Families of Legionnaires’ victims outraged by report on VA outbreak

Families of the men who died after contracting Legionnaires' disease at the Veterans Affairs Pittsburgh Healthcare System believe that two internal reviews that showed the VA knew early on what caused the outbreak of the disease in 2011 and 2012 prove that the agency was more concerned with a "cover-up" of what happened than letting them know what led to their loved ones' death.

"Sometimes I feel that I'm at a loss for words as I realize all of the deceit that has" gone on, said Debbie Balawejder, 58, of Monroeville, daughter of Frank "Sonny" Calcagno, who died after contracting Legionnaires' in November 2011. "What kind of people play cover-up with our veterans and loved ones? It sickens me."

The reports, detailed Wednesday by the Pittsburgh Post-Gazette, were completed within weeks of the first public announcement Nov. 16, 2012, that a Legionnaires' outbreak had occurred at the Pittsburgh VA. The outbreak later was found to have sickened 22 patients, six of whom later died.

The first report, completed Dec. 10, 2012, was a cursory review using Pittsburgh VA records and telephone interviews. The second, completed Dec. 22, 2012, involved a two-day, on-site visit by a blue ribbon panel of VA experts.

Despite the different methods, both reports essentially reached the same conclusion: that it was a series of human errors, mismanagement and a lack of knowledge that led to the outbreak -- and not any failure by the water disinfection system that the Pittsburgh VA tried to blame for the outbreak.

Judy Nicklas, daughter-in-law of William Nicklas, 87, of Hampton, who died in November 2012 after contracting the disease, said the two reviews are "more proof of exactly what happened."

"This is why I'm going to continue to try to reopen the criminal case," she said.

U.S. Attorney David J. Hickton said in November that after an investigation of the outbreak, he had decided not to not pursue any criminal charges, but he would reopen the case if new information surfaced that warranted doing so.

When the outbreak was first announced, Victor Yu and Janet Stout, two former VA researchers who are internationally known Legionnaires' experts, suspected much of what the December 2012 reports revealed.

"The scandal of it is that an internal review group had to come to the same conclusion," Dr. Yu said Wednesday after seeing the reports.

Dr. Yu was fired from his position at the Pittsburgh VA in 2006 in a dispute with management over the operation of his laboratory, which was focused on Legionnaires' research and had made many of the most significant findings in the field in the prior three decades.

After Dr. Yu was fired, Dr. Stout resigned under pressure, and their lab was closed -- decisions that many believe eventually led to the outbreak because many of the protocols that they had put in place over many years were gradually eroded by the Pittsburgh VA.

The second report essentially recognized this, concluding at one point: "In general [the Pittsburgh VA] has been known for robust Legionella prevention activities; however vigilance for Legionella prevention may have wanted in recent years."

U.S. Rep. Tim Murphy, R-Upper St. Clair, said Wednesday after reviewing the 2012 reports that "if the knowledge that the VA got rid of in Dr. Yu and Dr. Stout was not replaced, then this [outbreak] was an avoidable tragedy."

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

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