PHOENIX — The Secretary of Veteran’s Administration is now calling for a systemwide review of policies after an Office of Inspector General report found conflicting policies may have contributed to the death of an Arizona veteran.
“We recognize that we are far from perfect, so we have to learn,” said Sec. Denis McDonough to 12News during a trip to Phoenix.
McDonough made the comments after speaking at the Disabled American Veterans conference. He credits workers at the Phoenix VA Hospital with helping to launch the investigation.
“The report identified policies inside the VA that were conflicting. We’re in a position to make sure that this doesn’t happen again,” he added.
The OIG report found in March 2023, a veteran leaving the Phoenix VA Hospital suffered a medical issue in the hospital’s parking lot.
Despite being feet away from medical help, the veteran waited 11 minutes for Phoenix Fire to arrive on scene to provide basic life-saving measures.
Fire crews transported the veteran to another hospital where he died days later.
According to the OIG report, a policy at Phoenix VA hospital a Rapid Response Team can be activated to respond to patient emergencies, but only when patients are inside the building.
The report says when patients are outside the building, a Rapid Response Team cannot be activated, and that only 911 is called.
The report found a worker activated the Rapid Response Team, knowing it wasn’t within the facility’s policy, but hoping it would provide quicker access to help for the veteran.
The report said that Phoenix VA policy does not align with overall VA policy to “optimize patient safety for those requiring resuscitation” and “response capability to manage cardiac arrests on VHA property.”
“We plan to take a hard look at how this happened. We’re not fixing it here where it happened, but we plan to fix it across the system,” McDonough said.
The incident prompted Arizona’s entire congressional delegation to send McDonough a letter calling for answers about the incident.
McDonough says he appreciates working with lawmakers on Capitol Hill. He says he hasn’t responded to the letter yet, but he plans to.
The report also found there was a lack of CPR training among workers and a lack of an automatic external defibrillator.
The OIG report offered 10 recommendations including aligning the Phoenix VA hospital with the VA policy regarding rapid response to emergencies
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