Massachusetts VA hospital broke federal law in failed hunt for missing veteran found decomposing in stairwell

The Bedford VA hospital in Massachusetts violated federal law by failing to properly search for a missing 62-year-old Army veteran, whose decomposing body wasn’t found until a month after his disappearance in an emergency stairwell just 60 feet from the door of his residential room at the facility.  

A new 45-page report released last week by the Department of Veterans Affairs Office of Inspector General states that the body of Tim White was found on June 12, 2020, by another resident in an emergency exit stairwell at Bedford Veterans Quarters (BVQ), an independent-living facility privately operated by Caritas Communities Inc., an organization that provides services for homeless people. 

The facility is located on the campus of VA’s Edith Nourse Rogers Memorial Veterans Hospital. The Caritas house manager had reported him missing on May 13, 2020, to the Bedford Police Department, and though his whereabouts were unknown for about a month, White never left Building 5 before his death. His crumpled body, which was so badly decomposed that a medical examiner couldn’t determine exactly how he died, was found with the same Boston Red Sox jersey, jeans and baseball cap he was last seen wearing days before his disappearance. 

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U.S. Rep. Seth Moulton, D-Mass., who himself receives medical care at Bedford VA and had sought an investigation into White's death, said Thursday that the federal watchdog report shows the need for big improvements.

"Tim White deserved better from the country than dying alone in a stairwell," Moulton said in a statement. "His life might have been saved if the Bedford VA Police Department did its job… America’s veterans deserve the best health care in the world. Mr. White’s care didn’t come close. In the days ahead we must demand that the VA police department changes so that our country keeps its promises to those who have served."

The circumstances surrounding White’s disappearance revealed several deficiencies in Veterans Health Administration and Veterans Affairs policies "regarding missing persons on VA properties, local policing decisions, and oversight of enhanced-use leases," according to the report.

"Mr. White’s disappearance did not receive the attention it deserved from VA, an agency that is required by federal law to provide for the protection of all persons on its property," the report says. The OIG found that the medical center, including its VA police, "did not initiate a response to Mr. White’s disappearance under VHA’s missing patients policy because he was considered a resident and not a patient." 

The report also notes how "poor decision-making, misinformation and lack of oversight also prevented anyone at VA from encountering Mr. White during the month after he was reported missing through routine patrols or cleaning of the emergency exit stairwell in which his body was found."

"Although the OIG was unable to point to a single responsible individual, office or decision, each of these deficiencies contributed to VA’s failure to locate Mr. White," the report concludes. 

VA investigators determined the stairwell was never searched, in part because VA police wrongly believed that since White's residence building was privately operated, it wasn't their responsibility to search the stairwell. For the same reason, VA staff didn't monitor or clean the area.

The report identified other lapses amid "widespread confusion" over VA’s obligations in areas leased by Caritas. VA rules require staffers to follow a specific protocol when looking for missing patients that includes searching stairwells. But White was considered a resident, and not a patient. 

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"The OIG found that VA police would have been required to search the emergency stairwell if Mr. White had been considered an at-risk missing patient under VHA’s directive, and if VA police had followed the VHA directive, he likely would have been located by VA police shortly after he was reported missing," the report says. "However, whether or not Mr. White was a patient, other governing federal law and agency policies require VA police to patrol all VA property and to protect persons on that property." 

Three months before White’s disappearance, former VA police chief Shawn Kelley "improperly instructed his officers to stop patrolling Building 5." He claimed that it was at the request of Caritas managers, but there is conflicting testimony concerning this assertion, the report says.

That decision "violated the governing law and VA policy because substantial portions of Building 5 remained under VA’s jurisdiction, including the basement, the emergency exit stairwells, VA first-floor offices, and a VA-funded temporary bed program for veterans experiencing homelessness." Now, local VA chiefs can no longer make the decision not to patrol certain buildings in missing persons investigations. 

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During prior patrols before February 2020, it was common for officers to "do walk throughs of the area, talk to the people behind the desk, make conversation with veterans, and look through the building." In addition, VA police had commonly utilized its K-9 unit to conduct drug searches in the building and officers "were entering the stairwell space on a periodic basis."

The report also found that Kelley waited two weeks before responding to a request from Bedford town police to use police dogs in a search for White.

The OIG did not refer the case to criminal investigative agencies. A separate probe by Middlesex County District Attorney Marian Ryan concluded in December. It found egregious failures in the search for White but did not recommend criminal charges against anyone, the Boston Globe reported. 

The Associated Press contributed to this report.