Summary

An unexplained increase in patient deaths occurred in one ward of the Harry S. Truman Memorial Veterans Hospital in Columbia, Missouri, during the spring and summer of 1992. In October 1992, the Office of Inspector General (OIG) at the Department of Veterans Affairs (VA) and the FBI began a joint investigation into the suspicious deaths; in February, they received information alleging a coverup by the hospital director and the VA Central Region Chief of Staff. GAO reviewed the special inquiry conducted by the OIG, focusing on how VA's OIG planned, conducted, and reported its inquiry. In its report, the OIG concluded that management's actions could be attributed to bad judgment but found no conclusive proof of an intentional cover-up and no evidence of criminal conduct by top managers. GAO believes that the conclusion that no evidence of an intentional cover-up had been found was misleading because the OIG did not collect or analyze evidence in a manner that would identify intentional cover-up efforts.

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.