U.S. military service members developed life-altering ailments and even died from preventable conditions that a new government watchdog report determined may be caused by a lack of oversight at military hospitals.
On Wednesday, the Government Accountability Office (GAO) published a report finding gaps in oversight for dozens of military medical professionals. Sharon Silas, the director for GAO’s health care team explained that the oversight agency began reviewing issues within the Defense Health Agency (DHA) after news reports reaching as far back as 2014 documented “lapses in patient safety at military medical treatment facilities, including failures to review serious patient safety events, such as the misdiagnosis of a life-threatening condition.”
As part of its ongoing review of the DHA’s internal oversight practices, the GAO reviewed 100 healthcare providers at four selected military DHA-run medical facilities. They found those facilities failed to verify all medical licenses for a sixth of those healthcare providers before allowing them to practice. Further, the GAO report found the facilities failed to conduct required performance monitoring every six months for about three-quarters of the providers it reviewed.
This lack of oversight coincided with several concerning patient safety incidents. GAO documented at least 12 patient safety events at the four facilities that required patient compensation, of which it said the DHA did not always respond with its required review process.
The House Armed Services personnel subcommittee held a hearing on safety lapses at military medical facilities on Wednesday, following the publication of the GAO report. During the hearing, the subcommittee heard from Silas, as well as two different people affected by patient safety incidents.
Retired Army PFC Dez Del Barba was one DHA patient who developed a flesh-eating bacterial infection that went undiagnosed until his sixth sick call.
Del Barba was at Officer Candidate School, Fort Benning, Georgia in early 2019 when he contracted an infection. Only after his sixth hospital visit did a doctor order a blood test, confirming he had streptococcus A, which developed into necrotizing fasciitis. Just over three months later, the flesh-eating bacteria caused him to lose his left leg, most of the flesh on his right leg and require skin grafts for over 55 percent of his body.
“It only took 35 days for the military to destroy my life,” Del Barba said. “I was left grossly neglected by the U.S. military healthcare system and by my basic training leadership at Fort Benning, Georgia.”
Del Barba said his life-changing medical condition could have been avoided if he had received treatment earlier on.
“What happened to me did not have to happen,” he said. “This was preventable.”
While Del Barba survived, U.S. Navy Seaman Danyelle Luckey’s life-threatening illness went incorrectly treated and she died within a matter of days.
“She did not die in combat or any military operation,” her father, Derrick Luckey, testified Wednesday. “She died from gross negligence of the medical providers on the ship she was on.”
Luckey joined the Navy in May of 2016 and was assigned to the aircraft carrier USS Ronald Reagan in September of that year, while the ship was docked in Guam, NBC Bay Area reported in 2019.
Within about a week of arriving on the ship, she began vomiting. After initially seeking treatment, Luckey was given a flu vaccine, even though they are not recommended for sick patients. Days later, after her condition failed to improve, Luckey returned to the doctor and tested for flu and strep. She was prescribed fluids, Motrin and bed rest.
Military.com reported that after her case did not improve, Luckey’s shipmates took her back to the on-ship clinic, and after five days she was given a blood test which found kidney and liver failure. With her failing health, the ship’s leaders prepared to have her evacuated off the ship, but by Oct. 10 of 2016, she died of sepsis.
“If the medical providers aboard the USS Ronald Reagan had given her a simple treatment of antibiotics, instead of turning her away, she would be here today,” her father said.
Rep. Jackie Speier (D-CA), the subcommittee chairwoman, said, “It is incomprehensible and shameful that we cannot ensure [that service members] have quality medical care.”
Ranking subcommittee member Rep. Mike Gallagher (R-WI), a U.S. Marine veteran, said, “The bottom line is, the military health system is not where it needs to be.”