Here are some key excerpts from the court's opinion, on this shocking case. The complete opinion is available on http://www.vamalpractice.info on the "cases" PAGE. What I find to be the most troubling aspect of the court's opinion, is that the Judge found that the VA's doctors changed their testimony at time of trial, and attmepted to ignore and evade testimony that they had provided earlier, whoch demonstrated that the VA was responsible for these deaths. The VA has gone to great lenghts to publicize its policy of admitting medical mistakes, unfortunately while they may admit them to the family, this case shows the lenghtss that the VA will go to avoid paying for their mistakes.
Diamond, J. July 26, 2005
On March 23, 1999, Alejandro DeJesus, Sr. shot and killed his children, Alejandro, Jr. and Felicia (ages eighteen and seven), and their friends, Michael and Aaron Faulk (ages sixteen and fourteen), and then committed suicide. The Veterans Administration Medical Center in Coatesville, Pennsylvania had been treating Mr. DeJesus since 1997 for severe mental problems - - including Intermittent Explosive Disorder - - drug addiction, and domestic abuse. The VA’s medical records underscored that Mr. DeJesus was a severely disturbed, unstable individual who was likely to commit acts of domestic violence when frustrated or unemployed. Nonetheless, the day before the murders, the VA agreed to expel Mr. DeJesus from its transitional residence and fire him from his employment there because, for no rational reason, he had attacked another resident with a knife. Remarkably, the VA agreed to the expulsion even though DeJesus’s Primary Therapist wanted him first to be evaluated by a Psychiatrist because she feared his expulsion might provoke him to an act of domestic violence.
In the instant case, the mothers of the murdered children have sued the VA, alleging that in light of Mr. DeJesus’s severe mental illness and his violent, abusive history, the VA was grossly negligent in discharging Mr. DeJesus or in failing to treat, detain, or commit him after the knife fight. Following a six day non-jury trial, I returned a verdict in favor of Plaintiffs. ...
...During their depositions, all the VA professionals who treated Mr. DeJesus admitted to facts that underscored the VA’s appalling negligence in this matter. At trial, these same witnesses strove to undo, ignore, qualify, or evade their earlier testimony. In virtually all instances, I did not believe the witnesses’ revised versions, and instead credited their deposition admissions. See Davis v. United States Steel Supply, Civ. No. 80-2571, 1981 U.S. App. LEXIS 17407, at *20-*22 (3d Cir. Sep. 24, 1981) (allowing the crediting of deposition designations and documentary evidence over live testimony); see also FED. R. CIV. P. 52(a). My factual findings are based in no small part on these and other credibility determinations.
Perhaps the most striking deficiency in the VA’s treatment of Mr. DeJesus was the failure of any VA professional to familiarize him or herself fully with the VA’s own medical history of Mr. DeJesus. For instance, Mr. DeJesus’s Primary Therapist did not know that a VA Psychologist had diagnosed Mr. DeJesus with Intermittent Explosive Disorder. A VA Psychiatrist confirmed this diagnosis, and prescribed a psychotropic drug to moderate Mr. DeJesus’s explosive episodes. A second VA Psychiatrist who treated Mr. DeJesus for depression, however, did not know of the Intermittent Explosive Disorder diagnosis or the psychotropic medication. Mr. DeJesus’s Treating Psychologist did not know that a VA Therapist had reported his concern at Mr. DeJesus’s too-sanguine description of an earlier incident, when he shot and killed an individual. As a result of this universal ignorance of Mr. DeJesus’s mental condition, no one at the VA knew just how disturbed and dangerous Mr. DeJesus was.
Significantly, trial evidence underscored that the critical decisions respecting Mr. DeJesus’s expulsion from the LZ-II facility were made by the VA itself. Although LZ-II is a privately run transitional residence, the evidence showed quite clearly that it is a VA creation, receives its funding exclusively from the VA, operates exclusively on VA property, and exists solely to serve VA patients. No one at the VA ever informed LZ-II’s staff of Mr. DeJesus’s mental condition. On the contrary, Mr. DeJesus’s primary VA Therapist had unintentionally misled LZ-II staff, informing them that he was suffering from no mental illness when exactly the opposite was true. The VA had structured LZ-II so it would rely entirely upon the VA for all medical and psychological diagnoses and treatment. Accordingly, no one on LZ-II’s staff had medical or psychological training. My view of the evidence -- especially the testimony of the LZ-II witnesses -- leads me to find that although LZ-II staff thought to expel Mr. DeJesus after the March 22nd knife incident, LZ-II looked to the VA to determine the advisability of such action. In these circumstances, the VA effectively made the decision to expel Mr. DeJesus, as well as the decision not to treat, detain, or commit him -- decisions that had tragic consequences.
Finally, Plaintiffs presented the expert testimony of Dr. Robert Lloyd Goldstein. With a medical degree from the University of Chicago, a law degree from Columbia University, and a wealth of professional and academic experience, Dr. Goldstein is exceptionally well qualified to offer expert opinions respecting the evaluation, treatment, and detention of dangerous patients. Dr. Goldstein set out numerous instances in which the VA grossly breached the required standards of care respecting Mr. DeJesus. I found his testimony and report to be credible and compelling. The expert relied upon by the VA is an osteopath who is the Medical Director of a local Crisis Response Center. I found her testimony and report to be equivocal and far less persuasive. Yet, even the VA’s expert agreed with a number of Dr. Goldstein’s conclusions respecting the VA’s mistakes.
W. Robb Graham
