(Tribune News Service) — A Marine veteran died at the West Haven (Conn.) Veterans Affairs Medical Center after a demolition contractor severed the main oxygen line and there were problems with a portable oxygen tank, according to a VA inspector general’s report.

Frederick Rodney, 88, “experienced a period of time without adequate oxygen” before he died Jan. 14, 2022, according to the report.

VA staff also allegedly failed to tell Rodney’s daughter, Brenda Avellanet of Milford, the events leading up to her father’s death, according to her lawyer, Patrick Finan of Fairfield.

“It’s like you go through things and things get a little easier as things go on,” Avellanet said Tuesday. “And then when they called me I was kind of frozen in time because I was blindsided, especially with what they told me. I was extremely blindsided because I had no idea.”

Finan added, “And then several weeks ago, she got sent this OIG investigation, which found that the hospital … it would seem to be covering up the whole incident, saying, well, your father was elderly and he died, but in fact he died because the oxygen supply was cut by a contractor,” Finan said.

The inspector general’s report also states that the events leading up to Rodney’s death were not disclosed to Avellanet. Last summer, a doctor called her to tell her the inspector general’s report would be coming out and told her what it would say.

“She told me this is going to come up and she says I wanted you to know just in case you ever stumbled upon the report,” Avellanet said.

“I’m a visual person,” she said. She imagined her father “laying there and gasping for air and he’s flailing and I’m like, Oh, my God, this is horrible. Nobody should go through that. So that’s why I was upset. And it brings up all the emotion again, because I didn’t know; I had no idea. It was never mentioned.”

The inspector general’s report also criticizes VA staff for its lack of oversight of the outside contractor.

Rodney was a Marine veteran of the Korean War and a steelworker for Edgcomb Steel and Alinabal, according to his obituary.

While staff accounts of how long Rodney went without oxygen varied, he was apparently the only patient who was harmed by the three-day cutoff of the main oxygen supply, according to the inspector general’s report.

“The patient’s clinical condition materially changed during this time going from alert, but not oriented or responding to questions, to becoming unresponsive,” the report states. “The patient died several hours later.”

Rodney had “do not resuscitate/do not intubate status, COVID-19 pneumonia, hypoxic respiratory failure, and comorbidities to include chronic obstructive pulmonary disease, atrial fibrillation, heart failure, chronic kidney disease, diabetes mellitus, dysphagia and hearing loss,” the report states.

Once the main oxygen supply was lost, Rodney was given an oxygen tank, but it either became empty or low and his blood oxygen level dropped to 65%, according to the report. A new tank was brought in, but a wrench needed to switch tanks was not immediately available.

The tank finally was swapped out “without substantial improvement to the patient’s blood oxygen levels,” the report states.

Adjustments were made to Rodney’s mask and air pressure, and his “blood oxygen level started to improve, but the patient was unresponsive,” the report states. “The day resident contacted the patient’s family, and it was decided that the patient’s comfort would be the focus of the care provided.”

While recounting the events leading up to Rodney’s death, the inspector general’s office notes that it “was unable to determine whether the unresponsiveness or death experienced by the patient was associated with the provision, or attempted provision, of oxygen utilizing the alternate oxygen sources.”

However, the report also states, “The OIG found that a lack of accessible equipment to manage patients utilizing portable oxygen tanks, and a lack of training related to H-tanks, contributed to the patient’s adverse event.”

Failure to disclose

The inspector general noted that Rodney’s family was not told about the severed oxygen line or the problem with his oxygen tank and that this reflected on the VA’s values.

The report notes that the attending physician “expressed the opinion that the tank running out of oxygen did not significantly contribute to the patient’s death.”

It quotes the physician as saying, “Yeah, it was an adverse event that did not in the long run impact his outcome. So, he didn’t go into cardiac arrest. He didn’t develop V-tach as he was desaturating to 65 percent. So, I would say it’s a near miss.”

According to the report, “The commitment to disclose harmful adverse events to patients or their representatives fosters ethical principles consistent with the VA core values of integrity, commitment, advocacy, respect, and excellence.

“Failure to disclose adverse events to patients or patient representatives erodes trust and effective communication, the foundation of quality care,” it states.

Contractor used excavation machinery

The report found that while the construction company was warned “to exercise caution when excavating around the oxygen line,” it used excavation machinery. The inspector general recommended that VA facilities staff “directly observe the contractor’s work when digging around utilities, to protect ‘existing assets.’”

Among the inspector general’s recommendations are better communication with patients, families and staff during emergencies; better equipment, education and training for emergency oxygen procedures; conducting pre-construction risk assessments; participation in construction safety meetings; increased oversight of construction companies; annual drills and training; among others.

VA spokeswoman responds

Pamela Redmond, VA health care system spokeswoman, issued a statement:

“We at VA are committed to providing timely, patient-centered, high-quality care to all Veterans. In January 2022, the West Haven campus of the VA Connecticut Healthcare System experienced a disruption to our main oxygen line when that line was inadvertently severed by a contractor performing overnight demolition work. Although we successfully mitigated the impact of the disruption with temporary/portable oxygen resources, any disruption of this life-saving resource is unacceptable.

“We are actively working to ensure that we prevent a disruption like this from happening again. We are grateful for the oversight of the Inspector General, and we concur with all of the recommendations laid out in the OIG report. In response to these recommendations, we’ve already implemented several improvements to the facility’s overall construction processes to prevent similar disruptions in the future.

“We have also completed pre-construction risk assessments on all construction projects, which allow us to mitigate risk before a project even begins; designated a Quality Management staff member to participate in facility Construction Safety Committee meetings; use of incident command structure during utility shutdowns or failures; and increased Emergency Management and Facilities Safety staffing.

“The VA Office of Inspector General conducted an audit to review VA Connecticut’s response to this emergency and to determine if there was any connection to a patient death that happened during the time that the facility was utilizing emergency resources. The OIG and VA determined that the death was not caused by the oxygen disruption.

“Moving forward, we will continue to work this issue with the urgency and importance that it deserves. There is nothing more important to us than our patients, and we want them to know that whenever they come to one of our 10 locations statewide, they will receive the world-class care they deserve.”

estannard@courant.com.

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