VA patient’s death raises questions

VA patient’s death raises questions

Family files claim, FBI probes report’s inconsistencies

By Allyssa Lee

Daily Bruin Staff

A patient was scalded to death after being immersed in a bath of
extremely hot water Feb. 7 at the West Los Angeles Veterans Affairs
(VA) Medical Center, which is affiliated with UCLA’s hospital.

The patient, 45-year-old Thomas O’Neil, a veteran treated at the
Medical Center for an organic brain syndrome, suffered from
extensive thermal burns of second and third degrees to more than 80
percent of his body.

Harriett Bordenave, a VA spokeswoman, explained that O’Neil
completed his bath in a tub/shower combination and was splashing
water in the room. The attendant then drained the water out of the
tub and stepped out of the room to get some towels from a location
about 10 steps away. When the attendant returned, there was water
in the tub with O’Neil, she said.

"According to the report, the way they were handling O’Neil was
standard practice. The attendants were used to Mr. O’Neil,"
Bordenave said.

The patient, suffering from the burns, was then treated at the
VA site and later transferred to the burn treatment center at USC
Medical Center. O’Neil died 48 hours later on Feb. 10 from
cardiopulmonary arrest resulting from extensive thermal burns,
according to the clinical death report.

The official coroner’s report, however, attributed O’Neil’s
death solely to extensive thermal burns.

County Coroner investigators found other inconsistencies between
the death report ­ investigated by the FBI ­ and the
condition of the body. The death certificate stated the patient had
"burned himself with hot water while taking shower." According to
the coroner’s report, however, the burns appeared on the lower half
of the body, which could have only occurred if O’Neil was immersed
in a tub.

"The information that we had (from the FBI) is apparently not
consistent with the condition of the body," said Scott Carrier, the
L.A. County Department of Coroner’s spokesman. "The burns are
inconsistent with being burned in the shower."

Carrier said questions as to the nature of the death remain
unanswered, thus resulting in a reopening of the investigation.

In addition, legal action against the VA Medical Center has
commenced. James Fox, an attorney for the O’Neil family,
administered a federal tort claim for wrongful death, to
investigate the cause of death and prosecute an action for
malpractice.

"Mr. O’Neil was under strict orders by his physician to be
watched while bathing," Fox said. "The point is that it’s a rule of
parenting that you test the temperature of the water before you put
the baby into the tub. Mentally, this was a child, and the nurses
and attendants had a duty that it was at a proper temperature.

"As far as I know, he had the ability to feel pain on his skin,"
Fox continued. "I think he was discovered when the attendant came
back after the break. As far as I know, they didn’t respond to his
cries for help."

Although O’Neil’s complicated medical history was asked not to
be disclosed, one of the symptoms in his condition did make him
indifferent to pain, so he did not cry out when the scalding
occurred, Bordenave said.

"It was revealed by the chief of staff that he had asked for a
cigarette while he was being treated prior to his transfer," she
said.

Investigators who tested the water discovered the temperature to
be 160 degrees. While the VA hospitals are exempt from state
licensing regulation, there is an automatic regulation of 105-120
degrees Fahrenheit in the use of hot water by patients, according
to Title 22, the California Code of Regulation for state license
regulation.

VA officials said they were taking measures to ensure an
incident such as this will not occur again.

"I want to be very clear that this was an accident, and everyone
is terribly distraught," Bordenave said. "We’re making sure that
all remedies are in place and corrective actions are taken."

The two employees who were attending O’Neil have been reassigned
to non-clinical duties until further investigations have been
completed, according to Bordenave. Furthermore, Dr. Kenneth Kaiser,
the VA undersecretary for health, has directed a review of all
engineering and other systems.

The West Los Angeles VA Center is a medical hospital that is
closely associated with UCLA, according to Bordenave.

"We’re partners. We train their doctors here," Bordenave
said.

But according to the UCLA Medical Center, the connection is not
as tightly knit.

"UCLA’s affiliation with Westwood is an academic one. It
involves teaching and research, but no clinical care," said Roxanne
Moster, UCLA Hospital spokeswoman. "As an affiliated hospital, some
faculty and medical residents provide clinical care at the VA, but
they are accountable to the VA for the care, not to UCLA. The VA
hospital is accredited and regulated as a completely separate
entity from the UCLA hospital, under separate administrations."