The Middletown Press (Middletown, CT)
Report: Vet’s OD shows VA flaws
Inspector General: Shortcomings can’t be directly blamed for death
“Program protocols, processes and policies were not in place.”
VA Office of the Inspector General
WEST HAVEN — A VA watchdog agency’s report initiated following the 2015 heroin overdose of a veteran being treated in a West Haven VA residential rehab program found a number of process and protocol shortcomings that were present at that time.
But the report by the VA Office of the Inspector General says investigators could not determine how or to what extent the deficiencies contributed to the man’s death, which was found to be the result of an accidental overdose.
While several of the shortcomings were fixed and new protocols put in place after the incident, a subsequent investigation found that even after new protocols were in place, they were not always effectively communicated or understood by staff.
“The OIG reviewed the care provided to a Program patient who died of a drug overdose and determined that Program protocols, processes and policies were not in place for initiating (medication assisted therapy,) for tracking patients’ (substance abuse day program) no-shows, and updating (urine drug testing) procedures.
“OIG staff also found deficiencies in the CPR Committee’s review of code delays,” the report said.
A chief medical examiners office investigation found that the death appeared to be accidental and that the man who died was not in a locked inpatient facility, was free to come and go and likely got the drugs that killed him out in public, officials have said.
Because of privacy laws, nowhere in the report, dated July 2, 2018, does it mention either the specific VA facility involved or the name of the patient.
A VA Connecticut Healthcare System spokesman said that “due to patient and privacy concerns and the way that they released the report, we cannot confirm nor deny that the medical center mentioned is VA Connecticut.”
He declined any further comment.
But the facts detailed in the report closely mirror the facts of the death on Dec. 22 or early Dec. 23, 2015, of Zachary Greenough, a former Army medic who grew up in eastern Connecticut, served in the Iraq war and died while an inpatient at the VA Connecticut Healthcare System’s West Haven Campus.
The New Haven Register covered Greenough’s death at the time, reporting that Greenough may have obtained the drugs that killed him while a patient in the hospital.
Greenough was believed by a friend and fellow veteran to be 29. The Inspector General’s report identifies the patient who died as being under 30.
Shortly after Greenough’s death, U.S. Sen. Richard Blumenthal, D-Conn., ranking member on the Senate Committee on Veterans Affairs, requested that the VA Office of the Inspector General investigate the incident.
Officials speaking off the record confirmed that the July 2 report is the one Blumenthal requested.
While Blumenthal didn’t confirm the report refers to the West Haven VA hospital and Greenough’s death, he spoke in scathing terms about the VA’s need to improve.
“This report shows a life tragically lost — with heartbreaking lapses and failures at so many turns,” Blumenthal said in a written statement. “This failure must be an occasion for soul searching and selfevaluation at the VA, as well as strong outside scrutiny.
“Supervision and care were simply lacking,” Blumenthal said. “The VA must take a hard look at these findings and immediately implement all recommendations to ensure no veteran struggling with post-traumatic stress, mental health conditions, and/ or substance abuse disorders falls through the cracks.
“As a member of the Senate Veterans Affairs Committee, I will ensure these reforms are made and continue to fight for legislation and resources to support veterans and Connecticut constituents who suffer from substance abuse and mental health challenges,” he said.
Among other things, the Inspector General’s report found that:
⏩ In 2015, the facility “lacked a protocol” to initiate medication-assisted therapy — treatment with methadone and similar drugs.
⏩ In 2017, the OIG determined that a process for patients to obtain that therapy had been put in place “but that some (mental health) staff were unable to articulate the pathway” and protocols to do so “were not well understood by staff.”
⏩ In 2015, “there was no process in place to track patients who no-showed for required (substance abuse day program) therapy.” A tracking spreadsheet was created and put into use after the patient’s death, but it “lacked some key information, such as the time entries were made and which Program staff were notified.”
⏩ The facility developed a urine drug testing policy on how to handle patients who refused (or like the man who died, said they were unable) to provide a urine sample. The report found that the facility was following that policy for the period of time reviewed.
The report made three recommendations, including that the facility director ensure that:
⏩ Staff receive education about the processes to initiate medication assisted therapy.
⏩ A standard operating procedure is issued to track patients who fail to show for off-site substance-abuse day programs.
⏩ All appropriate staff receive training regarding standard operating procedures to track patients who fail to show for off-site appointments for substance-abuse day programs.
According to an Aug. 23, 2009, article in the Norwich Bulletin, Greenough — then Army Pvt. Zachary P. Greenough — graduated from basic combat training at Fort Sill in Lawton, Okla., and was the son of Kenneth and Debbie Hvarre of Uncasville and the nephew of Jill DeClerck of Ledyard.