ATLANTA - A family claims a string of medical mistakes cost a local man his kidneys, and then his life. Channel 2 investigative reporter Aaron Diamant found the case while digging through thousands of claims paid out by U.S. taxpayers.
What Diamant found left veterans' loved ones outraged, powerful lawmakers livid and one of the VA's top leaders playing defense.
Scott Williams told Diamant that shortly after his father died at the Atlanta VA Medical Center, a stranger came up to him and his mother.
"This lady comes out and says, 'Y'all are going to sue the hospital, aren't you?' And we're like, 'What are you talking about?'"
Days earlier, doctors had removed both of Jerry Williams supposedly cancerous kidneys. That was the first mistake. Williams did not have cancer.
But the family's malpractice suit, which the VA settled, also claimed bad post-operative care contributed to Williams' death.
"It was the worst thing that ever happened in my life," said Wlliams' son Scott. "If they truly felt that there was nothing that they did wrong, they wouldn't have offered anything."
Diamant found the case after the Channel 2 Action News investigative unit filed a Freedom of Information Act Request with the Department of Veterans Affairs, then poured through a database of every malpractice case the agency lost or settled between 2000 and 2012.
Diamant found 1,194 death-related payouts. Then he talked to members of Congress.
"This is a national crisis and a national disgrace," said Rep. David Scott (D-Jonesboro) "The failure here is that the top management at the VA has not come to that conclusion."
Diamant also found that Williams' death was one of 21 blamed on medical mistakes or delays in care at the Atlanta VA during that same time period. Of the hundreds of VA facilities in the US, just five others had more death-related payouts.
The House Veteran's Affairs Committee fumed, "These people need to be fired. When folks are fired or relieved from their responsibility other people will take notice," said Rep. Jeff Miller (R-Fla.)
Diamant sat down with the VA's head of quality control and safety.
"Any instance of avoidable harm, much less an avoidable death, is a tragedy and something we take very, very seriously," said Dr. Carolyn Clancy, the assistant deputy undersecretary for health, for quality, safety and value.
Clancy said the agency analyzes every case involving medical errors and has systems and policies in place, she said, to reduce the risk.
But, she told Diamant, "The execution can be less than perfect."
A scathing 2013 government accountability office report exposed major breakdowns in the VA risk management process.
Inspectors found that those gaps, "Weaken VAMC's ability to ensure they are identifying providers that are unable to deliver safe, quality patient care."
Clancy admitted, "At the end of the day, the only people who can improve care are the people providing the care.”
But lawmakers like Sen. Johnny Isakson told Diamant that VA leaders are the only ones responsible for all those who work under them.
"We need a culture of zero mistakes, zero excuses, zero casualties," said Isakson.
On top of those deaths, our investigation also found thousands more cases, coast to coast, claiming bad care caused patients harm.
And since 2000, at last count, the VA has shelled out more than $900 million in taxpayer dollars to settle those claims or payoff judgments.