Dangerous San Diego Research Prompts Congress To Hold Hearing On VA

October 1, 2019 at 10:24 AM PDT

Speaker 1: 00:00 Speaker 2: 00:20 Speaker 3: 00:22 Speaker 2: 00:30 Speaker 3: 00:34 Speaker 2: 00:55 Speaker 3: 01:13 Speaker 2: 01:37 Speaker 3: 01:46 Speaker 2: 01:59 Speaker 3: 02:09 Speaker 1: 02:49 Speaker 4: 03:00 Speaker 3: 03:06 Speaker 2: 03:53 Speaker 3: 04:11 Speaker 3: 05:13 Speaker 1: 06:18 Speaker 3: 06:30 Speaker 1: 07:18 Speaker 3: 07:27 Speaker 1: 08:06 Speaker 3: 08:19 Speaker 3: 09:26 Speaker 5: 10:04 Our partner. I knew source has spent months reporting on dangerous research done on San Diego veterans. Now Congress plans to hold a hearing into why a powerful veteran's affairs healthcare office did such a poor job investigating what went wrong with the study. I knew source reporter GL Castillano has more, I can't imagine what they were thinking. Martina buck has spent seven years trying to stop a dangerous research study at the San Diego VA and hold the wrongdoers accountable and what some of these people went through. No one should have to go through that. When this all started in 2013 buck was a liver researcher at the medical center. She became concerned that a colleague wanted to perform medically unnecessary liver biopsies on veterans', putting the patients at risk of internal bleeding and even death. Buck contacted our supervisors warning them not to approve the study. It was approved anyway. I was hopeful for like, I guess 15 minutes, but when I started talking to the people that could have stopped this, they just kept patting me on the head pretty much and telling me, it's okay. You convinced us we're not gonna do it that way. Now, in 2017 the department of veterans affairs finally investigated Buck's concerns. They sent a team to San Diego from the VA office of the medical inspector. The office is supposed to protect the 9 million patients in the VA healthcare system. The medical inspectors investigation concluded that the research did not pose a substantial danger to public health, but the report failed to address many of Buck's concerns. It wasn't professional. It wasn't what the veterans deserve. It wasn't what the whistleblowers deserve. It wasn't what the country deserves. This wasn't the only federal agency to get involved. The office of special counsel, which reports directly to the president about wrongdoing in the government, reviewed the medical inspectors investigation and declared it unreasonable. If their mission statement is to protect the veterans and to make sure that first do no harm is actually served. They failed. I knew source has collected hundreds of reports that show the medical inspector's office has a pattern of conducting poor investigations of the VA healthcare system. In fact, the medical inspector's investigations have been labeled unreasonable in about 16% of the reports sent to the special counsel's office. That's a higher percentage of unreasonable investigations than in other federal agencies. The VA would not comment on these findings. Hi Jill. Nick swell and buck used to be the communications director for the special counsel's office. He said our findings show that the office of the medical inspector or Oh M I isn't doing enough to protect veterans. Oh am I is doing a far worse job in terms of connecting the dots and coming up with reasonable conclusions. That to me suggests a bit of a disregard for the whistle blowers concern even when it confirms the underlying facts swell and Bach isn't the only one who feels this way. Since I knew Sora started reporting late last year on the dangerous liver research representative, Scott Peters has been pushing Congress to hold a hearing on the issue. We know this is not the first time that LMI has investigated wrongdoing and has come up short on the answers. That was the San Diego Democrats speaking last month to the house committee on veterans affairs. I asked you to work with me to get answers regarding this instance and also that is a committee that we examine the office of medical inspector veterans have served our nation, deserves the best care opportunities and support and proud to advocate for San Diego's veterans. I new source confirmed that the veterans affairs committee will hold a hearing on the medical inspector though no date has been set. Buck says the hearing is an interesting idea in theory, but she doubts it would lead to change. How are they going to go about investigating the OMI and can they not really already see what's everybody's been talking about? I mean, a lot of people have come out in public. He said the OMI doesn't find things because it doesn't want to. You can't hear anything if you don't want to listen. Joining me is I news source reporter Jill Castellano and Jill, welcome. Thank you. Can you remind us a bit more about the original research that sparked this complaint against the VA? Why were dangerous biopsies performed on these veterans? Yeah. The starts with a man named dr Samuel ho, who was a liver researcher at the San Diego VA back in 2013 he wanted the San Diego VA to join a really big international research project looking at alcoholic liver disease and he said, we can examine the liver tissue of patients with this disease and understand their problem a lot better. It's a very under-researched area. The problem was always how was he going to get these samples? These patients are extremely ill and a lot of them are close to their own death, so they are not good candidates to participate in a research study. It doesn't make sense to put them at risk to go in, perform a biopsy, potentially remove pieces of their liver if it could complicate their disease even further. What we ended up learning over time is that that's precisely what was done. Internal reports show that some of these liver biopsies were performed even though they were not medically necessary and the patients weren't told that and were not told about the risks that that could pose. So it came out to be quite an unethical research study that we've all been grappling with for awhile now. So how did the VA respond when these concerns were first raised by Martina buck? Did they change anything about the research? Unfortunately, the VA has never granted us an interview so we don't know what their perspective is, but buck has always maintained that they've never really done anything since she stepped forward and told her at the San Diego VA this is not right, that they've basically come back to her and said, okay, we'll take a closer look. But they never stopped the study and they didn't increase oversight over dr hoe. That seems pretty clear by the fact that he was able to do this kind of research for many years before people came back and finally looked at it and said, yeah, something went wrong here and I, it apparently took four years for VA medical investigators to look into the concerns originally raised by buck. Did she keep pressing them all the time to do some investigation? Absolutely. She is extremely persistent. She and her husband, they are the two whistleblowers in this case. He's a doctor at the San Diego VA, so they have access to quite a bit of uh, information and internal reports. And when they hit the wall at the San Diego VA and felt like they weren't being taken seriously, they went through different channels. One thing they did is they filed a whistleblower complaint with a separate government agency called the office of special counsel, which triggered a different kind of investigation. The office of special counsel could go to the VA in Washington, D C this national headquarters and say you have to go into San Diego and figure out what went wrong. That's when the office of the medical inspector came into San Diego and performed their own investigation of what happened. So the office of special council wound up by finding the VA's investigation to be unreasonable. What exactly does that mean? It's a really good question and there's not a real clear answer here. The office of special counsel has broad discretion to describe a report they receive as reasonable or unreasonable, but it's a case by case basis. One of the people I spoke to for this story who is, I'm an independent legal expert named Tom divine. He said that with this broad discretion, most of the time these cases are found to be reasonable even when things go wrong in these investigations and in fact case has to be really bad. Almost an insult to the intelligence or the words that he used. If the office of special counsel is going to find it unreasonable. Now the veteran's affairs committee in Congress is going to hold a hearing into the VA's office of medical inspector, but the woman you spoke with, Martina Bach doesn't hold out much hope for that. Why not? She doesn't. I think if you think about it from her perspective, she's been fighting this since 2013 and in her eyes she's made pretty small progress. She's had a few concessions people saying, yeah, things didn't go right, but no one has been held accountable at all. And she's reported this unethical San Diego research through many different channels of the government. So she's not holding her breath. She's wants to see something change and that's why she keeps fighting. But you know, I understand why she feels like it might not happen. In the meantime, do we know what happened to the veterans who got these dangerous liver biopsies? Well, buck has said one of her concerns is that the people who participated in this research did have some complications that some of them had bleeding and needed to get transfusions. In one case that one of the patients came out of the procedure oozing with blood from the neck is the way that it was described because something went wrong in the procedure when the needle was inserted into the neck for the biopsies. That was many years ago. Now we don't know if there were longterm complications, but it hasn't been thoroughly investigated and there is still a lot of questions. We do know that some of these patients, in fact most of them are actually now deceased because of how serious their diseases were at the time that they joined this research study back in 2013 we don't know whether they were told what went wrong in this research study and we don't know if they were compensated for it. I've been speaking with our new source reporter, Jill Castellano. Thank you very much. Thank you. [inaudible].

By KPBS Public Media

After inewsource reported on a shoddy investigation into whistleblower claims by the VA’s medical inspector’s office, a House committee developed “additional concerns” about how the office does its work and expanded the probe.