Recommendations by the Veterans Administration Inspector General’s office were released Thursday following a probe of policies and inactions that failed to prevent the June 2020 death of a resident at the Veterans Affairs Hospital on Springs Road are being implemented by the VA.
However, the head of VA in New England maintains that unique circumstances affected the outcome. And U.S. Rep. Seth Moulton, a critic of the VA police force, said he is continuing to advance legislation that will give local police authority at VA Hospital complexes.
The report addresses the case of Timothy White, a veteran who lived in a VA Hospital building as part of a residential program administered by Caritas Communities, Inc. Mr. White was last seen on May 8, 2020. His body was discovered in a neglected stairwell not far from his apartment on June 12, 2020.
The inspector general’s report concluded that the disappearance “did not receive the attention it deserved from VA,” which the report said is legally required “to provide for the protection of all persons on its property,” including residents in so-called enhanced-use lease apartments.
In a summary, the report said, “the medical center, including its VA police, did not initiate a response to Mr. White’s disappearance under VHA’s missing patient policy because he was considered a resident and not a patient.”
“Poor decision-making, misinformation, and lack of oversight also prevented anyone at VA from encountering Mr. White during the month after he was reported missing through routine patrols or cleaning of the emergency exit stairwell in which his body was found,” the report’s conclusions said.
The report stated that “the inspector general “was unable to point to a single responsible individual, office, or decision,” but “each of these deficiencies contributed to VA’s failure to locate Mr. White.”
Moulton was one of several Congressmen calling for the investigation. His office explained Thursday that the VA’s Office of Inspector General is “an independent watchdog that conducts routine and special investigations into the VA system.”
The Salem Democrat said in a statement Thursday that he is continuing to press for “legislation and policy changes that would provide local police departments with the lead investigatory authority on VA campuses when lives are on the line. I also believe the federal government should fund local police investigations on VA campuses.” U.S. Sen. Edward Markey also released a brief statement.
Meanwhile, Moulton’s statement said. “I believe that the VA can also fix this problem with a complete overhaul of the VA Police Department and by implementing the recommendations this report makes. That overhaul should start at the Bedford VA, and it must start today.” Moulton, a former Marine Corps infantry officer, added, “I depend on the Bedford VA myself.”
The report’s findings and recommendations, which will be addressed nationally, include:
- The VA Police did not consider the victim an “at-risk” patient.” This approach is inconsistent with federal law and “VA law enforcement policies to protect all
persons on VA property.” Policies and procedures should be developed “to conduct searches for all persons who are reported missing on medical center campuses.” The report said the appropriate federal agencies are drafting the changes, which are expected to be finalized in October.
- The VA police chief “exceeded his authority” by directing that his force cease patrolling the building where White lived. That order “contravened both VA policy requiring patrols of VA property and the express lease terms.” The inspector general called for safeguards to ensure that all parts of the campus are patrolled, and leases should not conflict with this. This also is scheduled for implementation next month.
- The report also cited a finding that if medical center, police, and emergency services leaders “had a better understanding as to the terms of the Caritas lease, it is likely that VA would have been cleaning the emergency exit stairwells at the time of Mr. White’s disappearance and would have found him earlier.”
In a response that was appended to the inspector general’s report, Ryan S. Lilly, director and CEO of the VA New England Health Care System, said that although he endorses the recommendations, there are “several contextual factors that are missing or incomplete” that could “yield a better public understanding of the nature of this event.”
Residents in enhanced-use lease apartments “are considered to be equivalent to private citizens in their own apartment as it relates to VA Police presence,” Lilly wrote. “There is a stark difference in VA policing of (leased) EUL spaces and VA operated spaces…. such as advance notice of intent to enter the premises, or specific language stating that VA Police will not routinely patrol common areas.”
Although the report concluded that the stairwell was the responsibility of the police, “the only way to enter those stairwells was through the Bedford Veterans Quarters space, and VA Police were sensitive to the need to respect the privacy of the residents by not frequently walking through their living space.”
He noted that VA and Caritas personnel “each had access to the stairwell for the purposes of conducting a search at any time, and access could and would have been granted to any other individual or entity at any time if there was any reason to believe that this was where Mr. White may be located. Any implication that lack of clarity on who owned the stairwell somehow prevented searching that area is false.”
Lilly also pointed out that “a common-sense reading of the situation… suggests that both Bedford Town Police and Bedford VA Medical Center Police were each operating under an assumption that the entire building had already been searched by Caritas personnel.” He said the report does not indicate if the inspector general questioned Caritas staff “more thoroughly on what steps were taken to locate Mr. White.”
The inspector general acknowledged that Lilly “was not requested or obligated to (comment) because none of the recommendations were directed to him.”
The report also issued recommendations for administrative changes: requiring hospitals “to discuss the terms of the enhanced-use leases and the lessee’s and VA’s responsibilities;” review “all active enhanced-use leases to determine whether any involve portions of buildings also occupied by VA, and, if so, whether they are clear regarding the maintenance and security obligations;” and review policies “with respect to any services VA is required to provide under the terms of enhanced-use leases.”
The report then notes that high-level offices are drafting procedures “that identify responsibilities of police and other VA staff to conduct searches for persons reported missing on VA medical center campuses.”
Mike Rosenberg can be reached at firstname.lastname@example.org, or 781-983-1763