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Missing veteran found dead in hospital stairwell a month later because employees never looked there, VA finds

Edith Nourse Rogers Memorial Veterans Hospital in Bedford, Mass. (Veterans Health/Flickr)
September 09, 2021

A new investigation by the Office of Inspector General (OIG) for the Department of Veterans Affairs found that the body of a veteran was missing for an entire month before it was found in the emergency exit stairwell and that the patient would have likely been found much sooner, had the facility conducted regular patrols and cleanings of those stairwells.

The OIG announced those findings on Thursday following its investigation into the disappearance and death of a veteran, Timothy White, at the Edith Nourse Rogers Memorial Veterans Hospital campus in Bedford, Mass.

White was a 62-year-old U.S. Army veteran who had previously struggled with homelessness and who had recently undergone hip surgery at the time of his disappearance on May 8, 2020. His body was found more than a month later on June 12. He was found just 60 feet from his room.

“Mr. Timothy White was a resident of the Bedford Veterans Quarters (BVQ), an independent living facility operated by Caritas Communities, Inc. (Caritas), in space leased to it through VA’s enhanced-use lease program,” the OIG report stated.

The OIG investigation found a number of factors that contributed to the failure to check the hospital’s emergency stairwell for more than a month.

“The VA police department’s failure to locate Mr. White resulted in part from the police and others at VA not considering the veteran an at-risk missing patient, which would have required a stairwell search,” the OIG report stated. “The Veterans Health Administration and the Office of Security and Law Enforcement lacked clear guidance regarding the obligations of VA police to search for nonpatients reported missing on VA property.”

“VA police also did not discover Mr. White in the stairwell because of an improper order by the then police chief to cease patrols of the building in which Mr. White was found,” the report added. “The OIG found that the VA police chief exceeded his authority as both VA policy and the lease required VA police to patrol VA property.”

The report noted that, while part of the hospital facility was being leased out, the particular stairwell White was found in was VA property.

“Lastly, because medical center staff mistakenly believed the emergency exit stairwells were not VA space, they did not clean them,” the report continued. “The confusion among medical center leaders and staff regarding the lease scope and VA’s obligations stemmed from a lack of clear guidance from the Office of Asset and Enterprise Management. Routine police patrols and stairwell cleanings likely would have led to Mr. White being found earlier.”

The OIG report went on to provide a list of seven recommendations. Those recommendations included:

  1. Having VA police and other VHA staff as appropriate, conduct searches for anyone reported missing on medical center campuses
  2. Updating security handbooks to clarify VA police responsibilities with respect to searching for persons who are reported missing on VA property.
  3. Requiring VA police chiefs at medical centers to obtain approval from the facility associate director or the medical center director prior to excluding parts of the building or the medical center’s campus from regular patrols
  4. For all medical centers that have property subject to enhanced-use leases, the medical center director or the director’s designee to meet with the assigned oversight monitor at the Office of Asset Enterprise Management, the designated local site monitor and a representative of the Office of General Counsel at least annually, if there is a change of lease terms or facility leadership.
  5. The executive director of the Office of Asset Enterprise Management sends a copy of the lease and VA Handbook 7454 to newly appointed lease site monitors.
  6. The executive director of the Office of Asset Enterprise Management, in conjunction with the Office of General Counsel, reviews all sites with enhanced-use leases to see if any involve portions of buildings also occupied by VA, and whether they are fully aware of the maintenance and security obligations.
  7. The executive director of the Office of Asset Enterprise Management modifies the VA’s Annual Oversight Compliance Certificate policies to include a review of the VA’s performance on any services the VA is required to provide at facilities with enhanced-use leases.

The OIG said the VA concurred with its seven recommendations, following White’s disappearance and death.