When U.S. Army veteran Juan Rivera turned 55 and decided it was time for a colonoscopy, he turned to the Veterans Affairs hospital in Miami. He had the test, got a clean bill of health and didn't give it another thought.
A year later, he received a chilling letter from the VA. It said the equipment used in the procedure might have been contaminated. And it asked him to come in for viral testing.
He came up HIV positive.
"He's shocked and mortified. He feels the government has given him a death sentence," said attorney Ira Leesfield, who has filed suit against the VA for $20 million on Rivera's behalf. "He has a wife and four children. He led a risk-free life, and he tested positive. There's only one possible source: the colonoscopy."
Rivera's suit is one of 45 filed against the VA so far in Miami, with 113 more in line to sue after filing the notice required when a government agency is involved.
There could be many more suits to come. Rivera was among 11,000 veterans who had colonoscopies performed in Miami, Tennessee and Georgia between 2004 and 2009 with equipment that the VA has acknowledged may have been improperly cleaned. The VA says 2,539 Miami vets are "potentially at risk for infection" from the colonoscopies, but insists that "there is currently no evidence to suggest these infections were acquired from the endoscopic equipment."
So far, five Miami-area vets who had colonoscopies at the VA during the five years have tested positive for HIV, eight for hepatitis C and one for hepatitis B.
For vets like Rivera — an Army truck driver for 13 years in Korea, Germany, Honduras and Panama — the idea that the VA's actions may have put them at risk for disease or death is difficult to handle.
"He served his country for so many years, and now his life is impacted forever," said Leesfield, Rivera's attorney.
How could it happen? Twenty-three months after the scandal broke, interviews, court documents and a VA investigative report obtained by the Miami Herald through public records laws show that the flawed colonoscopies were performed in an environment of inadequate training, lack of supervision and communication failures. Technicians and nurses performed procedures for which they were not adequately trained and failed to read manufacturers' instructions. Equipment vendors bypassed VA approval processes and delivered instrument samples directly to operating rooms.
According to the VA report, the problems in Miami came to light in 2009 after VA technicians heard about improperly cleaned colonoscopy equipment at VA hospitals in other states.
They discovered that some of the tubes hadn't been properly cleaned in the five years since they were acquired in 2004, according to a report by the VA's Clinical Risk Assessment Advisory Board.
Three days later, the life-altering letters went out to 2,600 South Florida vets to tell them they were at risk and should come in for testing.
But that wasn't the end of it. Sixteen months later, the Miami VA disclosed that its 2009 notification process had missed 79 vets who also had the flawed colonoscopies.
And six months after that, on Feb. 8, the VA announced its notices had missed another 12 veterans who potentially had been exposed to deadly diseases — diseases that doctors say are most effectively treated with early detection.
"I was heartbroken, you know," Mary Berrocal, Miami VA hospital director, said after the first reports of trouble. She said she disciplined 10 employees. She wouldn't say whom or how. She did not comment for this story.
When the scandal first broke, national VA officials reacted quickly. They set up hotlines that veterans could call for information and advice. They provided free testing. They staged surprise inspections at 42 of 56 VA hospitals around the country. The result: 43 percent failed to meet standards for cleanliness and safety. Miami wasn't part of the inspections because it already was under investigation.
South Florida legislators reacted with anger.
"This is inexcusable," said U.S. Rep. Ileana Ros-Lehtinen, R-Miami, who demanded a congressional hearing.
In the June 2009 hearing, Gerald Cross, acting undersecretary for health at the VA, said he was "distraught" at the poor results of the surprise inspections. "We did something wrong, and I expect it to be corrected," he said.
The VA announced it would spend $26 million to buy new equipment, institute better training and tighten procedures.