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Employee at Indianapolis VA reassigned after mix-up led to veteran’s leg amputation

Richard L. Roudebush VA Medical Center in Indianapolis, Ind. (Veterans Health/Flickr)

The Department of Veterans Affairs has reassigned an employee after whistleblower complaints outed delays and miscommunications at an Indiana facility that left a veteran untreated, leading to the amputation of his leg.

Another employee would’ve been fired but retired before the VA could take action, according to Peter Scovill, spokesman for the Richard L. Roudebush VA Medical Center in Indianapolis.

The U.S. Office of Special Counsel, an independent agency that protects whistleblowers, sent a letter to President Donald Trump this week with its findings about the incident at the medical center. Following up on a complaint from three whistleblowers, the special counsel discovered a policy change at the hospital in 2017 led to “significant delays in care and harm to veterans.”

The amputation was a direct result of the delays, the agency reported.

Scovill said Thursday in a statement that VA leaders were in close contact with the veteran and “will be apologizing and advising them of their options moving forward.”

The Office of Special Counsel substantiated whistleblower allegations that leaders within the VA social work service in Indianapolis directed social workers to stop entering home health care consults into a computerized patient record system. The lack of planning, communication and training with the change led to home visits not being properly logged, the special counsel found.

Because of a scheduling mix-up, one veteran didn’t receive the help that he needed in June 2017 to redress a foot abscess. The wound became infected and eventually led to a below-the-knee amputation, Special Counsel Henry Kerner wrote.

Scovill said Thursday that the assistant chief of social work was removed from that position and assigned to another job with less responsibility. The VA investigated the chief of social work at the time, but the person retired before the VA could fire them.

The hospital did not name the employees.

Since the investigation ended, the Indianapolis VA updated its procedures to allow social workers to enter information into the patient record system. It also has trained all key staff members, the special counsel said.

Kerner wrote to Trump that he commended the VA for taking steps to prevent future problems but was “nonetheless distressed that such a situation occurred in the first place.”


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