Summary: An unexplained increase in patient deaths occurred in one ward of the Harry S. Truman Memorial Veterans Hospital in Columbia, Missouri, during the spring and summer of 1992. In October 1992, the Office of Inspector General (OIG) at the Department of Veterans Affairs (VA) and the FBI began a joint investigation into the suspicious deaths; in February, they received information alleging a coverup by the hospital director and the VA Central Region Chief of Staff. GAO reviewed the special inquiry conducted by the OIG, focusing on how VA's OIG planned, conducted, and reported its inquiry. In its report, the OIG concluded that management's actions could be attributed to bad judgment but found no conclusive proof of an intentional cover-up and no evidence of criminal conduct by top managers. GAO believes that the conclusion that no evidence of an intentional cover-up had been found was misleading because the OIG did not collect or analyze evidence in a manner that would identify intentional cover-up efforts.
