Veteran died after VA turned him away because unconscious man didn't show his ID, watchdog says

A veteran in the throes of acute heart failure, septic shock, pneumonia, and with large, open wounds on his legs was refused emergency care at a Florida Veterans Affairs hospital because the barely conscious man could not prove his military service, according to an oversight investigation. The man later died at a civilian hospital.

The incident took place in the summer of 2020, at the Malcom Randall VA Medical Center in Gainesville, Fla., according to a May 31 report from the VA's Office of the Inspector General.

"The OIG determined that facility Emergency Department nurses failed to provide emergency care to a patient who arrived at the facility by ambulance," wrote oversight official Dr. John Daigh Jr., in the May 31 report. As a result, he added, his office "questioned the Emergency Department nurses' competence to treat patients seeking emergency care" at the facility.

The incident involved a tense standoff between the ambulance staff and VA employees in which some hospital staff argued with the emergency crew while other employees said that the facility was not supposed to refuse the patient, the report noted. 

The episode unfolded when a 60-year-old veteran was found unresponsive by a neighbor, who called an ambulance.

"Upon arrival, the neighbor informed EMS responders that the patient had been recently discharged from the VA hospital," according to the report. "The patient was in significant distress, had 'large amounts of swelling and large open wounds on both legs and feet,' made loud groaning sounds, and withdrew from touch, 'but did not open [their] eyes or speak,'" according to the report.

The ambulance crew determined that the patient — who also suffered from diabetes, hypertension, and other chronic ailments — needed lifesaving care and phoned the local VA to report that they were en route to the emergency room.

Several hospital staff members convened with a stretcher to meet the ambulance outside the emergency room. Instead of rushing to help the patient, though, they demanded proof that the desperately ill and unconscious man was a veteran. 

The exchange was witnessed by a contract security guard, according to the report.

"The contract security guard recalled facility staff arguing with the EMS personnel stating that if they could not obtain the patient's information, and determine veteran status, then they could not take the patient," the report reads.

One nurse reported that "the patient was moaning constantly and appeared to be in pain."

The EMS crew loaded the unconscious patient back into the ambulance, and drove him to a nearby hospital, where he died.

The death certificate showed that the cause of death included septic shock, acute onset chronic heart failure, acute pyelonephritis, and pneumonia.

A representative from the Malcolm Randall VA did not immediately respond to a request for comment.

The report follows recent findings that the VA overall has been backsliding in performance after making improvements from a scandal a decade ago, with fresh incidents involving lengthy patient wait times and concerns about employee behavior. 

Problems inside the Department of Veterans Affairs Department were outlined this month in a lengthy semiannual IG report that identified nearly $4 billion in losses and problems this year. Investigations resulted in 104 arrests and more than 500 administrative actions in the first half of 2022.

Officials from the VA Sunshine Healthcare Network, which oversees the Gainesville hospital, wrote that they would ask an external review team to investigate the incident from the summer of 2020. The investigation will determine whether anyone should be fired or disciplined, and will be completed by Sept. 30, officials wrote. 

The results of patient satisfaction surveys show that as of March 9, veterans report overall delays in receiving urgent care at the Gainseville facility. For primary care urgent appointments, 57% said they could be seen right away. For specialty care, 71% of veterans said they could be seen quickly.