A US Office of Special Counsel report based on complaints from three whistleblowers was sent to President Trump Wednesday, exposing scheduling and staffing issues at the Richard L. Roudebush VA Medical Center in Indianapolis that led to a delay in medical care for veterans. While the center says it has since remedied those issues, one such delay led to a mistake called "unconscionable": A veteran didn't receive the at-home care he needed, and ended up losing his leg as a result, per the Indianapolis Star. The report details what happened in June 2017 after the veteran was discharged from the center following treatment for diabetic ketoacidosis and an ulcerated foot abscess. Someone was supposed to come to his home to change his bandages; when that assistance got delayed, his foot became infected, leading to an amputation below the knee.
"It is unconscionable that after serving his country, a veteran lost his limb not on the battlefield, but because of mistakes made by the agency entrusted to take care of him," special counsel Henry J. Kerner says in his letter. Department of Veterans Affairs investigators found the unnamed chief and assistant chief of social work services at the center had told social workers to stop entering home consults into patient records because they felt it was "outside the social workers' scope of practice." In a letter last August sent to Kerner and seen by Task & Purpose, Secretary of Veterans Affairs Robert Wilkie agreed with the investigators' findings, noting the alleged issues led to a "system breakdown." A rep for the VA center told the Star they'll address the special counsel's report in a statement on Thursday. (Read more veterans stories.)