The new findings substantiate some allegations by whistleblowers highlighted in a CNN investigation
in 2014 and numerous stories examining delays in care and preventable deaths of veterans.
The OSC letter backs up allegations by whistleblowers who raised alarms about dangers and harmful incidents happening to U.S. veterans in various VA facilities. And the letter says VA officials did not protect those who came forward and even tried to harm them.
In a statement to CNN in response to the OSC letter, the VA said it is "committed to creating a work environment in which all employees -- from front-line staff through lower-level supervisors to senior managers and top VA officials -- feel safe sharing what they know, whether good news or bad, for the benefit of Veterans, without fear of reprisal."
One of the whistleblowers whose case was examined and substantiated by the OSC was Dr. Katherine Mitchell, a VA doctor who made public numerous problems at the Carl T. Hayden VA Medical Center in Phoenix.
Mitchell, who was featured in CNN's investigation, had raised alarms about dangerous delays in veterans' care, partly due to the lack of trained triage nurses in the Phoenix VA emergency room. But VA officials failed to act on Mitchell's disclosures for five years and also took no disciplinary action against responsible officials in Phoenix, the OSC found.
"The failure to take appropriate discipline, when presented with clear evidence of misconduct, can undermine accountability, impede progress, and discourage whistleblowers from coming forward," Special Counsel Carolyn Lerner said in the OSC letter.
According to the OSC, the VA confirmed that the Phoenix VAMC had no nurses in its Emergency Department comprehensively trained in medical triage, as Mitchell had pointed out. Yet Phoenix VAMC nursing supervisors required untrained nurses to triage patients, leading to at least 110 cases where patients experienced dangerous delays in care.
Mitchell settled her whistleblower case with the VA, but she is still speaking out about alarming situations that she says continue to exist inside the VA.
"There's no way I'd recommend anyone, any professional join the VA right now," she said in a recent interview. "Because (VA Secretary Robert) McDonald has not made any substantial progress in holding people that do whistleblower retaliation accountable."
The OSC substantiated dangerous situations in several other VA offices, including those disclosed by a worker at the Vet Center in Federal Way, Washington, and also situations in Maryland, in Montgomery, Alabama, and in Beckley, West Virginia. The OSC found that little to nothing was done by officials in most of these instances.
"The lack of accountability in these cases stands in stark contrast to disciplinary actions taken against VA whistleblowers," Lerner said in the letter.
"The VA has attempted to fire or suspend whistleblowers for minor indiscretions and, often, for activity directly related to the employee's whistleblowing. While OSC has worked with VA headquarters to rescind the disciplinary actions in these cases, the severity of the initial punishments chills other employees from stepping forward to report concerns," Lerner wrote.