LAS VEGAS (KLAS) — Two Nevada senators are demanding answers after a video leaked to the 8 News Now I-Team exposed a delay in medical care for an elderly veteran at a VA medical clinic. 

U.S. Senators Jacky Rosen and Catherine Cortez Masto sent a letter to the Office of the Inspector General in Washington, D.C. expressing concerns and requesting an investigation.

The leaked video showed an 88-year-old Marine Corps. veteran collapsed in the lobby of the Northeast Las Vegas VA clinic on June 7, 2021. 

It took approximately two minutes for a nurse to arrive, and approximately five minutes for staff to begin CPR.  The veteran was later taken to Sunrise Hospital and pronounced dead.

In an I-Team report which aired on May 23, Dr. Scott Glickman, a neurosurgeon who runs his own medical office, pointed out that the CPR delivered was not sufficient because no breaths were delivered to the patient. 

In an interview with the head of the VA Healthcare System of Southern Nevada on April 13th, the I-Team did not disclose possession of the leaked video. 

When asked about care for the patient, William Caron, who is the head of the VA Healthcare System in Southern Nevada, said the medical care was sufficient. 

After the VA learned that the I-Team had the leaked video, a spokesman sent a lengthy statement admitting mistakes were made.

In their letter dated June 7th, Senators Rosen and Cortez-Masto wrote, “…we believe the incident warrants closer review from an independent entity.” 

The I-Team reached out to the Office of the Inspector General. Spokesman Fred W. Baker III sent the following statement:

“The VA Office of Inspector General has received the letter from Senators Rosen and Cortez Masto. As a matter of course, the VA OIG does not confirm or deny any ongoing investigations, so I am unable to comment further.”

A family member of the veteran told the I-Team that the family was informed that the veteran died of a heart attack.  They were not aware of a delay in medical care or any video. 

An autopsy was not done, so it is unknown if the delay in care contributed to the veteran’s death.

In an email, Charles Ramey a VA spokesman responded to the I-Team’s questions about the senators’ calls for an investigation.

Have any changes been made at the VA since our report aired?

Per the statement provided on May 23, 2022, we reviewed this incident and made changes over a year ago. Specifically:

Emergency Management, VA Police, and Nursing Professional Services conducted refresher Incident Management and Life Safety training for all staff at the Northeast Las Vegas VA Clinic within two weeks of the event, and all staff at VASNHS’ other outpatient VA Clinic in the weeks that followed. The training re-educated staff on: 

a) Use of the Emergency Operations Plan and how to establish incident command and properly respond to medical emergencies (to include specific assigned roles and responsibilities for site managers, VA Police, nursing, primary care, mental health, and social work leaders); and

b) Reorientation on the location and proper use of life safety equipment and PPE to provide first aid and basic life support; as well as specific procedures to address cardiac arrest.

Additionally in the weeks, following the incident, VASNHS conducted comprehensive training on emergency medical response and notification procedures at each outpatient clinic, validating training with functional exercises. VASNHS also realigned VA clinic site managers directly under executive leadership to establish clearer roles and responsibilities, lines of authority, and command and control for day-to-day operations and emergency situations.

Do you have a comment or statement regarding their call for an investigation?

We have not heard anything locally regarding a request for an investigation and therefore cannot comment at this time.

However, based on KLAS-TV’s coverage, we took the opportunity after the report aired to brief our Congressional delegation and provide all the surrounding facts, the results of our internal reviews, and mitigation actions put in place immediately in the days and weeks following the incident.

If there are any further reviews of this incident, VA Southern Nevada will cooperate fully as we are a learning organization committed to a culture of safety and process improvement to achieve zero harm.