Healthcare Inspection Mortality Review, Aleda E. Lutz VA Medical Center, Saginaw, Michigan

The purpose of this review was to determine the validity of allegations regarding deaths at the Aleda E. Lutz VA Medical Center, Saginaw, Michigan. The complainant specifically alleged that clinical staff failed to obtain appropriate requests for autopsy and did not appropriately report deaths to the Medical Examiner. We did not substantiate the allegations; however, during the review of care for one patient we identified aspects of care warranting improvement. The VISN and Medical Center Directors concurred with our recommendations to ensure that staff follow acute coronary syndrome guidelines, appropriately monitor patients at all times, follow national resuscitation guidelines and review all resuscitation efforts for compliance with those guidelines, and comply with VHA policy for Out-of-Operating Room Airway Management. The actions taken are acceptable and we consider the recommendations closed.