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Sen. Casey: Federal Probe Into VA Legionnaires' Outbreak Shows Failures

PITTSBURGH (KDKA) -- Sen. Bob Casey says the findings of a federal investigation into an outbreak of Legionnaires' disease in the Pittsburgh VA health system are an important step toward preventing future occurrences.

The outbreak killed five patients and sickened at least 21 others.

According to a statement from Sen. Casey's office, the report concludes that:

  • VAPHS did not always follow their own guidelines in combating Legionella.
  • While the VAPHS often had processes in place at key times, those processes were not followed.
  • Three key failures were - inadequate maintenance of the copper silver ion system at all times, failure to conduct routine flushing of hot water faucets and showers, especially in infrequently used areas and failure to conduct appropriate tests on positive cases of hospital acquired pneumonia.

The report also includes recommendations for the future, like putting a process in place to combat Legionella that must be followed.

In a statement, Casey said that the report is a "critical step" to prevent similar mistakes in the future.
Sen. Casey also says he's developing legislation that would make sure that when Legionella is detected, it is reported to various health agencies.

"They certainly let down veterans in the sense that they weren't following basic rules and procedures to prevent this from happening," said Sen. Casey.

"I feel vindicated a little bit that what we suspected and knew in our hearts is true," said Maureen Ciarolla, whose 83-year-old father died of Legionnaire's at the Pittsburgh VA. "I feel as a family -- which, understand that the Inspector General did not interview any of the family, so how did -- it's really disturbing how they handled the families. They spent more time making us feel that they contracted the bacteria in our own homes than they spent on trying to find their problem."

  • Watch David Highfield's report:

"I don't understand how they sleep at night," Ciarolla continued. "If they had even taken care of the situation after my father died, all of these other people wouldn't be dead."

In written statement, the Pittsburgh VA said that it agrees with the report's recommendations. It goes on to say that the VA has already taken steps to control Legionella and to protect veterans.

RELATED LINKS:
Veterans Health Administration
Sen. Bob Casey Jr. Online
Casey Introduces Legislation Requiring VA To Report Legionnaires' (3/26/13)
More Reports on the Legionnaires' Outbreak

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