Veterans Affairs Special Inquiry Report Was Misleading
OSI-98-9: Published: May 13, 1998. Publicly Released: May 14, 1998.
- Full Report:
Pursuant to a congressional request, GAO reviewed the Department of Veterans Affairs (VA) Office of Inspector General's (OIG) Special Inquiry into the alleged cover-up of an unexplained increase in deaths at the Harry S Truman Memorial Veterans Medical Center, Columbia, Missouri, focusing on: (1) whether the Special Inquiry report represents the results of OIG's review; (2) whether OIG complied with its policies in conducting the Special Inquiry; (3) why a delay occurred between receipt of the cover-up allegations in February 1993 and the beginning of the Special Inquiry in January 1995; (4) whether OIG protected the confidentiality of the staff physician who made the allegations of a cover-up; and (5) if OIG processes and procedures are adequate for ensuring confidentiality.
GAO noted that: (1) the VA OIG conducted the Special Inquiry as a management review to determine how hospital and VA Central Region management had responded to an out-of-norm situation regarding unexplained deaths at the Hospital; (2) GAO determined that OIG did not collect or analyze evidence in a manner that would identify intentional cover-up efforts; (3) thus, the Special Inquiry's conclusion that no evidence of an intentional cover-up had been found was not consistent with the inquiry conducted and was misleading; (4) OIG failed to comply with its own reporting policies concerning completeness and accuracy by presenting statements that were not supported by the evidence contained in OIG files, including reference to a discussion that the Special Inquiry never verified; (5) OIG attributed the delay in acting upon the cover-up allegations received in February 1993 to administrative error; (6) the confidentiality of the staff physician who had made the allegations of a cover-up was breached on at least three occasions; and (7) OIG's current policies and procedures on confidentiality are adequate.