- Exclusive: VA whistleblower-protection worker asks for protection
- VA whistleblowers drive push for change
- Personal crusade
- Whistleblower: VA failed to properly assess hundreds of veterans for traumatic brain injuries
- “So deviant a number”
- “I took an oath”
- “New Orleans failed to provide appropriate care”
Exclusive: VA whistleblower-protection worker asks for protection
VA whistleblower Brandon Coleman, hired by VA to do outreach to whistleblowers, has some issues with the office established to protect them. USA TODAY
WASHINGTON – All Brandon Coleman wanted was a meeting.
The onetime addiction counselor and Veterans Affairs whistleblower known for exposing poor care of suicidal veterans at the Phoenix VA hospital has been doing outreach to other VA whistleblowers since 2017 on behalf of President Donald Trump’s whistleblower-protection office.
This year, the office got a new leader, VA Assistant Secretary Tamara Bonzanto, so Coleman asked her for a few minutes to brief her on his efforts, including a new mentorship program for other whistleblowers.
“'Absolutely, Brandon, we can work that in,'” Coleman recalled her telling him during an encounter in March. But the next day, he said a supervisor told him his program was being “put on hold” and he hasn’t heard from Bonzanto since.
Coleman told USA TODAY he has learned from colleagues in recent weeks that he has been excluded from meetings, his program is being eliminated, and he and dozens of other employees at the VA Office of Accountability and Whistleblower Protection are being asked to submit resumes and worry they could face possible demotion or worse.
Brandon Coleman, VA whistleblower, in front of White House (Photo: Matthew Sobocinski)
Coleman – one of the highest-profile employees of the whistleblower office – has now requested protection from another federal agency that protects whistleblowers, the U.S. Office of Special Counsel.
In his request, which he also sent to members of Congress, Coleman described the work environment as “toxic” and said the office has turned into a “Dumpster fire,” according to a copy of his complaint sent July 31.
In interviews and written complaints reviewed by USA TODAY, three other employees who requested anonymity described Bonzanto as a leader who has cut herself off from employees and issued blanket orders without listening to front-line staff.
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“We need help,” Coleman said. “How can you treat your employees the exact way we’re trying to protect employees from being treated?”
In response to inquiries from USA TODAY, the VA said Coleman's use of the terms “toxic” and “Dumpster fire” shows a “critical disregard” for the fact that problems at the office have been “over two years in the making”and include a “substantial backlog of cases.”
The agency said in a statement that Bonzanto is reorganizing the office to enhance communications with VA employees who report wrongdoing across the country and speed up investigations of the complaints.
The VA said leaders who conducted meetings to inform staff about the “proposed realignment” reassured them they “will not lose their job or have their pay reduced.”
“OAWP has remained transparent with staff throughout the realignment process; solicited and received feedback; and responded to staff questions during multiple meetings and discussions,” the VA said.
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The complaints from Coleman and his colleagues are the first to become public from inside the office. VA whistleblowers and advocates outside the agency have complained its operations have been ineffective and even vindictive.
VA whistleblowers drive push for change
Trump signed an executive order and later a law in 2017 creating the office to look into claims made by whistleblowers, protect them from retaliation and hold their managers accountable. Coleman stood behind Trump during the signing of the executive order.
Whistleblowing employees who have gone public to expose failures at the VA in recent years have played a critical role in driving a push for improvements at the agency. Health care workers revealed in 2014 that employees were keeping secret wait lists for appointments at the Phoenix VA and veterans had died while waiting.
Since then, they have come forward about the over-prescription of opioids to veterans in Wisconsin, equipment shortages in Washington, and dangerous conditions jeopardizing veteran care in Memphis, among other revelations.
President Trump holds up the Veterans Choice Program And Improvement Act with VA Secretary David Shulkin clapping behind him, center, at the White House on April 19, 2017. (Photo: Chip Somodevilla, Getty Images)
In response to inquiries about Coleman's recent complaints, the VA said Bonzanto didn’t hear from him after he asked for the meeting in March, and his customer service duties “will continue even after the office is realigned.”
After USA TODAY reached out to the VA for comment about Coleman's request for a meeting with Bonzanto, a senior official told his lawyer he could schedule an appointment.
“If employees have concerns, we encourage them to discuss them with OAWP leadership or provide specific examples so that we can address their concerns directly,” the agency said in a statement. “Unfortunately that didn't happen in this case.”
The whistleblower office has been under investigation by the VA inspector general for months and a report is expected in September. A Government Accountability Office report last year raised concerns about the independence of the office’s investigations of wrongdoing reported by whistleblowers.
The VA said Bonzanto’s reorganization is a key improvement she’s making to help address those concerns.
“The inspector general and congressional stakeholders have expressed the need for improvements at OAWP, and that’s precisely what VA Assistant Secretary for Accountability and Whistleblower Protection Dr. Tamara Bonzanto has been focusing on,” the agency said.
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Improving the VA has been a personal crusade for Coleman, a former Marine with six children, including three Marines. For years, he has backed giving veterans more options for outside care paid for by the VA – a proposal Trump ultimately signed into law.
After Coleman reported in 2014 that suicidal veterans were neglected and left to walk the Phoenix VA, his bosses at the time accused him of misconduct and shut down his addiction-treatment program. It took nearly two years to settle the case and get Coleman's program reinstated. He went on to testify before Congress about his experiences.
Coleman was hired to do outreach for the whistleblower office and provide insights to managers on policies and programs.
Phoenix VA whistleblower Brandon Coleman, center, working in the headquarters office of the agency's new Office of Accountability and Whistleblower Protection. (Photo: Jack Gruber, USA TODAY)
The office quickly began taking in reports from VA employees – more than 1,000 in the first six months, including more than 200 alleging retaliation by VA bosses for speaking out about problems and dozens about potential threats to veteran health and safety. The office staffed up with more than 50 employees to triage and investigate the reports.
Coleman created the mentorship program, which paired a whistleblower with a senior leader to create and implement an improvement project at their VA hospital. The first pairing Coleman oversaw was in Shreveport, Louisiana, where social worker Shea Wilkes faced retaliation in 2014 after he revealed schedulers had been manipulating appointment wait times.
He partnered with Shreveport VA Director Richard Crockett last year to work on a hotline for employees to anonymously report problems. The VA hailed Coleman’s success in Shreveport last October and said it would “serve as a model nationwide.”
But complaints about the office’s investigative division had been mounting, including allegations in the GAO report last July that the office allowed officials accused of wrongdoing to participate in investigations of the accusations.
An exciting day @DeptVetAffairs as Dr. Tamara Bonzanto is sworn in by @SecWilkie to lead our office. “This is a good day and it is my honor to welcome you,” Wilkie said. We look forward to sharing updates about the great work we’ll be doing for #Veterans under her leadership. pic..com/PWmJOBZx4u
— OAWP (@VAOAWP) January 7, 2019
Bonzanto, who was previously an investigator with the House Veterans Affairs Committee, was brought in as a change agent in January.
Meanwhile, Coleman continued to vet new whistleblower applicants for his mentorship program – they had to submit resumes and do interviews to be considered. He said he had eight lined up when he approached Bonzanto to ask for the meeting in March.
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After the program was put on hold, Coleman has continued to triage incoming calls from whistleblowers. When he was excluded from the reorganization meetings last month, he said he started receiving calls from colleagues reluctant to report problems because of fear of retaliation from their bosses.
That’s when, Coleman said, “It hit me.”
“I no longer feel confident referring whistleblowers to come to OAWP for help,” he said. “Something’s wrong with the office, and that’s why it was time to come forward. This needs to be fixed.”
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Whistleblower: VA failed to properly assess hundreds of veterans for traumatic brain injuries
NEW ORLEANS – Army Sergeant Daniel Murphy did five decorated combat tours in Afghanistan and Iraq, specializing in detonating battlefield explosives. Honorably discharged in 2013, Murphy suffered physically and psychologically. He had the classic symptoms of post-traumatic stress disorder—insomnia, anxiety, and a feeling that the enemy was lurking around every corner.
His brother, Jim Murphy, told CBS News there were also signs of brain damage, memory loss.
“We'd have stories together as children, and he would misconstrue the stories,” Jim Murphy told CBS News chief investigative correspondent Jim Axelrod. “We could sense something was wrong. He knew something was wrong with himself.”
Two VA sources confirm Murphy initially tested positive for a traumatic brain injury, or TBI, when he visited the New Orleans VA in June 2017. He told doctors he had been previously diagnosed with a TBI on active duty, when his Humvee hit an IED. Nevertheless, he did not receive a final TBI diagnosis or TBI treatment. Two months later, he took his own life. He was 32 years old.
“The last thing that my brother texted me was, 'hope to talk to you later,'” said Jim Murphy, who blames the VA for his brother's death. “I miss him.”
Dan Murphy's story haunts Dr. Frederic Sautter who retired last month as the head of the family mental health program at the Southeast Louisiana Veterans Healthcare System, also known as the New Orleans VA. Sautter said Murphy was one of hundreds of Iraq and Afghanistan vets from 2009 to 2019 who were not properly assessed for a traumatic brain injury in New Orleans.
“These are people who need to be identified,” Sautter told Axelrod. “They need to be brought into the VA and evaluated.”
A psychologist who spent nearly three decades counseling vets suffering from post-traumatic stress disorder (PTSD), Sautter started to grow suspicious about the quality of care at the VA in New Orleans in 2017.
He said many of his patients with PTSD, a psychological condition, were also presenting symptoms of a traumatic brain injury, which is a physical wound. Yet they hadn't been diagnosed or treated for a TBI.
Research shows vets with TBI are twice as ly to die by suicide.
“Most of my patients have been in a vehicle that's hit an IED [improvised explosive device] and exploded,” Sautter said. “I was noticing many of them were having headaches, having memory problems.”
Sautter wanted to find out why so few of his patients had a TBI diagnosis, so he set out to identify vets who had received the diagnosis at the New Orleans VA.
New Orleans VA whistleblower speaks out 06:21
“So deviant a number”
VA protocol requires all Iraq and Afghanistan vets to undergo a simple four-question screen for TBI during their first visit to any VA facility. A positive screen leads to further evaluation.
According to internal VA documents from the department's medical inspector, obtained by CBS News, most vets who receive further evaluation are ultimately diagnosed with TBI — 60% to 80% of patients across all VA hospitals.
But at New Orleans VA, Sautter found it was far lower — just 18%, about a quarter of the national average.
“It was so deviant a number,” Sautter told CBS News.
Sautter said he found nearly 600 vets who had further evaluation conducted by a neuropsychologist at New Orleans VA named John Mendoza. Sautter said Mendoza diagnosed TBI at an even lower rate — in just 9% of the vets he saw.
Three veterans told CBS News Mendoza told them he “didn't believe in traumatic brain injury.”
In July 2017, Daniel Murphy saw Dr. Mendoza after he screened positive for a traumatic brain injury. Mendoza's notes indicate Murphy complained of memory loss. And yet, while Mendoza diagnosed PTSD and depression, he wrote “there was nothing presented to suggest possible TBI.” Without a diagnosis, there would be no TBI treatment. Six weeks later, Daniel Murphy hanged himself.
Mendoza, who retired in 2017, did not respond to our request for comment.
The VA declined our request for an interview. In a statement to CBS News, the department said it's “committed to safe, well-coordinated care for those who have sacrificed for our nation.”
“I took an oath”
Upon discovering the low rate of diagnosis at the New Orleans VA, Sautter said he compiled a list of vets who screened positive for a possible traumatic brain injury but never got the VA-mandated follow-up. He said there were hundreds who didn't receive the proper care.
Sautter said he brought the list to colleagues in the hospital's Pain Management and Rehabilitation (PM&R) division, the unit charged with treating TBI. Among them, was Priscilla Peltier, a registered nurse who started working in PM&R in June 2017.
“It was a list compiled of veterans who basically just slipped through the cracks,” Peltier told Axelrod. “There was absolutely no treatment being provided to them.”
So in October 2017, Peltier and her team pitched a plan to her boss, the chief of PM&R, Dr. Robert Mipro. They would contact vets on the list and bring them into the VA for re-evaluation.
That's when Peltier said Mipro told them, the list was not their concern and to “lose the list.”
Peltier was appalled.
“How could we not try to do something?” she said. “That's why we're there. We took an oath. I took an oath when I became a nurse.”
Mipro declined our request for an interview. The VA denied that Mipro was personally resistant to re-evaluating the veterans on Sautter's list. In a statement the department said, “Dr. Robert Mipro was thoroughly vetted for his current position and has the full confidence and support of the Southeast Louisiana Veterans Health Care System leadership team.”
“These problems don't happen unless there's people who are allowing it to happen,” Sautter said.
“New Orleans failed to provide appropriate care”
Sautter pressed the VA to investigate his allegations, first through the VA's Office of Inspector General and then through the Office of Special Counsel.
The OSC ordered an internal investigation by the VA's medical inspector, which produced a report in March 2019 obtained by CBS News that was never made public.
Although it”did not identify a specific danger to public health and safety,” the medical inspector's investigation concluded: “New Orleans failed to provide appropriate care … to those veterans with positive initial screening for TBI.”
The medical inspector's report also confirmed New Orleans' relatively low TBI diagnosis rate of 18%, compared to a national average of 60% to 80% from 2008 through 2018.
After CBS News' initial story aired Wednesday, and a month after we first contacted them, a VA spokesperson said the medical inspector's report had relied on “bad data.
” He said the TBI diagnosis rates in New Orleans were in line with the national average, but did not provide any new underlying data, in response to a request from CBS News.
The medical inspector's report also called for the VA to contact and re-evaluate any vets who did not receive proper follow-up for a traumatic brain injury.
The VA told CBS News it followed through on all the recommendations in the report, but the experience of one Iraq vet who spoke with CBS News suggests at least some vets were missed.
The vet, who asked we conceal his identity saying he fears retaliation from the VA, said he did not receive the proper follow-up after testing positive for a traumatic brain injury.
“It's a farce,” said Peltier. “They're our nation's heroes who deserve the best care. You know you're going into some bureaucracy when you enter, but nothing could prepare you for how blatantly, incredibly bad the denial of care is.”