(CNSNews.com) - Officials from the Department of Veterans Affairs (VA) testified in Congress on Wednesday that “mistakes were made” and there was “a failure” by their department when it allowed a mentally ill veteran to walk out of a VA hospital and, within hours, shoot another veteran, who was a police officer, and effectively commit what the chairman of the House Committee on Veteran's Affairs is calling "suicide by cop."
The veteran was Catawaba Howard, a 32-year-old Miami resident who had spent eight years in the Air Force and Army Reserves. On August 11, as the Miami CBS affiliate reported the next day, she approached a stranger--carrying a handgun with her--and asked if he would accept a $1,600 payment to kill her. Instead, the stranger, Derek Nicholson, drove Howard to her mother's house--where she dropped off her gun--and then to Jackson Memorial Hospital, where he had her admitted.
Nicholson told CBS Miami at the time: "When I admitted her, I went back to her mom, and her mom said, 'My daughter always do this, you know what I’m saying’ thought it was a joke."
“She was troubled in her own little roundabout way and she was seeking help,” the mother told CBS Miami. “I know what was wrong. She was dealing with those issues.”
When Jackson Memorial Hospital realized Howard was a veteran, she was transferred to the Miami Veteran Affairs Medical Center (VAMC). This VA hospital released her back onto the streets.
At 3:30 am on Friday morning, as CBS Miami reported it, a 911 call brought two police officers, William Vazquez and Saul Rodriguez, to a street in Miami where Howard was wielding a gun. Vazquez was himself a veteran of two tours in Iraq, and thankfully that night he was wearing a bullet proof vest. Howard opened fire on the two police officers, striking Vazquez in his vest. The officers shot Howard dead.
In describing the situation at Wednesday's hearing, Veterans Affairs Chairman Jeff Miller (R-Fla.) said, “The veteran then escaped and committed suicide by a cop just one day after she’d been admitted to a system that should have protected her in her clearly fragile state of mind.”
The witnesses at the hearing, which was entitled “Failures at Miami VAMC: Window to a National Problem,” included William Schoenhard, the VA’s deputy undersecretary for health for operations management; Nevin Weaver, network director for VA Sunshine health care network; and Mary Berrocal, director of the Miami VA health care system.
Chairman Miller asked Weaver to describe the incident: “What did [the VA medical staff] say had occurred? This person had voluntarily committed themselves and walked out?”
Weaver said, “The person had, I believe, involuntarily committed themselves and as Ms. Berrocal mentioned, mistakes were made. The response by the [VA] staff was not appropriate. The issue is -- is that we looked at an RCA [root-cause analysis], looking at the process, but we also looked at individuals who were responsible for and we held them accountable.”
“I think that any time a patient is admitted we have to do our due diligence and make sure that the patient remains with us and is safe and secure and that we respond appropriately by having the person placed in the facility, in the medical center,” said Weaver.
Rep. Miller then asked, “So was this a failure or not a failure?”
“It was, I think, a failure,” said Weaver.
Berrocal said there was miscommunication between the two hospitals about whether Howard was initially admitted on an involuntary or voluntary basis, although she also said that Howard’s paperwork from Jackson Memorial Hospital was clear in stating that she was involuntarily admitted.
“There was initially some miscommunication [between Jackson and the VA hospital] about whether she was being transferred on a voluntary or involuntary [basis],” Berrocal told the committee, later adding that “there was some verbal communication which was not clear.”
However, Berrocal then said, “Jackson’s papers when they came in indicated that it was involuntary. So the verbal communication was that it was voluntary; the paper work upon receipt was that it was not.”
Berrocal declined to say whether communicating the state of patients is something that is normally done verbally.
Although Weaver told the congressional panel that the medical personnel responsible for Howard leaving the VA hospital were held accountable, Berrocal said those individuals still work for Veteran Affairs.
Miller asked, “And somebody has in fact been reprimanded for the failure?”
Berrocal said, “We have done a series of things. We recognize that there were some process failures through the RCA. In addition to that, we recognize that there were some failures of individuals to follow, you know, the policy … to conduct their job appropriately.”
Chairman Miller then asked, “Has anybody been disciplined for this veteran being allowed to walk out of a hospital after saying that they were going to commit suicide by a cop, allowing her to pull a gun on a police officer, shoot the police officer and being killed by that police officer. Has anybody been disciplined at your facility?”
Berrocal answered, “I have taken the people out of the position and the fact-finding is being finalized.”
Miller said, “They still have a job?”
“As of today, they do,” said Berrocal.
Despite admitting “failure” in the manner in which they handled Howard, Schoenhard said in a statement that the Miami VA hospital has “demonstrated considerable improvement over the past several years and have aligned resources, leadership, and emphasis to realize a better, safer, and more accountable environment for patient care.”
Nevertheless, Chairman Miller said, “I am so saddened by what I have heard today. Things that are going on at the Miami VA medical center that are atrocious. And if it’s better today … I can only imagine how bad it must have been if you think that it is moving in the right direction.”
“Somebody has to be held accountable and it hasn’t happened,” said Miller. “People are scared to death of the director; they are scared to tell the truth. Why? Because they’ll be stuffed in a box somewhere in an office with no windows making phone calls to veterans in an attempt to get them to leave on their own so that it can be said that they were forced out. I intend to talk to some employees at the facility.”
“I think our veterans deserve better, I think they expect better and we got a lot of questions that have been asked and entered here today and, Mr. Chairman, I’m even more concerned leaving the hearing than I was before I came in,” said Rep. Bill Johnson (R-Ohio), a veteran who was visibly outraged by what happened at the Miami VAMC.