A botched change in the way home-care visits were scheduled for patients released from the Veterans Affairs Medical Center in Indianapolis resulted in a veteran losing part of his leg, according to a copy of an investigative report and letter to the president.
The letter to President Donald Trump said a Department of Veterans Affairs investigation prompted by three whistle-blower complaints revealed "a system breakdown because leadership attempted to implement the change without collaborating with key services or allowing time for coordination and education." The letter is from Henry J. Kerner of the U.S. Office of Special Counsel, an independent federal agency that looks at whistleblower disclosures and helps protect them from retaliation.
That breakdown resulted in delays in the care of veterans, the investigation found, including one man discharged from the Indianapolis medical center in 2017 after receiving treatment for diabetic ketoacidosis and an ulcerated foot abscess. Because of delays attributed to the new process, the letter said, "the veteran did not receive the necessary home health care."
The letter explained the VA investigation determined the man's wound "became infected and required below-the knee amputation due to the delay in receiving dressing changes" from a home health care provider.
“It is unconscionable that after serving his country, a veteran lost his limb not on the battlefield, but because of mistakes made by the agency entrusted to take care of him," said Special Counsel Kerner. "While I commend the VA for taking the necessary steps to prevent similar problems from occurring in the future, this situation should never have happened.”