Families of some of the victims of the Legionnaires' disease outbreak at the Pittsburgh Veterans Affairs facilities were upset that a federal report on it released last week didn't hold anybody directly responsible.
But the two top officials with the U.S. Veteran' Affairs Office of Inspector General most directly involved in the four-month-long review said their goal was never to point fingers at specific people.
"It is not my job to do that," said John D. Daigh, assistant inspector general for health care inspections. "There are human resources methods involved and people to decide what other actions to take" after the report was completed.
Even though much of the evidence seemed to point to groups of people, Jerome E. Herbers, associate director of medical consultation and review in the office of health care inspections, said they tried to look more at the processes that were at fault than the individuals involved.
For example, Dr. Herbers said: "When you look at the reports from the lab on the copper-silver tests, the folks who got that data were not accurately transmitting that data and the people who maintained the system were not adjusting the system accurately based on that data."
"We're not saying the pipefitters and the plumbers weren't doing their job," he said.
The investigation also avoided trying to determine scientifically if the copper-silver ionization water treatment system in use at the Pittsburgh VA was ever effective.
"But we would expect, for example, with the copper-silver system -- which may or may not have been effective -- that if you're going to have a system in place, we think you should at least operate to the manufacturer's specifications," Dr. Daigh said.
Not operating the copper-silver system to manufacturer's specifications was one of the problems the review detected.
After all the hard work they did on the review, inspector general investigators aren't done with the issue just yet.
The inspector general will continue to investigate an allegation made at a congressional hearing in January that Pittsburgh Veterans Affairs employees may have falsified records related to the maintenance of the copper-silver ionization system, officials said.
"It's still ongoing," inspector general spokeswoman Catherine Gromek said.
That investigation could lead to a referral for prosecution to the U.S. attorney for Western Pennsylvania, David Hickton, who was provided with a copy of last week's report.
Mr. Hickton would not comment about the release of the report, but his spokeswoman sent out the same prepared comments he made in February: "We have been in communications with the Inspector General to share our interest and to offer resources."
The statement continued, "After the report of the Inspector General has been completed we will conduct our own independent review and take appropriate action as necessary."
A second investigation, looking into whether all of the country's VA medical centers have successfully followed the recommendations made in an inspector general's report in 2007 about Legionnaires' control and prevention, should be completed in July, the spokeswoman said.
Sean D. Hamill: email@example.com or 412-263-2579