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Days before she died, Dr. Sarah Kemble cited lapses in care at VA center; federal probe now underway

  • Dr. Sarah Kemble, center, with former U.S. Congressman John W. Olver and former Northampton Mayor Mary Ford. Submitted Photo

  • Dr. Sarah Kemble Submitted Photo



For the Recorder
Monday, April 16, 2018

NORTHAMPTON — A federal investigation into allegations of substandard care is underway at the Veterans Affairs Central Western Massachusetts Healthcare System in Leeds after a former chief of medicine filed a complaint just days before she died.

In a 23-page affidavit, Dr. Sarah Kemble, of Chester, Vt., detailed a slew of alleged shortcomings in the medical center’s health care services, including a lack of communication between the VA and a contractor responsible for handling outside care and payments, which led to delays in patients being seen or not being seen at all and important medical information not making it back to primary care providers.

Kemble also alleged that overnight and weekend shifts were understaffed or improperly staffed, making key services such as labs for testing and radiology and psychiatric care unavailable.

Other aspects of Kemble’s complaint included concerns over access to illegal drugs and their use on the VA campus. Her complaint implicates Soldier On, the nonprofit homeless shelter for veterans on the VA’s Leeds campus, as part of the problem.

Among the people named in the affidavit are John P. Collins, the medical center director for the VA Central Western Massachusetts Health Care System and Dr. Michael Mayo-Smith, a recently retired network director of the Veterans Administration New England Health Care System.

Soldier On’s President John Downing denied the claims involving his organization, while the VA Central Western Massachusetts Healthcare System said in a statement that it is cooperating with the investigation into Kemble’s claims.

Andre Bowser, a spokesman at the Leeds campus, said the VA employees named in the complaint are prohibited from commenting.

Kemble died on Dec. 13 of cancer, five days after giving testimony to the Department of Veterans’ Affairs Office of Accountability and Whistleblower Protection.

“Sarah knew she was going to be dead by the time that the world knew about this,” said her attorney, Lisa Brodeur-McGan. “Her goal was to make the public know and the people in power know that there were horrific systemic issues going on. Not just in Leeds, but in the region.”

Kemble joined the VA in November 2014 as the chief of medicine of the Veterans Affairs Central Western Massachusetts Healthcare System.

Her husband, Jerry Lund of Leyden, said she took the position hoping to have a greater impact on the health care system using her connections, resources and knowledge. Instead, Kemble joined an organization she alleged was rife with problems and when she spoke out against them, was demoted and moved to other facilities.

“She could see right at the very beginning when she took over at the VA as chief of medicine that there were really serious issues,” Lund said. “It really revolves around the fact that VA in western Mass was not treating patient care seriously, other than nominally saying, ‘We’re always here for the vets.’”

Complaint in detail

Brodeur-McGan, Kemble’s attorney, said it was apparent to Kemble that the issues she raised in her affidavit were long-standing problems to which everyone had became immune.

“It was her goal to shoulder the responsibility of letting the world know about these problems because she couldn’t be harmed anymore by their retaliation,” Brodeur-McGan said. “She was not only trying to protect the patients, but she was trying to protect other good caregivers there that were trying to do the right thing and they were afraid.”

Lund said Kemble tried to make changes and immediately met resistance.

In the area of patient care, Kemble alleged that the hospital — which she said bills itself as a 24/7 urgent care and hospital facility — did not have lab service, radiology service, a clinical pharmacist or appropriate psychiatric service on nights and weekends.

“This substandard care means patient harm. For instance, if you come into this facility (during off hours) with crushing chest pain, you are more than likely going to die if you are having a heart attack because the facility does not have a cardiologist or a cath lab,” Kemble wrote in her affadavit. “Not only that, while an EKG can be obtained, a simple blood test cannot because there is no lab during off tour hours, which is a basic industry/professional standard of care for such patients.”

In the affidavit, Kemble detailed her efforts to change the Veterans Choice Program, which was created in 2014 to allow veterans to receive treatments from non-VA doctors but have it paid for by VA. Kemble alleged poor communication would result in patient information and test results never making it back to the primary care doctors at the VA. She also alleged that VA doctors would often not even know whether their patients ever got to see the outside doctors.

As an example, Kemble described a patient who went outside the VA health care system for a screening colonoscopy. The results, which determined the patient had cancer, never made it back to the patient’s VA doctors.

“Fortunately, the patient came to the office in person to let his primary care team know of his results; however, this could have delayed the patient’s care for cancer treatment, as delay in care for cancer increase the probability of patient harm,” Kemble wrote.

She also alleged that the VA essentially used the Veterans Choice Program as an excuse to spend less of the local facility’s budget on patient care at a time when wait times for appointments and treatments were at a crisis there. She testified that VA Central Western Massachusetts changed its stance and said it would pay for patients to receive non-VA services out of its local budget program after she reported the issue.

Lund said that less than a month after she reported her concerns, she was demoted to chief of primary care instead of chief of medicine.

“I received no new job description or any reason for a demotion, or even acknowledgment that it was a demotion,” Kemble’s affidavit reads. “I believe it was in retaliation for my report to the Regional Ethics Counsel of the very clear patient care violation.”

Soldier On complaints

In regard to Soldier On, Kemble claimed that VA doctors were putting themselves at risk by responding to emergencies at Soldier On’s residences on the VA campus without police first arriving at the scene, as is typically the case in emergency responses.

Solider On’s president, Downing, said he never met with or talked to Kemble during her tenure and that he found it “hard to react to anything she said based as factual.”

“I am sorry that this doctor never spoke to us,” Downing said, but added that there has been an increased level of cooperation and communication between the VA and Soldier On during the last three to four years. Kemble worked for the VA system from 2014 to 2017.

Downing said he was not aware of specific allegations within the affidavit and hasn’t been contacted by investigators to answer to the claims. He denied allegations that VA doctors were called to respond to medical emergencies and said that the VA has medical response standards on the campus that they all follow.

Reporting the issues

On Dec. 8, 2017, Kemble gave testimony to the Department of Veterans Affairs Office of Accountability and Whistleblower Protection regarding the issues of substandard care, harmful delays and retaliation she faced during her brief tenure with the VA.

Philip Works, a senior adviser at the federal agency, took her testimony.

“The things she were raising were of great concern to us,” Works said.

Despite the limitations imposed by her medical condition, Works said, Kemble was dedicated to getting her message across.

“She was very passionate about needing to bring these issues forward to the department so that we could address them,” he said. “It was that significant to her that she wanted to make sure we got these things recorded for posterity. We needed to carry her message, carry her banner forward when she no longer could.”

He said Kemble’s death has not altered the investigation.

Other reporting

In addition to her affidavit, Kemble filed a complaint with the Massachusetts Commission Against Discrimination in November 2017 alleging she was demoted in retaliation for reporting issues and that the VA discriminated against her because she was a woman and had cancer. The commission dismissed the complaint in January, stating it lacked jurisdiction because Kemble was a federal employee.

Kemble also filed a claim with the U.S. Equal Employment Opportunity Commission, according to Brodeur-McGan.

Since filing the affidavit with Office of Accountability and Whistleblower Protection, Brodeur-McGan said there has been no response from the VA Central Western Massachusetts Health Care System.

Meanwhile, Lund, Kemble’s husband, said he doesn’t have a choice but to carry on in his wife’s place.

“To me, there is no alternative but to go forward because if people like ourselves don’t take action and try to make the changes at the various levels happen, even though they may be small, then things only get worse,” Lund said. “My goal is to support Sarah’s life work, but it is more broad than that. It is work for our people, for our folks who need health care. We all need health care.”