An inpatient pharmacy technician supervisor at the VA Palo Alto Health Care System's Palo Alto facility said he experienced retaliation and a gag order from his superiors after speaking up about errors and delays in delivery of medication to patients.
Stuart Kallio said he was placed on administrative leave in June after writing a string of emails to his superiors, beginning on Feb. 5, that described the pharmacy as being incompetent and led by uncaring management, with consequences to patient care.
Kallio, a veteran who served nine years in the Navy, was among 800 current and former VA employees and veterans who responded to a call from the Project on Government Oversight (POGO), a nonpartisan, independent watchdog group that champions good government reforms. POGO teamed up with the Iraq and Afghanistan Veterans of America to put out a call for the stories following recent disclosures of sometimes fatal delays in treatment at VA facilities across the country.
Kallio's story was among those detailed in a July 21 POGO report titled "Fear and Retaliation at the VA."
"Until we eliminate the VA's culture of intimidation and climate of fear, no reforms will be able to turn this broken agency around," POGO Executive Director Danielle Brian said.
Palo Alto VA spokesman Michael Hill-Jackson said the agency could not comment on Kallio's case pending an investigation, which he said is underway.
"As far as any patient safety issue, we take that very seriously and if anything is brought up we investigate every single report," including any allegation Kallio made, Hill-Jackson said. He said he did not know the outcome of the investigation of any of Kallio's specific allegations.
Kallio shared with POGO a series of critical emails that he sent up the VA chain of command, eventually as high as Elizabeth (Lisa) Joyce Freeman, who served as director of the Palo Alto VA Health Care System until she left this month to become interim director of the VA's Southwest Health Care Network in Arizona.
In an email on Feb. 5, Kallio wrote to a superior, "In summation, patients are experiencing inordinate delays in their healthcare as a result of your failure and refusal to comply with VHA regulations."
On Feb. 26, he wrote, "In essence, after all these years of suffering under gross mismanagement and wonton (sic) violation of VHA regulations, the processes utilized by the Pharmacy Service have steadily deteriorated and atrophied to the point that the Inpatient Pharmacy is in reality in a perpetual state of failure, failing to provide timely, quality care to veterans."
In an April 7 letter, the chief of the pharmacy service threatened to suspend Kallio for sending a dozen emails "that contained disrespectful and inappropriate statements about your Service Chief" and others, including "VA Palo Alto Health Care System Leadership."
In a response to the chief of pharmacy service defending himself three weeks later, Kallio said that patients were suffering "missed doses, late doses, wrong doses," quoting hospital records of medication errors and copying Congressional overseers.
On May 29, the chief of pharmacy service informed Kallio he would be suspended from June 8 through June 21.
On the first day of his suspension, Kallio reiterated his complaints and accused the VA of retaliation in an email to Freeman.
"For almost two years now I have been communicating my concerns regarding the VAPAHCS Palo Alto Division Inpatient Pharmacy up the chain of command up to and including your office," he wrote. "Your response has been to unlawfully retaliate against me."
Kallio cited a case in which a patient's epidural drip of pain medication ran dry and another in which a chemotherapy drug that requires refrigeration was administered two and a half hours after its expiration and the patient developed a fever.
On June 20, the Friday before he was supposed to return to work, Kallio received notice placing him on paid administrative leave pending an investigation. The same day, he received a letter from the pharmacy service chief with the heading "Direct Order," warning him not to discuss his case "with anyone inquiring outside of official representational role or management investigative capacity and who does not have a need to know."
"As far as I am concerned, this is a public safety issue and the public has a need to know," Kallio told POGO.
Whether Kallio is right or wrong, POGO said, "punishing and trying to silence him sends precisely the wrong message for the VA. Furthermore the gag order was placed on Kallio after his VA superiors could see that he was copying Congress on correspondence; it is against the law to attempt to interfere with a person's communications with Congress."
Kallio told POGO his suspension is unpaid and he is living paycheck to paycheck, with a heavy financial and emotional toll.
The Palo Alto VA recently hosted a community meeting, lead by Freeman and Reps. Anna Eshoo and Jackie Speier, during which local veterans both decried and lauded the hospital. In June, Hill-Jackson defended the Palo Alto hospital against widespread criticism about VA wait times nationwide.
"A lot of vets are concerned, of course, but not all VA's are the same," he told the Weekly. "That's the message we're trying to get out there: 'If you're in Palo Alto, you're OK.'"