MARION - Nineteen deaths at the VA Medical Center were linked to surgical errors or substandard care - a total nearly doubling earlier estimates of 10 patient deaths - in a report made public Monday from an investigation into the medical center's surgical unit.

Of 29 deaths that occurred at the Marion facility during Fiscal Year 2007, the Inspector General's Office of Healthcare Inspections reported that 19 deaths were either the result of surgical error or because patients had received less-than-optimum care. Six physicians have been linked to patient care problems, with two resigning their duties and the remaining four prohibited from performing complex surgeries.

Congressman Jerry Costello described Monday's report as "shocking."

"First and foremost, the families of the (additional) nine veterans who have died due to substandard care need to be notified. The report must be released to the public immediately. Changes must also be made in the management structure of the facility."

Costello said it appears to him that Marion officials made "poor" management decisions and ignored procedures that were already in place.

The report indicates that the surgical specialty care line at the Marion hospital was "in complete disarray," according to Dr. John Daigh Jr., assistant inspector general for healthcare inspections.

Daigh said problems included pre-operative, intra-operative, and post-operative quality of care issues. He cited three mortality cases as examples of those which did not meet the standard of care.

l One veteran suffered a traumatic rupture of his spleen requiring urgent surgery. Sufficient blood transfusions were prepared for this patient, but were administered too late to be effective.

l The second case involved a patient whose heart disease placed him at increased risk for surgery. This patient, who died one day after surgery, received inadequate intra- and post-operative care.

l The last case involved a death after elective gallbladder surgery, with clear evidence of inadequate management of the patient's ventilation and post-operative instability."

Investigators also identified examples of non-fatal complications resulting from poor care involving other patients treated by surgeons.

l In one case, a Marion physician failed to appropriately diagnose and treat a young Operation Iraqi Freedom Marine veteran after the onset of severe abdominal pain.

l Another veteran received substandard care by an orthopedic surgeon managing a knee infection after total knee replacement surgery.

l A third case involved a urologist who perforated both the bladder and the sigmoid colon of a patient while attempting to incise a urethral stricture.

Substantiated allegations of poor medical care involving two patients treated by non-surgical providers also were cited in the report.

l One case involved allegations relating to the follow-up of a patient with a thoracic aortic aneurysm and the other the medical management of a patient with hypertension.

William Feeley, deputy undersecretary for health operations and management with VA in Washington, addressed the issues at a press conference at the Marion facility late Monday afternoon.

"This is tough news for any institution, but I'm pleased to see morale is high here," Feeley said, adding that patient safety is the hospital's top concern and that complex surgeries will not resume until "all appropriate actions have been taken."

The in-depth investigation came on the heels of an annual report conducted by the National Surgical Quality Improvement program, which identified Marion as having a mortality rate four times the expected rate used by the Veterans Health Administration during the first two quarters of Fiscal Year 2007.

By the end of its two-day investigation last August, NSQIP also identified concerns with the quality of surgical care provided patients and deficiencies related to medical center leadership and the surgery service, including quality management processes such as peer reviews and credentialing and privileging of physicians.

john.homan@thesouthern.com / 351-5805@thesouthern.com / 351-5805