Editorial: Immediate investigation needed at VA in Leeds

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Published: 4/17/2018 7:54:53 PM

An immediate and thorough investigation is needed of alleged substandard care at the U.S. Department of Veterans Affairs medical center in Leeds described by a former chief of medicine days before she died of cancer in December.

Dr. Sarah Kemble alleged, among other things, that deaths resulted from illegal drug use at the Veterans Affairs Central Western Massachusetts Healthcare System facility, and that patients were put at risk as a result of miscommunication as well as improper staffing at nights and on weekends that resulted in critical services being unavailable.

Kemble also alleged in a 23-page affidavit that she was demoted after she first reported her concerns about care at the VA facility. “I received no new job description or any reason for a demotion, or even acknowledgment that it was a demotion. I believe it was in retaliation for my report to the Regional Ethics Counsel of the very clear patient care violation.”

Kemble, who joined the VA as chief of medicine at the Leeds medical center in November 2014, gave her testimony to the Department of Veterans Affairs Office of Accountability and Whistleblower Protection on Dec. 8, 2017. Five days later, she died at age 59.

Her lawyer, Lisa Brodeur-McGan, of Southampton, told Daily Hampshire Gazette reporter Emily Cutts that “Sarah knew she was going to be dead by the time that the world knew about this. Her goal was to make the public know and the people in power know that there were horrific systemic issues going on. Not just in Leeds, but in the region. … She was not only trying to protect the patients but she was trying to protect other good caregivers there that were trying to do the right thing and they were afraid.”

Kemble’s credentials are impressive and extensive. They include founding the Community Health Center of Franklin County in 1995, where she was medical director and executive director; serving as chief medical officer at the Springfield Medical Care Systems in Chester, Vermont; and appointments at the University of Vermont College of Medicine and the University of Massachusetts Medical School.

Her allegations of substandard care in the VA health care system are part of a pattern of concerns raised by other whistleblowers in New England. Since the Office of Accountability and Whistleblower Protection was established a year ago to conduct unbiased investigations of such allegations, it has received 44 reports from New England, including 32 from Massachusetts.

Philip Works, a senior adviser at the VA who took Kemble’s testimony, says, “We consider the matters extremely important. We as an agency have an obligation to our veterans and we as an office have an obligation to make sure these allegations are thoroughly and accurately investigated.”

Among the most troubling of Kemble’s allegations is her report of “multiple drug overdose deaths, as high as twice a month on the campus” of the medical center in Leeds.

She also reported that it lacked lab or radiology services, a clinical pharmacist, and appropriate psychiatric staffing on nights and weekends.

“This substandard care means patient harm. For instance, if you come into this facility (during off hours) with crushing chest pain, you are more than likely going to die if you are having a heart attack because the facility does not have a cardiologist or a cath lab,” Kemble wrote in her affidavit.

She also alleged that communications problems plagued the Veterans Choice Program that allows veterans to seek treatments by doctors outside the VA system. According to Kemble, treatment records and test results often were not reported to the patients’ primary care doctors at the VA.

Previous findings substantiate Kemble’s assertion that the shortcomings are systemic. A 150-page report released last month by VA Inspector General Michael Missal, the agency’s internal watchdog, concluded that “failed leadership at multiple levels” and communications breakdowns put patients “at unnecessary risk” at the VA medical center in Washington, D.C.

The Boston Globe Spotlight team last year reported on substandard care of spinal patients and other problems at the VA medical center in Manchester, New Hampshire, leading to the removal of four top officials.

We urge Congressmen James McGovern of Worcester and Richard Neal of Springfield to make certain that the VA quickly follows through on its pledge to investigate Kemble’s allegations and takes immediate steps to correct shortcomings that it documents. The lives of hundreds of patients are at stake.




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