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Massachusetts VA Hospital broke federal law in failed search of missing veteran found decomposing in stairwell

Bedford VA Hospital in Massachusetts violated federal law by failing to properly search for a missing 62-year-old Army veteran whose decaying body was only found a month after he disappeared from a cage emergency staircase only 60 feet from the door of his living room in the establishment.

A new 45-page report released last week by the Office of the Inspector General of the Department of Veterans Affairs indicates that the body of Tim White was found on June 12, 2020 by another resident in an exit stairwell of relief at Bedford Veterans Quarters (BVQ), an independent living facility privately operated by Caritas Communities Inc., an organization that provides services to the homeless.

The facility is located on the campus of the Edith Nourse Rogers Memorial Veterans Hospital in Virginia. The manager of the Caritas house had reported his disappearance on May 13, 2020 to the Bedford Police Department, and although his whereabouts have not been known for about a month, White never left Building 5 until his death. His crumpled body, which was so badly decomposed that a medical examiner could not determine exactly how he died, was found with the same Boston Red Sox jersey, jeans and baseball cap he was wearing. had been last seen a few days before his disappearance.


U.S. Representative Seth Moulton, D-Mass., Who himself receives medical attention at Bedford VA and had called for an investigation into White’s death, said Thursday the federal watchdog’s report showed the need for big improvements .

“Tim White deserved better of the country than to die alone in a stairwell,” Moulton said in a statement. “His life could have been saved if the Bedford VA Police Department had done its job… American veterans deserve the best health care in the world. Mr. White’s care has not been close. coming, we must demand that the VA Police Department change so that our country keeps its promises to those who have served. “

The circumstances surrounding White’s disappearance revealed several gaps in the Veterans’ Health Administration’s policies “regarding missing persons on VA property, local police decisions and surveillance. improved usage leases, “according to the report.

“Mr. White’s disappearance has not received the attention it deserves from VA, an agency that is required by federal law to protect everyone on his property,” indicates the report. The OIG found that the medical center, including its VA police, “did not initiate a response to Mr. White’s disappearance under VHA’s missing patient policy because he was considered a resident and not a patient “.

The report also notes how “poor decision-making, misinformation and lack of oversight also prevented anyone in VA from meeting Mr. White within a month of his disappearance while on routine patrols or cleaning the cage. stairs to the emergency exit where his body was found. “

“While the OIG has not been able to identify a single responsible individual, office or decision-maker, each of these shortcomings contributed to VA’s failure to locate Mr. White,” the report concludes.

VA investigators determined that the stairwell had never been searched, in part because VA police mistakenly believed that since White’s residence building was privately owned, it was not. of their responsibility to search the stairwell. For the same reason, VA staff did not monitor or clean the area.

The report identified other shortcomings amid “widespread confusion” over IL obligations in areas leased by Caritas. VA rules require staff members to follow a specific protocol when searching for missing patients, which includes searching for stairwells. But White was viewed as a resident, not a patient.


“The OIG found that VA police would have been required to search the emergency stairwell if Mr. White had been found to be a missing patient at risk under the VHA directive, and if the police in VA had followed VHA’s directive, he would likely have been located by Virginia Police shortly after his disappearance, “the report said. “However, whether or not Mr. White is a patient, other federal laws and agency policies require VA police to patrol all VA property and protect those on that property.”

Three months before White’s disappearance, former VA Police Chief Shawn Kelley “improperly asked his officers to stop patrolling Building 5.” He claimed it was at the request of Caritas officials, but there is conflicting testimony to this claim, according to the report.

This decision “violated applicable law and VA policy as substantial parts of Building 5 remained under VA jurisdiction, including the basement, emergency exit stairs, offices on the first floor of VA. and a VA-funded temporary bed program for homeless veterans. From now on, local AV chiefs can no longer make the decision not to patrol certain buildings in the investigation of missing persons.


During previous patrols before February 2020, it was common for officers to “walk around the area, talk to people behind the desk, chat with veterans, and look through the building.” Additionally, VA police routinely used their K-9 unit to search the building for drugs, and officers periodically “entered the stairwell.”

The report also revealed that Kelley waited two weeks before responding to a request from the City of Bedford Police to use police dogs to search for White.

The OIG did not refer the case to criminal investigation agencies. A separate investigation by Middlesex County Prosecutor Marian Ryan ended in December. He found glaring failures in White’s search, but did not recommend any criminal charges against anyone, the Boston Globe reported.

The Associated Press contributed to this report.

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