It is particularly worrisome that an outbreak of Legionnaires' disease occurred at the Pittsburgh VA Healthcare System, the institution that was home to ground-breaking researchers when they discovered that the spread of the pneumonia-like ailment was tied to water systems.
If nothing else, that storied history -- Victor Yu and Janet Stout made the landmark finding in 1982 -- should have caused officials at the Oakland hospital to be vigilant in properly maintaining and monitoring its water purification system.
Apparently, they were not.
Dr. Stout said flatly that it "wasn't performing optimally because it wasn't being managed properly."
Even more troubling is that officials apparently knew there was a problem long before they confirmed five cases of Legionnaires' disease on Nov. 15 and started treatment of the hospital's water system. Over the past few days we've learned that one of those patients has died and that another 24 cases have been reported at the hospital since January 2011 -- eight in which the patients picked up the disease elsewhere and 16 of unknown origin.
Dr. Yu and Dr. Stout, who both left the VA after disputes with management and now run a private laboratory and consulting business, said the VA knew it had problems with its the copper-silver purification system in June and had called in another consultant, who recommended changes as early as July. However, a source told the Post-Gazette's Sean D. Hamill that the consultant was not called back to make the adjustments until October.
U.S. Sen. Bob Casey, a Pennsylvania Democrat, last week sent a letter to Veterans Affairs Secretary Eric K. Shinseki, asking why the outbreak was able to occur. He correctly stated that such a failure "is a true disservice" to veterans who went to the facility for medical treatment and then acquired another condition "in a manner that is proven to be preventable."
Local VA officials have been tight-lipped about why the purification system failed to operate properly or why the consultant was called in during the summer.
The public deserves a complete explanation from the VA of what took place and what officials are doing to insure that nothing like it will occur again.