Vietnam veteran dies following Do Not Resuscitate error at Sacramento VA hospital

SACRAMENTO – The Veterans Administration confirmed that a “do not resuscitate” armband was mistakenly placed on a patient who died following surgery Friday at the Sacramento VA Medical Center, but insisted the error was not fatal.

Family members identified the patient as Roland Mayo, 65, a Vietnam veteran and former Riverside County deputy sheriff and marshal.

“He was a great guy. He loved his kids. He loved his grandkids,” said Niecy Mayo, who is married to Roland Mayo, Jr. “This came out of the blue.”

Delania Mayo Kenton, the youngest of Mayo’s three grown children, said her father was hospitalized Oct. 8 for a stent replacement in his carotid artery but that complications from previous cancer surgery required a second operation.

Delania, who lives in Southern California, said reports from family members at the hospital were that the second surgery had gone well.

“Friday morning he was smiling and doing fine,” Delania said.

Later, Delania was told, her father began vomiting and then choking on the vomit.

An anonymous tip to News10 on Friday said the staff had mistakenly placed a DNR band on Mayo’s arm, which the VA confirmed on Monday– but the VA said it doesn’t believe the error contributed to Mayo’s death.

VA spokeswoman Tara Ricks offered the following statement:

After an initial investigation, we can confirm that a do not resuscitate (DNR) band was incorrectly placed on one of our patients who passed away on Friday. At the time of the code, the response team reviewed the patient’s medical record and clarified that the patient was not a DNR status. The arm band did not contribute to a delay in the response of the code team, which attempted to resuscitate the patient within minutes of the code being called. At this time, initial findings indicate that timely resuscitation was performed. Leadership at VA Northern California Health Care System has made contact with the patient’s family to apologize and express our sincerest condolences for their loss.

Family members said Mayo’s twin brother and best friend, Noland, was heartbroken over Roland’s death and was too distraught to talk about it.

Delania said the brothers had served together in the US Army’s 101st Airborne Division. They lived a few miles apart in Citrus Heights and spoke on the phone several times a day, she said.

She expressed frustration that hospital officials had not returned her phone calls seeking a detailed explanation of the incident.

Ricks, the VA spokeswoman, said privacy rules prevented staff from releasing information to anyone other than the person identified as Mayo’s next of kin, who is his twin brother.

Because of the circumstances surrounding Roland Mayo’s death, funeral arrangements had not been made.

via Vietnam veteran dies following Do Not Resuscitate error at Sacramento VA hospital.

Virginia businessman indicted on charges he bribed former VA Medical Center Director William Montague |

CLEVELAND, Ohio — A Virginia executive is facing charges that he bribed former Veterans Affairs Medical Center Director William Montague in exchange for confidential information on construction projects.

The 23-count federal indictment charges Mark S. Farmer, 54 with crimes including wire and mail fraud, embezzlement and theft.

Farmer worked for a design firm that performed work for the VA. The business is identified in the indictment only as “Business 75.”

Montague, the former director of the Cleveland and Dayton VA Medical Centers, pleaded guilty earlier this year to 64 counts related to his role in the conspiracy. Last month, Montague said he would cooperate with federal authorities in exchange for a lesser prison sentence. He faced more than six years in prison but now faces as few as 4 ½.

“Bribing a public official to obtain internal government documents and information for a competitive business advantage is illegal,” Stephen D. Anthony, Special Agent in Charge of the Federal Bureau of Investigation’s Cleveland Office said in a press release from the U.S. Attorneys office.

According to federal officials, Montague used his power to give Farmer information concerning VA contracts and business. Montague also lied to other employees about why he was getting the information, officials said.

“Contractors and employees conspiring to defraud the VA is particularly intolerable as the VA struggles to effectively serve our nation’s veterans,” said Gavin McClaren, who heads the Cleveland office of the Inspector General for the U.S. Department of Veterans Affairs.

via Virginia businessman indicted on charges he bribed former VA Medical Center Director William Montague |

Phoenix VA hospital fails outside compliance review

The Department of Veterans Affairs health-care system in Phoenix does not comply with U.S. standards for safety, patient care and management, according to a non-profit organization that reviews medical facilities nationwide.

In findings published online, The Joint Commission says Carl T. Hayden VA Medical Center failed a July inspection in 13 quality-control categories.

Experts who conducted the review in July found that Phoenix administrators did not maintain a “safe, functional environment” or “a culture of safety and quality.” They concluded that the hospital does not have adequate policies and procedures to “guide and support patient care, treatment and services.”

The inspectors also determined that VA employees were unable to report concerns “without retaliatory action from the hospital.”

The Joint Commission is an independent, nongovernmental agency that accredits and certifies more than 20,500 health-care programs in the United States. For many medical centers, accreditation is a precursor to qualify for federal Medicare funding.

Elizabeth Eaken Zhani, media relations manager at the commission, stressed that noncompliance findings do not typically lead to a loss of accreditation. Instead, Phoenix VA has a right to appeal and an opportunity to correct failings so the hospital meets national standards.

The Phoenix VA system serves about 80,000 Arizona veterans. In a written statement Monday, VA officials said plans have been developed with an expectation that compliance issues will be resolved within 120 days.

“We anticipate and welcome a return visit from The Joint Commission within the next month, which is a follow-up survey,” the statement continued.

“We are also working diligently to address the cultural issues identified by The Joint Commission and have implemented a number of items to enable employees to raise concerns about safety or quality without fear of retaliation…”

Zhani said the list of problem areas can be interpreted as a message: “This is where you need to improve. This is where you have gaps in patient safety.”

Of more than 4,000 medical facilities evaluated each year, she said, less than 1 percent are denied accreditation.

via Phoenix VA hospital fails outside compliance review.

Concerned About Retaliation, VA Wants To Restrict When Vets Can View Disability Claims Online – Defense One

Veterans Affairs officials want to change when veterans can view some of their medical records online, fearing that some could become violent if they see negative comments and think their disability claims will be denied.



Jordain Carney is a defense reporter at National Journal. She previously worked as a staff writer for the Hotline, covering congressional and gubernatorial elections in the South. Jordain graduated from the University of Arkansas with a bachelor’s degree in English, political science, and … Full Bio

Veterans must get a medical exam as part of the process for filing a disability claim for a service-related injury. Within days or weeks of the exam, veterans can see the doctor’s forms or notes by using the “Blue Button” on My HealtheVet, the VA’s website for health records.

A group of department officials said Monday that they fear some veterans could see the notes from the exam, assume from this partial picture that their claim is being denied, and take out their anger on local VA officials. They voiced their safety concerns Monday to members of the department’s Advisory Committee on Disability Compensation at their meeting this week in Washington.

“He walks past the [compensation-and-pension] clinic, and he’s very angry. Goes into the C-and-P clinic, and we have an incident of some kind,” said Gerald Cross, the chief officer in the Veterans Health Administration’s office of disability and medical assessment. ”Some of our C-and-P clinics are quite small, … and it doesn’t have much in the way of reasonable defense. We’re very concerned about that.”

Patricia Murray, the director of the VA’s clinical program and administrative operations, said that to try to prevent any misunderstandings, the VA is removing the compensation-and-pension medical exam from a veteran’s online health record until after a decision on his or her disability claim has been made.

“I think sometimes when they see [the medical records], they think the determination to grant [benefits] is solely based on the C-and-P file,” she said, adding that “our examiners feel like they’re sometimes at risk.”

But some committee members were concerned about removing the compensation-and-pension exam records, but not other health documents, from the website.

“I hate to say this, but what is the ethical justification of removing the C-and-P exams from the Blue Button?” asked Michael Simberkoff, executive chief of staff at the VA’s NY Harbor Healthcare System.

But department officials tied the move to one factor: Potential risk to VA staffers. In addition to changing when a veteran can see part of his or her file online, they are also considering adding extra security to the clinics, such as requiring a code to unlock doors.

“Many of the C-and-P docs are females, and they seem to be the ones that seem to have the evening hours or are in these far-flung [clinics],” said Denny Devine, the VA’s project executive for disability and medical assessments. “Those are the ones on our weekly calls raising these concerns.”

The VA received more than 1 million requests for disability exams during fiscal 2014. It has almost 527,500 pay and pension claims currently waiting to be decided, with more than 46 percent—or 244,727—waiting more than 125 days for a decision.

via Concerned About Retaliation, VA Wants To Restrict When Vets Can View Disability Claims Online – Defense One.

Family says VA owes them for Metro Atlanta man’s death – CBS46 News


A Metro Atlanta family said the Atlanta VA Medical Center is responsible for Otis Hughey’s death.

CBS46 first reported this in early October.

Hughey died in April, 2014. His family said the VA Hospital, in Decatur had treated Hughey for prostate cancer. According to Hughey’s family, doctors said Hughey had gotten over the disease.

“I just knew something was wrong with him,” said Fandra Hughey.

Fandra Hughey said her husband, Otis developed a cough in 2013 that wouldn’t stop.

“It was real hoarse and he couldn’t catch his breath,” said Fandra Hughey. “I just miss him, just him.”

Otis went to Urgent Care, and doctors did an x-ray. Results showed a problem with his lungs. Doctors urged him to go to the VA. Otis did, but didn’t get far. Tyrone Matthews, Otis Hughey’s brother said it took a month to get x-rays at the VA. And he didn’t receive treatment until October for lung cancer. By then, his cancer had spread.

“He had got prostate cancer, then lung cancer, then he had lesions on the brain and now he’s gone,” said Fandra Hughey.

Hughey’s family has expressed anger with Dr. Bradford Priddy.

“I did tell him ‘if I see you outside this hospital I will be willing to hurt you,'” said Matthews.

According to Hughey’s family, Dr. Priddy went on record with this statement:

I explained that they were justified in their feelings and that he should have been called back in for those CT scans within a week because I had ordered it for as soon as possible.

“You almost never hear that in a medical malpractice case,” said attorney, Jonathan Johnson. “He was basically blaming the staff for dropping the ball.”

Atlanta VA Medical Center released a statement:

The Atlanta VA Medical Center places the highest priority on delivering quality care while respecting the privacy of Veterans. Our focus has always been to deliver this care in a professional, compassionate and safe environment. When issues occur in our system we conduct reviews to identify, correct and work to prevent additional risk. This matter is currently under review, and as such, it would be inappropriate to comment at this time.

Johnson said he has filed paperwork to sue the VA Medical Center. According to Johnson, the VA Medical center has until February to respond.

via Family says VA owes them for Metro Atlanta man’s death – CBS46 News.

Unbelievable VISN 4 continues its traditionof see no evil speak no evil! VA promotion for administrator stuns legislator | TribLIVE

VA promotion for administrator stuns legislator | TribLIVE.

The Department of Veterans Affairs is promoting an administrator who advised against publicly disclosing a deadly Legionnaires’ outbreak at its Pittsburgh hospital system, the agency told Congress.

David Cord, deputy director of VA Pittsburgh Healthcare System since June 2012, will become director of the Erie VA Medical Center within 60 days, the VA informed Congress.

The VA disclosed the Legionnaires’ outbreak that killed at least six and sickened at least 16 others on Nov. 16, 2012 — two days after Cord told a VA spokesman not to alert the public about it, according to an internal email from the spokesman obtained as part of a Tribune-Review investigation.

The VA did not respond to requests to interview Cord, disclose his new salary, or say why the agency chose him to replace Dr. Michael Adelman in Erie.

Cord, a 13-year veteran of the agency, did not return calls to his office and home.

Cord’s salary in 2013 was $127,531, according to a database of federal salaries.

Gary Devansky, director of the Pittsburgh-based Veterans Integrated Service Network 4, said in an email to Congress he was “excited to bring Mr. Cord on board” as director in Erie. VISN4 region includes most of Pennsylvania, all of Delaware, and parts of New Jersey, New York, Ohio and West Virginia.

“His unique leadership experience and insight as an Air Force veteran will be valuable assets for the facility, the employees and volunteers, and most importantly for the veterans we are honored to serve,” Devansky wrote.

U.S. Rep. Tim Murphy, R-Upper St. Clair, called the promotion “incomprehensible and indefensible.” Rep. Mike Kelly, R-Butler, who represents Erie, declined comment until he talks to Cord, a spokesman said.

Murphy and Cord tangled during a contentious series of phone calls on May 29 in which Cord said veterans in Pittsburgh didn’t wait longer than 30 days for care, and that the facility didn’t keep a secret waiting list like one in Phoenix that caused a national outcry, an aide to Murphy said.

That same day, VA Pittsburgh Director Terry Gerigk Wolf told Rep. Mike Doyle, D-Forest Hills, that a separate list included more than 700 veterans trying to enroll for care. Some waited longer than a year for their first appointment.

Two weeks later, acting VA Secretary Sloan Gibson suspended Wolf with pay for her role in the Legionnaires’ outbreak, which the VA and the Centers for Disease Control said occurred between February 2011 and November 2012.

On Nov. 14, 2012, two days before the VA Pittsburgh disclosed the outbreak, former spokesman David Cowgill wrote to an aide of VA Pittsburgh Chief of Staff Dr. Ali Sonel that Cord “does not want to be proactive and go to the media with a statement.”

Instead, Cord wanted Cowgill to prepare a statement, in case “they come to us, which we are anticipating they will,” said the email that the Trib obtained through a Freedom of Information Act request.

Six months later, when the VA Office of Inspector General issued a report documenting failures that led to the outbreak, Cord emailed Cowgill expressing worry about demands from Congress and veterans’ families that VA Pittsburgh officials face discipline.

“Great. Its(sic) clear the lawmakers want a head on a platter at this point,” Cord wrote to Cowgill on April 24, 2013.

As director of the VA Erie Medical Center, Cord will oversee 650 employees and facilities in six counties, serving 23,000 veterans, according to the VA. The center has a budget of nearly $116 million.

In an emailed response to Trib questions about Cord’s promotion, VA Pittsburgh spokesman Mark Ray responded: “VA extends its condolences to the families of the veterans affected by acquiring Legionella in our healthcare system,” and has taken steps to beef up its Legionella prevention.

Mike Wereschagin is a Trib Total Media staff writer. Reach him at 412-320-7900 or

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Did safety net fail suicidal Marine? |



Jeremy Sears is the kind of combat veteran that America desperately wants to help — a Marine who served multiple tours in Iraq and Afghanistan.

Yet the safety net designed to support returning troops seems to have failed in his case, according to his wife and veterans advocates.

After waiting 16 months in the U.S. Department of Veterans Affairs claims logjam, Sears was denied all disability payments and, untreated for trauma injuries and facing financial difficulties, took his own life.

Jeremy and Tami Sears— Facebook photo

The 35-year-old former Camp Pendleton infantryman killed himself last week, almost exactly two years after being discharged. On Monday, Oct. 6, Sears went to an Oceanside shooting range and put the gun to his head.

Just days before, he first admitted to his wife that he might have “survivor’s guilt” — sometimes seen as a symptom of post-traumatic stress disorder.

According to people close to him, Sears became despondent in February. That’s when the VA sent a letter saying that the government wouldn’t pay him anything, despite acknowledging that he had traumatic brain injury and hearing loss from his military service.


VA denial letter


Additionally, Sears never got medical help for the brain injury.

Jeremy Sears’ widow, Tami, said this week that she sees a failure in care starting years back, but climaxing under the VA.

“I just don’t want anyone else to suffer and go through the pain that my husband went through for so many years and didn’t tell anyone,” Tami Sears said.

“I don’t know what the VA needs to do, but they need an overhaul and to take care of these veterans.”

Officials from the San Diego VA health care system and VA regional benefits office put out a joint statement on Tuesday, in response to questions from U-T San Diego.

“The Department of Veterans Affairs deeply regrets the loss of veteran Jeremy Sears, and our sincere condolences go out to his family. VA wants to ensure that all veterans receive the benefits and health care to which they are entitled under the law,” the statement said.

“We are presently looking into the specifics of Mr. Sear’s case and will be reaching out to the family to provide support and assistance.”

Sears left the Marine Corps as a sergeant in October 2012 after eight years of service. His wife and friends said he knew staying in would likely mean a desk job, which he didn’t want.

via Did safety net fail suicidal Marine? |

Cancer-stricken Vietnam vet blames VA hospital for not catching illness sooner | News – Home


During the carnage of the Vietnam War, then-Pvt. Stanley Korenek fought hard for all of us as a soldier in the United States Army.

“I mean, I served my country,” Korenek said. “You know, when they called me, I went. I was glad to do it.”

Now, decades later, Stanley, a 63-year-old grandfather living in Pasadena, is dying of stage 4 liver cancer, and he said the doctors he saw at the Michael DeBakey VA Medical Center in Houston are to blame.

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“I kept going and I kept saying, ‘I’m sleeping all the time, I’m sick all of the time, there’s something really wrong with me.’ And they kept telling me, ‘There’s nothing wrong with you, everything is fine,'” Stanley said, wiping tears from his bloodshot eyes.

Stanley said he blames the VA because for the last three years, he’s been going to see VA doctors on a regular basis and complaining about lots of pain in his stomach region, cramps, stomach sickness, muscle weakness

and exhaustion. At one point, Stanley said he lost more than 50 pounds, but when he complained about that, he said doctors told him, “That’s great, you need to lose weight.”

“I asked (the doctor) point blank, ‘How’s my kidneys?'” Stanley said. “They’d said, ‘Oh, your kidneys are fine.’  ‘How’s my liver?’ They’d say, ‘Oh, your liver is fine.’ I’d say, ‘But I’m losing so much weight.’ They would say, ‘Good, that means you don’t have to diet to help with your diabetes problem.'”

Local 2 Investigates obtained a copy of Stanley’s medical records prepared by doctors at the VA and found nothing about extreme stomach pain, but Stanley said that’s because doctors didn’t write all of his complaints down in the medical records.

Local 2 did find that VA doctors ordered all kinds of blood tests, prescribed dozens of different medications, and examined everything from Stanley’s heart to his knees to his feet, but never detected any sign of cancer. They didn’t detect anything involving cancer — that is, until this past July.

At that time, Stanley claimed he demanded his doctors give him a CT scan because he was in such intense pain.

That scan detected a mass growing on Stanley’s liver.

“I’m so angry it’s not even funny, because this should have been detected so much earlier and I wonder how many other men are in the same boat that I am in,” Stanley said.

An emergency room doctor from a private hospital, who checked Stanley out after his cancer diagnosis, agreed with Stanley, saying, “It’s an insult, it’s reprehensible, it’s damning. The VA didn’t find this until just recently. We’ve got such fine diagnostic tools these days, you find these things before they become symptomatic. I mean CT scans today are like for the abdomen, the pelvis region, it’s almost a routine test for someone in abdominal pain, get the information.”

That ER doctor, who didn’t want to be identified, said the large a mass of cancer should have been found two to three years ago. He said that would’ve been possible had anyone at the VA bothered to do a CT scan.

Now, Stanley said he has been diagnosed with 24 different tumors growing on his liver, with more cancer spreading into his lungs. He is undergoing chemotherapy at The Michael DeBakey VA Medical Center,

but has been told he may only have a short time left to live.

“I shouldn’t be dying, this should have been detected a long time ago”, Stanley said.

Local 2 Investigates asked top officials at the CeBakey center for an on-camera interview to discuss all of this, but they refused, instead issuing a written statement.

“Mr. Korenek has been receiving care at the Houston VA Medical Center for several years for a number of chronic conditions,” said Maureen Dyman, the director of communications at the center. “We are extremely saddened by his diagnosis of cancer and are glad we are able to treat him in our state-of-the-art Cancer Center. The first time Mr. Korenek presented to the Houston VA with complaints of severe abdominal pain was in July of 2014. He was provided a CT scan that same day, with immediate diagnosis. The Houston VA stands by the quality of care we have provided to Mr. Korenek and we are confident that our records illustrate that the proper treatment was given in an appropriate and timely manner.”

via Cancer-stricken Vietnam vet blames VA hospital for not catching illness sooner | News – Home.

VA bills dead veteran for 59 cents

AVONDALE, Pa. (Delaware Online) – The first letter addressed to the late David Perry arrived five weeks after he died at home June 5.

Sent from the Department of Veterans Affairs, the envelope was to be opened “by addressee only.” Perry’s wife Helena opened it anyway.

“You remain eligible to receive (VA) health benefits,” it read. A handwritten yellow sticky note added, “Please provide copy of death certificate.”

Helena thought she’d notified VA. Regardless, she said, “It’s kind of hard for him to open it when he’s not here – and even harder for him to send the death certificate.”

Several days later, a VA billing statement addressed to David Perry arrived. Helena opened that one too. Her late husband, it seemed, owes the government 59 cents.

“So if it’s not paid by October the 11th, I’m going to have additional – or he will have additional charges on his 59 cents,” she said. “So I did call and talk to them, and informed them again that he was dead, and I just didn’t think he would be able to pay it.”

via VA bills dead veteran for 59 cents.

Changes at Wilmington VA raise concerns

Union clinicians at the Wilmington Veterans Affairs Medical Center fear that a recent reduction in surgical capability and other changes are signals the facility could lose its independent status, will continue shrinking and become a branch of the much larger Philadelphia VA hospital.

The Wilmington director doesn’t say it won’t. Rather, she says with conviction, that she hasn’t heard it being talked about during meetings at the regional and central office level.

“Each VA has its little niche that they provide, and they help each other out – and so that’s still ongoing,” said Robin Aube-Warren during an interview Friday. “But there is nothing that I’ve ever been made aware of that there were any discussions about changing our role and having us fall under Philly, or anything like that.”

Aube-Warren, in charge since March, did acknowledge the possibility.

“As [VA] Secretary [Robert] McDonald has said, he has a plan to reorganize VA as we move forward,” she said. “That hasn’t been shared yet. And I don’t know what those changes will be, and we’re all anxious to see what he has in mind.”

via Changes at Wilmington VA raise concerns.