Veterans Affairs to investigate death in Klamath County

Veteran who served in Korea died in November after waiting for three days for life-saving procedure. “Breakdowns in the system all over the place.”

The U.S. Department of Veterans Affairs is conducting an investigation into the death of a Klamath County man who died last November after waiting for three days for the agency to authorize a procedure that could have saved his life.

Lyle Cory, 65, died November 4 of complications of a heart attack at Sky Lakes Medical Center in Klamath Falls. He had been admitted three days earlier, but could only wait in the intensive care unit while the hospital attempted to get Veterans Affairs to approve a cardiac catheterization.

“I was going to sell my house, sell my soul, to get it done. But they won’t even let you pay for it yourself,” recalled his wife, Kaye Cory. “They let us down completely.”

Cory’s heart disease was well documented by Veterans Affairs, which makes his case all the more unfortunate. He received a stress test on September 22 at a clinic run by the VA in Klamath Falls. It found “severe coronary artery disease in his left anterior descending coronary artery,” according to a letter Michael Sheets, the primary care provider for the Cory family, sent to Veterans Affairs Secretary Robert A. McDonald requesting an investigation into the death and changes to the way veterans are provided acute care in the county.

After the stress test, Lyle Cory was scheduled for a cardiac catheterization at the VA Medical Center in Portland on November 17. Then, in October, Lyle and Kaye traveled 300 miles to the very same facility for a procedure to insert a stimulator to relieve neck pain, but it was canceled because of his heart condition.

Staff at the medical center in Portland told the Corys that it wasn’t possible to reschedule his heart catheterization, so they returned home to wait for his scheduled procedure on November 17.

“He was at three facilities and nobody did what needed to be done. That’s what is so sad,” said Kathy Pierce, veterans service officer for Klamath County, who is handling the Cory case. “If they had just set him down for the catheterization when he was in Portland in October, we wouldn’t be here today,” said Kathy. “I don’t know why they couldn’t have done it while they were there.”

“There were breakdowns in the system all over the place,” Sheets said. He hopes that the Veterans Affairs clinic in Klamath Falls will replace its answering machine with a clerk, a simple step to improve communication. And, he’d like to see local VA medical centers be given the authority to move patients to private facilities when care is needed immediately, exactly the sort of change envisioned by Congress last year when passed legislation aimed at cutting the lengthy wait times at VA locations nationwide.

“You cannot make someone wait eight weeks when they’ve been diagnosed with a heart problem,” said Kaye Cory. “We as lay people thought it can’t be that bad if they made us wait that long. But it turned out to be that bad.”

“This is about fixing it for the next guy,” she said. “Nobody should have to go through what we went through. His death was not in vain. We need to make a change.”

The VA investigation of Cory’s death was initiated at the request of Rep. Greg Walden, who represents Klamath County. He was informed of the case by Pierce, who says she has never seen a similar situation in Oregon.

“Congressman Walden is very concerned about this issue and we’re going to keep a close eye on it,” said spokesman Andrew Malcolm.

The VA informed Walden’s office on Monday that it planned an investigation. In a letter that Walden forwarded to Kaye Cory, the agency said it “wanted to compensate me for my loss. I’m sorry, there’s not enough money to compensate me for my loss,” she said.

The VA has never replied to the letter that Sheets sent more than two months ago. In it, he wrote that “A central number distributed to private facilities, and manned 24/7 to immediately authorize urgent and emergent care would save lives. American veterans deserve the best that all health professionals can give and I hope you will investigate and make changes to help veterans who come after Lyle.”

He added that Klamath Falls is 300 miles away from any VA Medical Center. “Travel for many of the veterans is costly as we recently lost air service here also. I understand systems become overloaded but patients like Lyle that I have cared for were taken either that day or next day to the cardiac catheter lab. I believe if this would have happened Lyle would be here.”

Sheets, who signed the Cory death certificate, listed “delay for intervention for identified coronary artery disease” as one of the three causes of death.

After her husband’s death, Kaye Cory attempted to contact the VA in Portland to cancel his appointment for November 17. “It took them a week for someone to call me back,” she said. “The whole thing is incredible.”

She has never received an explanation from Veterans Affairs about why it took 3 days to approve the heart catheterization. A spokesman for the Portland VA Medical Center declined to comment on the case, citing privacy concerns.

Lyle Cory served in Korea from 1967 to 1970, followed by two years of inactive reserve. He is survived by his wife Kaye, two children, and four grandchildren.

Christopher can be reached at [email protected].

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