Internal Reviews Find Human Error At VA Responsible For Legionnaires’ Outbreak
PITTSBURGH (KDKA) – When House Veterans Affairs Chairman Jeff Miller held hearings in Pittsburgh last fall on the VA Hospital’s Legionnaires’ ordeal, he was clear.
“In Pittsburgh, VA officials knew they had a Legionnaire’s disease outbreak on their hands but they kept it secret for more than a year,” the Republican said at the time.
It was actually worse than that.
In documents obtained by KDKA-TV from committee investigators, emails and two internal reviews found human error was at fault for the outbreak while local VA officials were publicly blaming an old water system for Legionella.
“Either the employees there were not being properly trained or they just weren’t carrying out the monitoring functions and testing functions that they needed to carry out,” U.S. Rep. Mike Doyle, a Forest Hills Democrat, told KDKA’s political editor Jon Delano.
Not only was the water system not maintained, but internal reviews also found hospital staff failed to keep the hot water tanks at the VA-recommended 140-degree temperature.
And that’s not all.
Internal VA emails just released by the Committee suggest that more than a year before the VA went public about Legionnaire’s disease, the top physician at the hospital suspected a problem and recommended that everyone use bottled water.
Yet no patient was alerted about water concerns for more 14 months.
Ultimately, at least 22 were affected, and six died.
“These were preventable deaths at the hospital, and we still wait for accountability,” said U.S. Rep. Keith Rothfus, a Sewickley Republican.
The VA Hospital is now safe, but local congressmen want the VA to hold individuals accountable.
“There’s no way that VHA can just sweep this away. There’s going to be a final reckoning. People will be held accountable,” noted Doyle.