Report Spreads Blame For VA Legionnaires’ Disease Outbreak

Systemic failures at the VA Pittsburgh Healthcare System allowed a deadly Legionnaires' disease outbreak to fester, even as leaders believed they were solving the problem, a Tribune-Review analysis of a report by the Veterans Affairs Office of Inspector General found.

The scathing report issued last week showed the hospital system paid scant attention to the importance of water temperature in killing the deadly Legionella bacteria. No one from the facilities management team actively belonged to the infection control team, and local VA officials failed to test some patients with pneumonia for Legionnaires' disease.

The outbreak lasted from February 2011 through November 2012, according to the Centers for Disease Control and Prevention.

“When something bad happens, I take ultimate responsibility,” Pittsburgh VA director and CEO Terry Gerigk Wolf told the Trib.