WASHINGTON — After five suicidal veterans walked out of the emergency room without getting help during a single week in January, Brandon Coleman brought his concerns to his supervisor at the VA Hospital in Phoenix. Coleman, a therapist and decorated veteran himself, urgently warned that there was a broader problem with how suicidal patients were being handled.
Six days after he spoke with his boss, Coleman recalled, he was suspended from his job. He thinks it was in retaliation.
At a time when top officials at the Department of Veterans Affairs are pledging to end the agency's pervasive culture of punishing whistleblowers, Coleman's experience is evidence of what reformers are up against.
VA Secretary Robert McDonald came to office in July amid the largest scandal in the agency's history and announced that he wanted to make "every employee a whistleblower" and create a fresh culture that "celebrates them."
In the months before, a group of whistleblowers at the Phoenix center had come forward to expose the common practice inside VA of covering up how long some veterans had to wait to see a doctor by falsifying patient wait times. The revelations prompted a public uproar and cost McDonald's predecessor, Eric Shinseki, his job.
As investigators dug into the fraudulent wait times, they discovered that whistleblowers across the country have faced reprisals for reporting a range of concerns, including accounting irregularities, nursing shortages and mishandling of health care funds, according to the Office of Special Counsel.
Yet despite promises from Washington, retribution against whistleblowers continues inside VA. The OSC, an independent federal agency that investigates whistleblower claims, said it has received 111 VA reprisal cases involving health and safety issues across 36 states plus the District of Columbia and Puerto Rico since McDonald became secretary in July.
"VA's leadership is sending a positive message," said the OSC's head Carolyn Lerner. "… But when you're trying to change the culture in a system as large as the VA, it's not surprising that it may take longer for change to happen on the ground."
Coleman, who has filed a complaint with the OSC, recounted in an interview that he was blindsided by his supervisor's rebuke in response to his concerns about handling suicidal veterans. After all, Coleman had successfully graduated 51 people from a program he had designed to help high-risk veterans stay sober, keep out of jail and cope with suicidal thoughts.
"After I came forward, the director wanted a meeting with me. I thought, 'This is great, we can fix this — no suicidal veteran should leave the VA without talking to somebody, that shouldn't be allowed to happen,' " Coleman said. "But, instead, the meeting was just eerie."
He was put on paid administrative leave.
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" 'Brandon,' " he recalled being told, " 'I want you to know, you are not being terminated. Not yet.' "
Coleman said he wonders why VA discouraged its staff from taking steps to improve the agency. "I'm a veteran first before I'm a VA employee, looking to cover it all up and save my butt," he said.
Two other VA employees have come forward in recent weeks in support of Coleman's claims and have also filed for whistleblower protection with the OSC.
The veterans in Coleman's program said they are the ones suffering because his therapy program has been canceled.
"His program just brought me back," said former Army Sgt. John Negrete, who enrolled in June when he was near suicide. "There's no one who can teach this program the way he teaches it. We have veterans crying over this."
VA officials declined to comment on Coleman's case, saying they don't discuss personnel matters. But they said they are committed to changing the culture and supporting whistleblowers.
The OSC says VA has taken "important steps to improve" and that agency cooperation is one key reason why the office has been able to obtain more than 25 corrective actions since April for VA whistleblowers, which include getting jobs back, monetary payments and removing negative performance reviews.
While advocates for whistleblowers say the Washington leadership may be sincere about change, the new approach has not yet filtered down to VA's 1,700 health care facilities.
In Denver, for example, the director of the VA Hospital told employees in January to stop talking to the media about recent delays in care and a secret wait-time list. "Once you talk to the media, you are on your own," the director said, according to a tape of the meeting aired on Denver's 9NEWS television station. "Once you are in hot water, nobody will help you."
In St. Louis, Jose Mathews said he was removed from his position as chief of psychiatry at the VA Hospital there after he raised concerns that his superiors exhibited a "disregard for veteran care and safety," according to his complaint filed with the OSC.
During the VA scandal last summer, Katherine Mitchell was one of the first whistleblowers to go public with her concerns. She testified before Congress that she was removed as emergency room director after reporting understaffing and inadequate training in Phoenix.
In a recent interview, Mitchell said the culture inside the hospitals and health centers of VA has not changed. She said she receives three or four calls or emails a week from other whistleblowers seeking her advice.
"The sad thing is I don't have any place to tell them to go report it where they can be 100 percent certain there will be no retaliation," she said. "There's real fear at VAs across the nation that if you speak out, you run the risk of losing your entire career."