Inspectors General:

Veterans Affairs Special Inquiry Report Was Misleading

OSI-98-9: Published: May 13, 1998. Publicly Released: May 14, 1998.

Additional Materials:


Eljay B. Bowron
(202) 512-3000


Office of Public Affairs
(202) 512-4800

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.

Oct 3, 2018

Sep 28, 2018

Sep 27, 2018

Sep 13, 2018

Sep 5, 2018

Sep 4, 2018

Jul 31, 2018

Jul 24, 2018

Jul 19, 2018

Jun 26, 2018

Looking for more? Browse all our products here