Fatal Flaws

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      Fatal Flaws

      Today we begin with an investigation into the taxpayer funded bureaucracy where millions of our military veterans get their medical care. The V.A. It’s a story about the intersection of two Army vets who never met but—together— exposed what some see as fatal flaws in a troubled system.

      After three tours of duty in Iraq and Kuwait, 28-year old Nicholas Horner returned home to Pennsylvania a broken soldier. He suffered Traumatic Brain Injuries after multiple explosions.

      Daniel Horner: He got blowed back and under a Humvee and he said he was trying to come outhe thought he was buried.

      Karen and Daniel Horner are Nick’s parents.

      Daniel Horner: And then one other time a grenade went off. He was in a Humvee and a grenade rolled over roof and went off, you know.

      Experts say since 2001 as many as 750,000 U.S. military service members have suffered traumatic brain injury or TBI from concussive blasts.

      Karen Horner: His personality was just totally off.

      Sharyl: He changed?

      Karen: Oh yes.

      Daniel Horner: I noticed he just wasn't the same anymore. He didn't hardly talk and stuff and he just wasn't the same old friendly guy - I just don't know what to say. It was different.

      By the time he was discharged with TBI and Post Traumatic Stress Disorder, the Army had prescribed no fewer than eleven drugs, according to his records. And he reported suffering hallucinations, seizures, depression, anxiety and flashbacks.

      Daniel Horner: He said that he was going to come and work with me at my business, you know, and I thought, “Oh, that'd be great.” The next thing I know, he calls me up one day and he says, “I got out Dad, in Altoona.” I said, “What are you doing in Altoona?” He said, “I want to be near the VA hospital.” And then I finally started realizing this must really be bad, you know.

      The James E. Van Zandt VA Medical Center in Altoona was an hour’s drive from Horner’s hometown of Johnstown, Pennsylvania. His plan was to be close to the hospital so he could get intensive help. But he told his parents that his repeat requests to be admitted for in-patient treatment were declined. And he only got worse.

      Karen Horner: He had guns hidden all through his house, under couch cushions, in the bedroom, in the basement. When he'd even go to the bathroom or he was home by himself. He would lock all the doors because he was just so afraid.

      Daniel Horner: And he'd hide in the corner even.

      Karen Horner: And cry.

      Sharyl: What do you think, just in the big picture, what could have or should have been done initially when he came back that last time and was suffering?

      Daniel: The VA should have got him a room in there and put them in there and helped him get off all them drugs and helped him and treat him for TBI.

      Horner wasn’t the only vet who didn’t get the help he said he needed at the Altoona VA Center for his Traumatic Brain Injury.

      James DeNofrio: These are high-risk patients that have homicidal, suicidal behavior, self-destructive behavior, so they're supposed to be one-to-one closely monitored.

      James DeNofrioan Army vet and an administrator at the Altoona VA Centersays he was shocked to discover a long list of vets languishing without a treatment plan for their Traumatic Brain Injury.

      James DeNofrio: What the hospital was doing, anybody who had a traumatic brain injury in the military, they went on a list and then they never received traumatic brain injury care. So there were, I believe, 600 patients on that list. Out of that 600, as I drilled down, six had committed suicide, one veteran had gone and shot up a local Subway

      The vet who’d “shot up a local Subway” restaurant was Nick Horner. He shot two employees—killing one—during a robbery attempt, then shot and killed another man a few blocks away. It all happened not long after a last desperate visit to the Altoona VA Center.

      Daniel Horner: Well he was at the VA hospital crying to them. He even told me, “I cried to them,” Dad, “I got to be an in-patient. You got to put me in. I'm having all kinds of problems,” you know. And he listed them all down for them— everything you could imagine— and they told him come back in a month.

      Karen Horner got the sickening news about her son while recovering after a heart procedure.

      Karen Horner: I was in the hospital and everyone showed up to tell me that Nick shot and killed some people. My son would never do this. Never in his right mind would he ever do this.

      Sharyl: What did he say to you afterwards? Did he say if he was in any kind of thought process or did you talk to him about it?

      Daniel Horner: He had no idea what really happened. He thought— what he really said, he thought he was chasing somebody that did the shooting, he said. And when the police did arrest him and taser him and everything, he asked the police if they caught the guy. He didn't know what was going on. The thing with Nick though is he said, “I don't remember doing it, but if I did it, I need to be put to death.” That's what he told me and he ended up, getting life, two life sentences, but he said that was fine with him. He did it. He needed to pay.

      Alarmed by what he discovered about Horner and other vets on the wait list, DeNofrio blew the whistle.

      Sharyl: Who did you report it to?

      James Denofrio: I reported to my leadership, gave the report, went all the way to D.C., and my assumption was that it was to be addressed. Came back a year later, did my own review, found out that the patients were still on the list. There was, I think, 100 that still weren't getting care after I had identified every single veteran, giving them their names. And there were more patients on the list. Another veteran shot himself, which is, I mean, as a soldier myself that's heartbreaking, especially when you literally hand it to them on a golden platter and say "Here's how you fix.”

      Instead of fixing it, DeNofrio says the leadership at the Altoona VA Center launched a lengthy retaliatory campaign against him turning his job into a nightmare while he continued to blow the whistle on other problems he said put vets’ lives at risk.

      James DeNofrio: At that point you're basically persona non-grata and people don't speak to you. I think I've had 18 investigations launched against me and the people that testified on my behalf.

      Sharyl: They do things to you to make you suffer or regret being a whistleblower?

      James Denofrio: Yes. As a military intelligence officer, if I treated my prisoners the way that the V.A. treats me as a whistleblower, they'd probably charge me with war crimes. That's what it's like to be a whistle blower in the V.A.

      The Altoona VA Center denied our interview requests. In a written statement, they said:

      "VA conducted an in depth review of these allegations, which date back more than a decade to the previous administration and determined all of the most serious charges were not substantiated." They added, the Inspector General "determined VA adequately addressed the allegations and closed its case in 2016." And they deny retaliating against DeNofrio, "Just because someone identifies as a whistleblower, doesn't automatically give credence to their claims."

      DeNofrio still works for the VA as he pushes national initiatives to protect whistleblowers and clear backlogs of federal whistleblower cases.

      James DeNofrio: I kept my job but I went through hell for 6 years.

      What makes you stay at a job when that's going on? It must be very stressful, why don't you just call it a day?

      James DeNofrio: If I wouldn't have done it, and I don't continue to do it who will?

      There’s a final tragic note to the story of Nick Horner, who was still suffering his brain injuries in prison when we began investigating this story. In August, he reportedly committed suicide in prison by stabbing himself with a pen. He was 39.

      Ultimately, Horner’s parents blame a broken system for their son’s death — and the deaths of the innocent people he shot.

      Daniel Horner: If the VA would have done its job those people would still be alive.

      Karen Horner: Yeah

      Daniel Horner: Three people would be alive.

      Sharyl: You said he wrote you a letter. What was the gist of that in the letter?

      Karen Horner: How much he loved us and how thankful he was for us and he even tried to make us smile with these letters, this letter, and he wants us to help. Help the soldiers.

      Sharyl: To the whistleblower that I guess you haven't met and haven't heard of, but he tried to blow the whistle on these people who are languishing on the list. Any thoughts about that?

      Daniel Horner: Too late for us. Maybe—

      Karen: For us.

      Daniel: —Maybe, can help a lot of other ones though.

      Karen: Yes. That's what Nick would want. He wants us to do as much as we can for the vets everywhere.

      Among other complaints, DeNofrio, the whistleblower, claims reprisal by the very federal office created in 2017 to protect whistleblowers: the Office of Accountability and Whistleblower Protection. They told us they’re committed to protecting whistleblowers and correcting any issues.