VA Medical Malpractice

 A new report shows that thousands of Veterans may have suffered from VA medical malpractice

VA medical malpractice allegedly caused more than 1,000 veterans to die.  This information comes from the disturbing findings in a new report entitled “Friendly Fire: Death, Delay and Dismay in the VA” that was released by US Senator Tom Coburn.

“I look back at how they treated me over the years, but what can I do?  I’m too old to punch them in the face.”

Government investigations, whistle-blower reports, and media findings are combined to trace a history of fraudulent scheduling practices, budget mismanagement, and lack of oversight that have led to the current controversy plaguing the Veterans Association.

Fox Law examined “Friendly Fire: Death, Delay and Dismay at the VA” and spotlights below some of the VA medical malpractice incidents that stood out the most to us when reading the 40 page report.  The report identifies crimes committed by VA staff.  The crimes include VA medical malpractice, drug dealing, theft and sexual abuse of patients, dating back many years.


Barry Coates

Barry Coates is one of hundreds of veterans who has suffered from VA medical malpractice due to a delay in care. Coates was having excruciating pain and rectal bleeding in 2011. For a year the Army veteran went to several VA clinics and hospitals in South Carolina, trying to get help. But the VA’s diagnosis was hemorrhoids, and aside from simple pain medication he was told he might need a colonoscopy.

“The problem was getting worse and I was having more pain,” Coates said, talking about one specific VA doctor who he saw every few months. “She again examined me and gave me some prescriptions for other things as far as pain and stuff like that and I noticed again she made another comment — ‘may need colonoscopy.’  “I told her that something needed to be done,” said Coates. “But nothing was ever set up … a consult was never set up.”  “I had already been in pain and suffering from this problem for over six months and it wasn’t getting better,” Coates said. “I told her that if you were in as much pain as I was and had been going through you wouldn’t wait another two months to see what’s going on. You would probably do it this week.”

Coates waited months, even begging for an appointment to have his colonoscopy. But he only found himself on a growing list of veterans also waiting for appointments and procedures. He was finally told he could have a colonoscopy, many months later.

“I took it upon my own self to call the department that scheduled that and ask them about it. And they said this was the earliest appointment that I could get. And I explained to the lady what I had already been through and how much pain I had, and I said if I wait this long there might not be … (anything) we can do about it then. I could be even dead by then. And the only thing she could tell me was ‘I understand that, sir, but I don’t have any control over that.’”

Finally about a year after first complaining to his doctors of the pain, Coates got a colonoscopy and doctors discovered a cancerous tumor the size of a baseball.  The now 44-year-old veteran is undergoing chemotherapy in an effort to save his life.

Jesse Lee Chain

A Veterans hospital nurse at the Lexington medical center was charged with VA medical malpractice for killing World War II veteran Jesse Lee Chain.  When she eventually admitted fault but there was very little consequence. The veteran, who served in Europe, was killed by a morphine overdose at a VA Hospital in Lexington, Kentucky in September 2006. The nurse who administered the lethal dose was charged with murder.

Some of the veteran’s family members said the nurse “harassed them for two years to try to get them to admit guilt” in the death.  The veteran’s stepdaughter said, “the FBI was here a couple of times. They interrogated me and tried to make me say I did it and not to ruin the VA hospital’s reputation.”

The court found the “additional doses of morphine provided by” the nurse “were a contributory cause of” the veteran’s death and she eventually pled guilty to involuntary manslaughter.  At least two other veterans cared for by the same nurse “died under suspicious circumstances” after being given morphine, according to a special agent with the VA Inspector General.  The nurse was sentenced to “time served of eight days” as a result of her VA medical malpractice and wrongful death charge.

Dr. Margaret Moxness 

With twenty-two Veterans committing suicide on a daily basis, mental health treatment and assistance for vets is of the utmost importance.  A West Virginia doctor is coming forward with new allegations against the Department of Veterans Affairs, claiming that she too was told to put patients seeking treatment off for months on end — and that at least two of them committed suicide.  Dr. Margaret Moxness, who was employed at the Huntington VA Medical Center in Charleston, W.Va., said that she was told to delay treatment even after she told supervisors they needed immediate care. She said at least two patients committed suicide while waiting for treatment between appointments.

Claude V. D’Unger

Claude V. D’Unger, a 68-year-old Army veteran from Texas, said he stopped seeking care through the VA after he was unable to timely schedule a CT scan of his lungs.

“After calling for an appointment and being told that he would have to wait at least two months . . . he contacted a private doctor who performed the scan the next day.”

D’Unger also had problems getting in touch with people at VA clinics regarding his medical claims – someone rarely answered the phones when he called.  “The claims side has a 1-800 number we refer to as dial-a-prayer. Nobody answers, nobody   listens.”

Christopher Ellison 

In 2007, military veteran Christopher Ellison visited a Philadelphia VA facility for a routine tooth extraction. He suffered a stroke on his way home because doctors performed the procedure despite Ellison’s dangerously low blood-pressure.  He is now permanently paralyzed. The $17.5 million Ellison and his family received in a VA medical malpractice judgment against the Department of Veterans Affairs was the largest against the agency in over twelve years — and one of more than 400 payments the U.S. government made last year to resolve VA medical malpractice claims.

Oneal Sessions  

Oneal Sessions is a 63-year-old Vietnam veteran.  Sessions said a Doctor informed him at Dorn Medical Center this year that he didn’t need a colonoscopy. Instead, he said, they gave him a routine test that would show whether he had polyps that are cancerous or in danger of becoming cancerous.  Sessions said the VA told him to return in several years.  Thankfully Sessions ignored that advice and had a colonoscopy in the office of his private physician, Dr. Lloyd. In that procedure, Dr. Lloyd found and removed four polyps. Two of those polyps were pre-cancerous, the physician said.  His physician told Sessions that had he waited a few more years, he might have developed cancer.

Jerletta Halford-Pandos

Jerletta Halford-Pandos is a completely disabled veteran from Kellyville, Oklahoma. Mrs. Halford-Pandos, who served her country from 1980-2002, had both of her knees replaced by VA—twice each. On her second knee surgery on her left knee, the VA placed a 5-inch rod in her femur, which extended her leg one inch.  The VA failed to notify Mrs. Pandos that the rod would extend her leg —until six months into her physical therapy. “It would have been nice if the VA would have told me,” she said.  She now has to have her shoes altered, costing her at least $50 per shoe. Mrs. Pandos also suffers from knots and bunions on her feet. Pandos had been waiting for 18 months for follow-up knee surgery, and now the VA has declined another knee surgery.  Despite her harships, she does not plan to sue for VA medical malpractice even though the doctors failed to mention that the rod would extend their leg.  Mrs. Harlford-Pandos is more concerned with those coming home from war today.

Mrs. Pandos is “frustrated with how long everything takes. Right now we have a lot of kids coming now from Iraq and Afghanistan that need immediate care. They shouldn’t have to ‘take a number’ and wait months” to see a doctor.

Danny L. Turner

The chief of dental services at the John Cochran VA Medical Center says he welcomes investigations into the handling of dental equipment at the hospital.  He blamed politics for distorting the controversy.  “I have a lot of information that proves we were doing things correctly,” Danny L. Turner said in an interview after he had been put on administrative leave.  More than 1,800 veterans were sent letters warning that they may have been exposed to viruses from improperly cleaned dental equipment at Cochran.  The warning touched off an outcry.  Two investigations are now planned.  The Veterans Affairs secretary is calling the mistakes at Cochran “unacceptable.”

Turner is 63-years old and has been at Cochran since 2001.  He said he wanted a chance to voice his opinion.  He defended the dental department at Cochran, saying, “My staff is extremely upset. I have people who have been here 35 years. They all take pride in what they do.”  Turner denied a claim made by a former Cochran employee that she saw dental instruments with dried blood even after they had gone through the cleaning process. “Our dental instruments are never that way,” he said. “I don’t know what she was talking about.” And he lamented that politics had clouded the picture.  “Things are done to get votes, and that’s a shame,” Turner said.

Jamie Carlson

Jamie Carlson is a social worker fired by the Roseburg Veterans Affairs Medical Center for allegedly having sex with a client.  She has admitted to the wrongdoing and has been stripped of her license.Carlson is 32-years old.  She will be barred from practicing social work in the state for at least three years.  “Sometimes people make a stupid choice,” she told the newspaper.  Carlson originally denied any improper behavior with the veteran throughout the investigation, which she called “a witch hunt.” Carlson accused VA officials of discriminating against her because she is young, a woman and Pakistani American.  The order from the Oregon Board of Licensed Social Workers also sanctions Carlson for socializing with five clients and fines her $15,000 for those ethical violations. Two-thirds of the fine will be suspended if Carlson complies with the terms of the order.  Carlson admitted she had an intimate relationship with a man who attended 19 group sessions she led at the VA between 2007 and 2011 for veterans with post-traumatic stress disorder. She told investigators the relationship began in 2011, after the last session he attended.  Carlson said the man twice asked her to marry him, but she turned him down.  State ethics rules forbid social workers from entering into a relationship with a client within three years of counseling.  The VA barred Carlson from counseling patients as it investigated her case between August 2012 and November 2013, when her dismissal was made final. During that time, Carlson remained on the payroll and collected her $65,000 annual salary.  Carlson was employed by Roseburg VA Medical Center for six years.

Jose Bejar  

Charges were filed after five female veterans who were patients at the Topeka hospital claimed mistreatment at the hands of Jose Bejar from 2007 to 2011. Bejar was fired by the U.S. Department of Veterans Affairs in May.  He lost his medical license and must register as a sex offender.  Bejar’s employment at Colmery-O’Neil overlapped briefly with that of physician Kayode Sotonwa, who was hired within two years of acquittal on Florida charges.  The charges of Sontonwa were that he sexually abused multiple patients by performing breast and pelvis examinations unrelated to their medical needs. Prosecutors said 16 patients filed VA medical malpractice complaints against Sotonwa, but the doctor was welcome at Colmery-O’Neal in 2011 and 2012 before taking a job in Texas. Two other Colmery-O’Neal doctors wrote dozens of prescriptions to an administrative colleague for nearly 4,000 powerful painkillers in a 12-month period.

Jonathan Monatano 

After waiting for four hours for dialysis with a shunt in his arm, 65-year old veteran Johnathan Montano told a Veterans Administration hospital he was leaving.  VA security thought the appropriate response to this was to physically assault him.  While attacking Monatano, a VA hospital officer stomped on his carotid artery, causing the stroke that killed him.  As a result, Norma Montano sued the United States of America in Federal Court, for the death of her husband of 44 years, Jonathan Montano. The Montanos’ son and daughter also are plaintiffs in the negligence suit.  Norma Montano does not attribute her husband’s death to the long wait, but to the needless beating.  Jonathan Montano died on June 11, 2011.

The VA medical malpractice complaint stated that Jonathan told his wife to get the car to take him to Long Beach. As she went to get it, her husband “was told by the nursing staff not to leave the hospital,” the VA medical malpractice complaint continued.  “Jonathan Montana told the nurse that he was leaving and was going to the VA Hospital in Long Beach, California.  He wanted to leave the needle apparatus in his arm, so they wouldn’t have to put a new one in at the Long Beach VA Hospital.  The nursing staff called VA Police Department to stop Jonathan Montano from leaving the hospital.  The VA medical malpractice complaint stated that the summoned VA Police Department police officers then stopped Jonathan Montano from leaving the VA Hospital in Loma Linda, by tackling him to the floor, slamming his head on the floor, and kneeing and stomping on his neck, and otherwise brutalizing and restraining him.  “This kneeing and stomping on his neck by the VA Police Department police officers caused the dissection of his carotid artery, that resulted in immediate blood clotting, which resulted in him suffering a stroke. Moreover, the brutalization of Jonathan Montano resulted in him suffering other serious physical injuries, and associated physical, mental and emotional pain, suffering and distress.”  The VA medical malpractice report also gives a heartbreaking account of when Mrs. Montano discovered her husband was injured. Norma Montano, wondering why her husband had not come to the car, went inside to look for him. Inside the hospital “she was told by a member of the nursing staff that Jonathan Montano suffered a stroke,” and was in the emergency department.

In the VA medical malpractice suit, Norma Montano seeks damages and punitive damages for wrongful death, assault and battery, false imprisonment, constitutional violations, negligence, loss of consortium and intentional infliction of emotional distress.

Richard Meltz 


Richard Meltz pled guilty to charges arising from his involvement in two separate conspiracies to kidnap, rape, and murder specific women. Meltz, at the time the chief of police of the United States Department of Veterans Affairs, at the Bedford Veterans Affairs Medical Center.  Meltz conspired to kidnap, rape, and murder the wife of a man he had met over the Internet and a female Federal Bureau of Investigation agent working in an undercover capacity. Meltz was charged in April 2013 and pled guilty before U.S. District Court Judge Paul G. Gardephe.

Manhattan U.S. Attorney Preet Bharara said, “Richard Meltz, a former law enforcement officer, now stands convicted of serious federal crimes for his involvement in two sadistic kidnapping, rape, and murder conspiracies. Prosecuting and bringing to justice perpetrators of such depraved and violent crimes is at the core of this office’s mission. Meltz’s guilty plea today furthers that mission and brings us one step closer to resolving this case.”

VA Hospitals in Pennsylvania

U.S. Senator Pat Toomey stated that at least one Veterans Affairs facility in Pennsylvania is among 29 under investigation for VA medical malpractice.  After this statement he introduced a “VA Accountability” bill in Montgomery County to make sure those that those who suffered from VA medical malpractice receive their retribution.  The Department of Veterans Affairs operates medical centers in eight Pennsylvania cities and smaller outpatient facilities in many more, including Allentown and Washington Township near Bangor.  Toomey’s bill “would allow victims to sue VA employees if they knowingly and willfully misrepresent, lie about or misreport any aspect of veterans’ health status,” he said.  Another bill, by U.S. Senator Marco Rubio, would allow top Veteran administrators to fire employees, without going through existing due-process rights, if they are found to have knowingly falsified patient records.  Toomey is co-sponsor of the Rubio bill. He said both Rubio’s bill and his need to be approved immediately by Congress to ensure that veterans receive the care they deserve and need.  Toomey cautioned that these bills are simply a step in the right direction, and will not fix the problem.

“Let me be clear: Neither of these things by themselves will help veterans get their health care when they need it,” Toomey said. “They need to be first in line for the best quality health care in the world; today they are neither.”

The U.S. Department of Veterans Affairs has medical centers in the following areas of Pennsylvania:

Altoona     Butler     Coatesville     Erie     Lebanon     Philadelphia     Pittsburgh
And outpatient clinics (locally) in:
Allentown     Bangor     Frackville      Horsham     Pottsville     Reading

Acting VA Secretary Sloan Gibson said in a news conference in Washington last week that he plans to remove more VA officials from their positions once he receives more information from the inspector general.


1 thought on “VA Medical Malpractice”

  1. Mr. Fox at your unofficial telephonic advice I completed an sf 95 to use as mere leverage to persuade my nurse practioner/primary care provider to follow a protocol referral for spinal issues that were worsening. However, after doing so the NP/PCP urged me to agree to a mental health admission, then sent an email to a psychiatrist in an effort to back up this attempt at an admidsion against my will. I was desperately seeking relief and treatment for recent and some ongoing spinal problems. For reasons unknown my provider and others at the Philly VA either dismiss, redirect or bypass my repeated requests for a clear orthopaedic exam with recommended appropriate dx and treatment. My attempt to use the sf 95 resiltrd in a number of unexpected events, 1) the attempt by my provider to have me “committed” (as opposed to admitted), 2) an angry email “blitz” to my so called treatment team, 3) several merry go round calls from the patient advocates office, and a very disturbing session with a doctor I’ve seen regularly for the past 16 years…this doctor, completely out of character accussed me of being a “killer,” stated I had abused him, badgered me about suing the primary provider, warned me that a law suit would not hurt anyone but me, and he forgot to order my medicine and due blood work as he normally would do. What next? An unwanted and undeserved “admission” or a false arrest for the purpose of stopping a law suit would be very disruptive to my life style, not to mention the spinal problems simply worsening. What am I to do..? Should I modify the sf 95 to include the badgering and threats from the other doctor? Should I go ahead and actually file the sf 95 and include an estimated cost of any possible remaining medical costs plus the claim of what is clearly deliberate and intentional infliction of emotional distress? Can you help Mr. Fox? Have a great holiday season.

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