A federal investigation into the Phoenix VA Hospital verifies damning allegations of broken protocol, suicidal veterans going unchecked and whistleblowers being put under microscope at work.
The report into the Phoenix VA, dated August, 2015, was prompted by Brandon Coleman’s claims to the Office of Special Counsel of Retaliation after coming forward as a whistleblower.
The report finds that is exactly what was happening, stating a coworker illegally opened up Coleman’s medical records on multiple occasions.
"You don't go into a coworker's records unless there's ill intent," Coleman said.
While some were busy keeping tabs on Coleman, it seems no one was watching veterans who were at risk.
The report finds the VA knew 10 suicidal vets walked right out of the emergency department.
Seven were on a medical hold, five were found while the others vanished.
"My question, 'What happened to those five other vets?'" Coleman said. "They’re not getting the care they need and suicidal vets continue to walk out of the VA's ER."
It is that finding that hits Coleman the hardest.
His role at the VA was helping patients turn their lives around. Instead he says, the VA turned its back on them.
But Coleman says by risking it all to come forward, the changes have happened.
"Telling the truth turned my life upside down, but I'd do it all over again because it saved veteran lives."
As a result of the probe, investigators verified the VA has righted some wrongs when it comes to suicidal veterans.
- Staff will only be assigned one suicidal patient to monitor at a time.
- Rooms for suicidal vets have been moved further from the exits.
- The are timer delays on the exits.
- The clothing and personal belongings of a potentially suicidal patient are locked up.