Inspectors General:

Veterans Affairs Special Inquiry Report Was Misleading

T-OSI-98-12: Published: May 14, 1998. Publicly Released: May 14, 1998.

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Eljay B. Bowron
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Pursuant to a congressional request, GAO discussed 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.

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; (2) GAO determined that the OIG did not collect or analyze evidence in an 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 on 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 nearly 2-year delay in acting on 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 by OIG on at least three occasions; and (7) current OIG policies and procedures on confidentiality are adequate.

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