An Army veteran whose badly decomposing body was found in the stairwell of his care home had been left there for a month, it emerged on Thursday, in a report which strongly criticized the facility's managers.
Timothy White, 62, was found dead in June 2020 at Veterans' Affairs hospital in Bedford, Massachusetts - 15 miles north of Boston.
He had moved into the facility about five months earlier, having struggled with homelessness prior to moving to the site, and had surgery on his hip that spring.
White was using a walker, but disappeared on May 8 in the grounds of the Edith Nourse Rogers Memorial Veterans Hospital.
The private nonprofit that managed White's building reported him missing to local police five days later, but White's body was not discovered until June 12 - wearing the same baseball cap, Red Sox jersey, and jeans he was last seen wearing in early May.
He was found in a stairwell, 60 feet from the door of his room.
A cause of death could not be determined 'due to the delay in discovering the body and its resulting state,' officials said.
On Thursday the VA's Office of Inspector General published its report into the scandal, speaking to 24 people over the course of a year.
Edith Nourse Rogers Memorial Veterans Hospital, also known as the Bedford VA Hospital, was where White lived from January 2020 until his death in May 2020
The report concluded that a series of mistakes led to White's grim fate - from the belated decision to send search parties to confusion over who was responsible for what within the complex, and White's situation on campus.
It recommended that the management of the site be simplified and clarified, and criticized some of the actions taken by senior leaders - who have since resigned.
He was considered a resident, rather than a patient, which led to administrative delays in raising the alarm.
'The OIG found that VA police would have been required to search the emergency stairwell if Mr. White had been considered an at-risk missing patient under VHA’s directive, and if VA police had followed the VHA directive, he likely would have been located by VA police shortly after he was reported missing,' the report stated.
Despite rarely leaving the Bedford Veterans Quarters (BVQ), housed in Building Five on the VA Campus, he was free to come and go as he pleased, which slowed proceedings as some believed he could have left the area.
'White had no cellphone, no car on campus, and 'had never been known to leave without explanation,'' the report stated.
'Yet tragically those who were informed about his disappearance - including BVQ management, and VA police and staff - never searched the emergency exit stairwell ... at any time during the month.'
A man passes down a hall at the Edith Nourse Rogers Memorial Veterans Hospital in Bedford
The OIG report showed White's room, and the stairwell 60ft away where he was found
The Bedford VA police chief had also told his team to stop inspecting the area, amid a disagreement with Caritas, which ran the site.
'Just months before Mr. White's disappearance, the VA police chief had improperly instructed his officers to stop patrolling Building 5,' the OIG reported.
'He claimed that it was at the request of Caritas managers, but there is conflicting testimony concerning this assertion.'
The police chief, Shawn Kelley, resigned from his job earlier this year, citing poor health.
Shawn Kelley, chief of Bedford VP police, resigned due to poor health shortly after White's death
'At a basic level, VA failed to ensure that the medical center had a clear understanding of what space belonged to VA and what its maintenance responsibilities were under the lease — even with respect to spaces that affected tenant safety, such as the emergency exit stairwells,' the report said.
There was also confusion about rival jurisdictions of the police, VA and Caritas.
VA police conducted an exterior search of VA property only, the report found, and they did not search the dormitory where White lived.
VA police Sergeant Colton Reeder told investigators from the District Attorney's office for a December 2020 report, that 'he wanted to be careful not to involve himself in another agency's investigation' - an apparent reference to the Bedford town police.
Bedford town police told the District Attorney that they entered White's name into a national database for missing persons, while officers checked hospitals and jails to see if they could locate him. They also searched the campus, police said.
Kelley waited nearly two weeks before responding to a request from the Bedford town police to search for White with police dogs. The search was never conducted.
Caritas officials, for their part, told The Boston Globe when White's body was found that their staff had been ordered by the VA police to stay away from the stairwells and were threatened with penalties if they violated that order.
Karin Cassel, executive director of Caritas Communities, told the paper at the time that her staff searched all areas they had access to and promptly notified the VA and the VA police when White was discovered missing.
The facility where White lived is pictured in November 2017. He moved in in January 2020
But White's two daughters, Karen and Katherine, said that they were dismayed by the confusion and accusations.
'It is disheartening to see everyone pointing fingers and placing blame on each other before all the details are known,' said Karen, speaking in June 2020.
'We are waiting for answers, we hope to know more soon.'
Katherine added: 'No one else should have to feel the way my sister and I are feeling right now.'
The pair have not responded to Thursday's report, but their local congressman Seth Moulton, who has championed the investigation into the saga, said it exposed serious deficiencies.
'Tim White deserved better from the country than dying alone in a stairwell,' said Moulton, in a statement issued on Thursday.
'His life might have been saved if the Bedford VA Police Department did its job.'
Moulton said his staff have been working on legislation and policy changes that would provide local police departments with the lead investigatory authority on VA campuses.
'America's veterans deserve the best healthcare in the world,' he said.
'Mr. White's care didn't come close.
'In the days ahead, we must demand that the VA Police department changes so that our country keeps its promises to those who have served.'
No comments:
Post a Comment