No charges to be filed in Pittsburgh VA Legionnaires' outbreak

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Former Veterans Affairs' employees, consultants and family of the victims of a Legionnaires' outbreak at the Pittsburgh VA don't believe the United States attorney conducted a thorough investigation before deciding on Thursday to not file criminal charges because few of them were interviewed by federal agents.

"They never contacted me," said Evelyn McChesney, whose husband, John, 63, of Columbus, Pa., died Oct. 23, 2012, after contracting Legionnaires' disease at the Pittsburgh VA. "And shouldn't they have spoken to all of the families?

"I just don't understand how this [outbreak] can happen and no one is responsible," she said.

U.S. Attorney David J. Hickton said in a news release Thursday no one will face federal criminal charges despite the "tragic" illnesses and deaths.

"The investigation has been a high priority of my office and federal law enforcement for the last nine months," he said. "The focus of our work was not to determine exactly how patients contracted the disease, but rather whether there was evidence of any material false statements by VA officials or employees, and whether there was evidence justice had been obstructed in any way."

His announcement came almost exactly one year since the outbreak was first revealed by the Pittsburgh VA, and two days shy of the one-year anniversary of the death of William Nicklas, 87, of Hampton, the last victim of the outbreak.

Not having charges filed is disappointing, said Mr. Nicklas' wife of 59 years, Greta, "because I think they should be held accountable for what they did."

The Centers for Disease Control and Prevention concluded earlier this year that during the outbreak in 2011 and 2012 a total of 22 veterans were sickened and five of them died after contracting the disease at the Pittsburgh VA. The Pittsburgh Post-Gazette reported that at least one more of those 22 veterans also may have died after contracting the disease at the Pittsburgh VA.

Mr. Hickton said his staff and agents from the FBI and the VA's Office of Inspector General did about 30 interviews, from maintenance workers to high-level hospital officials and consultants.

In addition, he said they analyzed and reviewed 250,000 internal VA emails, as well as maintenance logbooks for the water treatment system the VA used to control Legionella in its water and purchase orders for parts for the system. Also, test results and reports from the CDC and the VA inspector general were reviewed.

But family members who were the caregivers for all six men whose deaths were tied to the outbreak have all said they were at best mislead by VA doctors about the cause of their loved ones' illness and then death.

"The way I feel, my father's death certificate was falsified. But obviously that is not a federal offense," Maureen Ciarolla, whose father, John, 83, of North Versailles, was the first victim of the outbreak when he died July 18, 2011, said sarcastically.

Ms. Ciarolla's family was the only one interviewed by the FBI, and she said during the three-hour meeting last month, agents asked no questions and just told her to tell her father's story.

In addition, neither the FBI nor the Inspector General's agents interviewed Victor Yu and Janet Stout, former Pittsburgh VA employees and Legionnaires' experts who drew up the standards that the Pittsburgh VA was supposed to be following when the outbreak occurred.

"I think it would have almost been mandatory of them to talk to us and see what the standards were and if [VA employees] violated the standards," said Dr. Yu, who was fired by the VA, and his Special Pathogens Laboratory there was closed, after a dispute with management in 2006.

"It sounds like they just went through the motions of conducting an investigation," he said.

Federal agents never called another VA consultant, Aaron Marshall of Wilkinsburg-based Enrich, a water treatment company that was called in for advice during the outbreak.

"But I guess it doesn't surprise me very much" that no one will be charged, he said, "because those people [in management at the Pittsburgh VA] were pretty connected in the VA Health System."

The criminal investigation grew out of a request last year by U.S. Sen. Bob Casey, D-Pa., U.S. Rep. Mike Doyle, D-Forest Hills, and U.S. Rep. Tim Murphy, R-Upper St. Clair, for the VA's inspector general to conduct an investigation.

Mr. Murphy said he remains worried that the public will never know who the VA holds accountable for the outbreak -- which remains the goal of the families -- because VA Secretary Eric Shinseki said in a letter to him this summer that he would not reveal any discipline.

"I'm sure I won't be satisfied with that," he said. "I think it's important to know.

"What we're not going to do is let this go. We want to know why this happened," he said.

Sean D. Hamill: shamill@post-gazette.com or 412-263-2579.


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