Report Requested by Bera on Veteran Death at Mather Completed, Reveals VA Responsible for "Delay in Life-Saving Intervention"

Statement

A report released by the U.S. Department of Veterans Affairs (VA) this week on the death of a Sacramento County Vietnam Veteran at the Mather VA Hospital revealed the hospital was responsible for "delay in life-saving intervention." The investigation, requested by Congressman Ami Bera, M.D. last October, took place after the patient died following an incorrect do-not-resuscitate band was placed on him.

Among the report's findings:

The facility staff did not follow through on the patient's request upon admission to discuss advance directives.
There was no evidence of advance care planning discussion during the patient's hospital stay.
The patient's wristband had the incorrect code status of "Do Not Resuscitate/Do Not Intubate" printed on it and that staff did not verify the wristband code status during the patient's hospital stay.

In response to the report, Bera called on VA Secretary Robert McDonald to immediately ensure procedures to prevent repeat incidents be implemented nationwide.

"Our veterans have served us, and we have the responsibility to provide them with the highest quality health care," said Bera. "I'm deeply saddened that a local Veteran being treated at the Mather VA Hospital passed away, and extremely troubled that preventable mistakes lead to a delay in lifesaving treatment. As a doctor, I know that every second counts in an emergency. I commend the Office of the Inspector General (OIG) on their responsive and thorough investigation into the circumstances surrounding this tragedy. In light of their findings that suggest several contributing factors may have been larger institutional problems, not isolated facility incidents, I've requested further clarification on VA hospital procedures to implement appropriate procedures throughout the VA system nationwide so this kind of tragic incident does not happen to any more of our Veterans."

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