Pittsburgh, PA — Congressman Tim Murphy (R-PA) released the following statement upon release of a report by the Inspector General for the Department of Veterans Affairs reviewing the circumstances surrounding the recent outbreaks of Legionnaires’ Disease at the VA Pittsburgh Healthcare System (VAPHS) that resulted in 21 cases of Legionnaires’ Disease, including five deaths.

In early December, Congressman Murphy brought professional staff from the House Veterans Affairs Committee to Pittsburgh to review protocols and procedures at the Oakland hospital. Following that meeting, on December 17, 2012, Rep. Murphy called on the Inspector General for the Department of Veterans Affairs to investigate the outbreak of Legionnaires’ Disease at VAPHS. Murphy also is helping to lead a congressional probe of the outbreak.

After reading the report, Congressman Murphy stated:

“The IG’s report tragically documents what we feared to be true: the Legionella outbreak is a serious and unacceptable failure of the VA Pittsburgh Health System that could have been prevented. It is a disturbing list of failures and a breach of trust on the most basic level between our veterans and the leadership of the VA Pittsburgh Healthcare System.”
 
“"As the VA Pittsburgh is known for its excellence in many areas of medical care, my hope is that appropriate action will be taken quickly to restore that status of excellence and public trust. All of those responsible for the failure to communicate, monitor, document, report, maintain equipment, and take corrective action that led to the illnesses and deaths of our veterans should be held fully accountable.”
 
“Based on what was discovered through the Inspector General’s review as well as the allegations revealed at the congressional hearing by employees of the VA, my hope is the US Attorney’s office will review this case to determine whether there was anyone involved in falsifying records, negligence, or willfully thwarting this investigation.”

From the Inspector General Slide Summary of the Report
•    “VAPHS allowed ion levels inadequate for Legionella control to persist. There was a lack of documentation of system monitoring for substantial periods of time and inconsistent communication and coordination between the infection prevention team and facility management service staff.”

•    “VAPHS did not conduct routine weekly or bi-weekly flushing of hot water faucets and showers, especially in areas that are infrequently used, as recommended by the [copper-silver] ionization manufacturer."

•    “...VAPHS responded to positive cultures in February 2011 by flushing distal outlets with normal temperature hot water, a corrective action not consistent with VHA or CDC guidance.”

•    “VAPHS did not test all healthcare associated pneumonia patients for Legionella as expected by VHA guidance for transplant centers with a history of HC-associated Legionnaires’ disease.”

The full IG report will be posted on Murphy.House.Gov at 2PM. Under questioning by Rep. Murphy at a February 2013 congressional hearing on the outbreak, witnesses said VA officials told employees not to participate in the congressional probe, and alleged that VA employees falsified data in order to hide mismanagement of the copper-silver ionization system at the Oakland hospital. Murphy and the House Veterans Affairs Committee are continuing to investigate these allegations.

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