn’t do the right thing.” Sally said: “No. They neglected Pop.”

First hidden — and then removed

Foote says Breen is a perfect example of a veteran who needed an urgent appointment with a primary doctor and who was instead put on the secret waiting list — where he remained hidden.

Foote adds that when veterans waiting on the secret list die, they are simply removed.

“They could just remove you from that list, and there’s no record that you ever came to the VA and presented for care. … It’s pretty sad.”

Foote said that the number of dead veterans who died waiting for care is at least 40.

“That’s correct. The number’s actually higher. … I would say that 40, there’s more than that that I know of, but 40’s probably a good number.”

CNN has obtained e-mails from July 2013 showing that top management, including Phoenix VA Director Sharon Helman, was well-aware about the actual wait times, knew about the electronic off-the-books list and even defended its use to her staff.

In one internal Phoenix VA e-mail dated July 3, 2013, one staffer raised concerns about the secret electronic list and raised alarms that Phoenix VA officials were praising its use.

“I have to say, I think it’s unfair to call any of this a success when Veterans are waiting 6 weeks on an electronic waiting list before they’re called to schedule their first PCP (primary care physician) appointment,” the e-mail states. “Sure, when their appointment is created, it can be 14 days out, but we’re making them wait 6-20 weeks to create that appointment.”

The e-mail adds pointedly: “That is unethical and a disservice to our Veterans.”

Last year and earlier this year, Foote also sent letters to officials at the VA Office of the Inspector General with details about the secret electronic waiting list and about the large number of veterans who died waiting for care, many hidden on the secret list. Foote and several other sources inside the Phoenix VA confirmed to CNN that IG inspectors have interviewed them about the allegations.

VA: ‘It is disheartening to hear allegations’

CNN has made numerous requests to Helman and her staff for an interview about the secret list, the e-mails showing she was aware of it and the allegations of the 40 veterans who died waiting on the list, to no avail.

But CNN was sent a statement from VA officials in Texas, quoting Helman.

“It is disheartening to hear allegations about Veterans care being compromised,” the statement from Helman reads, “and we are open to any collaborative discussion that assists in our goal to continually improve patient care.”

Just before deadline Wednesday, the VA sent an additional comment to CNN.

It stated, in part: “We have conducted robust internal reviews since these allegations surfaced and welcome the results from the Office of Inspector General’s review. We take these allegations seriously.”

The VA statement to CNN added: “To ensure new Veterans waiting for appointments are managed appropriately, we maintain an Electronic Wait List (EWL) in accordance with the national VHA Scheduling Directive. The ability of new and established patients to get more timely care has showed significant improvement in the last two years which is attributable to increased budget, staffing, efficiency and infrastructure.”

Foote says Helman’s response in the first statement is stunning, explaining the entire secret list and the reason for its existence was planned and created by top management at the Phoenix VA, specifically to avoid detection of the long wait times by veterans there.

“This was a plan that involved the Pentad, which includes the director, the associate director, the assistant director, the chief of nursing, along with the medical chief of staff — in collaboration with the chief of H.A.S.”

Washington is paying attention

The Phoenix VA’s “off the books” waiting list has now gotten the attention of the U.S. House Veterans Affairs Committee in Washington, whose chairman has been investigating delays in care at veterans hospitals across the country.

According to Rep. Jeff Miller, chairman of the House Committee on Veterans’ Affairs, what was happening in Phoenix is even worse than veterans dying while waiting for care.

Even as CNN was working to report this story, the Florida Republican demanded the VA preserve all records in anticipation of a congressional investigation.

In a hearing on April 9, Miller learned even the undersecretary of health for the VA wasn’t being told the truth about the secret list:

“It appears as though there could be as many as 40 veterans whose deaths could be related to delays in care. Were you made aware of these unofficial lists in any part of your look back?” asked Miller.

“Mr. Chairman, I was not,” replied Dr. Thomas Lynch, assistant deputy undersecretary, Veterans Health Administration.

Congress has now ordered all records in Phoenix, secret or not, be preserved.

That would include the record of a 71-year-old Navy veteran named Thomas Breen.

By Scott Bronstein and Drew Griffin with contributions from Curt Devine and Jessica Jimenez.

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21 comments

    • RB

      Sheila, you are absolutely right. If VA “government healthcare” is this bad, imagine how bad it will be with an entirely government run system!

      This is absolutely deplorable! Our Veterans have fought for our freedom, and this is how we repay them? They already make diddly-squat compared to other, lower-risk, domestic jobs. The least we can do is give them the medical help they need! Everyone involved in this horrendous disservice to our Veterans should be sent to the Middle East for 10 years to serve on the U.S. Military front line. Maybe then they will understand what it is like to be under-appreciated!

    • Justin

      Shiela: You ignorant, conservative, racist, fool. This has been going happening for years in various degrees. Our government sends our men and women to war with empty promises of medical care. President Obama did not start these wars but Obamacare is treating millions of otherwise uninsured Americans. It is time for the redneck republicans to open the check book and give the VA whatever they need.

      • Guy

        Justin I read your comments here and want to ask…..are you a veteran and why would you call some one “You ignorant, conservative, racist, fool”. I don’t know you but do feel you are a very small “little man” with no intelligence above that of a Taliban owned goat. It is apparent you are a liberal and can not feel this Nation sliding away and into a terrible state of irreversible harm. State your mind about your weak revelations but do not call a person names because you have no tolerance for their opinions. Oh and by the way I really would like an answer on your Service to this Nation!

  • Carroll McCarroll

    This CNN Report on the “Secret Waiting List” at the Phoenix VA Hospital is deplorable. Yes, a Congressional Investigation needs to be launched, and it should go through the entire VA system.

  • Dyan

    We live in Kansas City and they va is NOT helping my brother. He has gone thru this for four years now and still no help. He has thought of suicide so many times. This just makes me sick. First hand know the feeling of how nasty the va can be and not care.

    • RB

      Dyan, I totally understand. My dad’s cousin was a Vietnam Veteran, and he insisted on going to the VA for all of his medical tests and medical care. It’s been so long ago that I don’t remember what he died of, but most of it can be attributed to VA neglect.

    • Justin

      Dyan: You may want to contact an attorney and ask if you can bring suit against the VA for medical malpractice and/or neglect. In some cases, it could be neglect that results in death. Good luck but you need to do whatever it takes to get him the care he deserves. He was promised free medical care when he enlisted and should demand that the gov. hold up it’s end of the agreement.

  • Ken Browning

    This is what Obamacare looks like in action. We need to get the government completely out of the healthcare business. The Feds need to outsource veterans’ medical care so it’s done right.

    • Justin

      Ken: Surely, you aren’t that stupid….are you? Obamacare has absolutely nothing to do with the VA and these problems have existed for decades. How would you suggest we fix the VA when our President cannot get anything passed thru the republican controlled house? Do you really think Boehner and his posse would allocate tens of millions for our veterans? Please don’t have any children.

      • RB

        This has everything to do with Obamacare, Justin. I don’t care if it is called Obamacare or Hillarycare, or Whoevercare, it is still government-run insurance. VA hospitals are government run. Do you see the connection? Soon our hospitals will no longer be privately owned. They will be government owned/funded, and EVERYONE will be receiving this deplorable treatment.

        Do you see it now, Justin? Probably not.

  • aaron

    I would like to start by saying I am a Veteran with 13 years active duty, and another 11 in the reserves. I served in Panama-1989, Desert Shield/Storm 1990-1992, and Iraq 2003-2004. I have a Purple Heart from injuries sustained in service of my country. I say this not to bring attention to myself, but to head off the responses that will say I don’t know what I’m talking about.

    I would not go to a VA facility to have a splinter removed, not even on a dare. I’m sorry to those few good people who are associated with VA, but overall it is a complete fiasco, even worse I believe they intentionally let vets die to get them off the rolls and save money. The stories you hear are 100% true, my own father (Korean War Vet) went to the VA for blood in his urine and was given a diuretic for weight loss!! No, I’m not making this up, a real (?) MD did this. He was subsequently diagnosed with an agressive form of bladder cancer at a real hospital. My cousin, a Vietnam Vet, died from pancreatic cancer, after doctors failed to inform him 1.5 years prior to his death that they were aware of his cancer. They opened him up for back surgery, saw the cancer, sewed him back shut, and didn’t tell him about the cancer because they were treating a spinal condition, not cancer.

    I will never, ever go to a VA anything, nor will my wife, also a vet, they are a complete disgrace and inept at even the simplest of tasks.

    A dead Veteran costs the Government/VA nothing.

    • RB

      Excellent points, Aaron. I am not a Veteran, but after everything I’ve heard about VA hospitals from friends, relatives, and now the media, I would never, ever suggest going there to *anyone*. I would rather pay for my own insurance (private!) and go to real doctors and real hospitals than use VA coverage.

      There is much to be said from the experiences at VA hospitals about the condition and quality of care they provide, not to mention the unethical treatment of patients (whether or not they are veterans!). I don’t think Justin has caught on quite yet: this is certainly a foreshadowing of the operation of the government run healthcare system that will soon deplete private healthcare/insurance. Do you really want to go to a government-run hospital, Justin, where they hide what disease you really have so they can save money? Where they put you on a waiting list until you die so they don’t have to treat you? This is real, Justin.

  • Justin

    John McCain needs to take care of vets he voted to send to war. Instead, he just keeps wanting to fight more wars and to heck with the vets who need the promised medical care but are not getting it.

  • Tom greenia

    I just found out today that I had a critical liver issue, from a screening that was two years old. My VA primary care provider at the time was in the national guard and deployed without leaving anyone to take over his patients (or so I was told) I was also told that to see another primary care provider, I needed him to sign off on it. But he wasnt there to sign off on it, so S.O.L was I. Jump forward two years and I have some young buck VA Dr, asking why I was never treated for this right away. Cuz i didnt know!!! In addition to that, the VA apparently dropped me and now I am a “New Patient” and need to go through all the BS i went through at the beginning, essentially starting my healthcare process all over again. I wish I could sue…..