This week, the Government Accountability Office (GAO) released a scathing report detailing how the Department of Veterans Affairs is failing at both preventing and tracking sexual assaults at VA facilities across the country. The report focused on a lack of oversight, inconsistent procedures, and weaknesses in protective measures. The report went on to enumerate numerous problems and made recommendations for how the VA might start to address these serious issues.

The review found that from January of 2007 to July of 2010, nearly 300 sexual assault incidents were reported to VA Police.

Although all sexual assault reports received by VA police are required to be reported to both the Veterans Integrated Service Network (VISN) and the Office of the Inspector General (OIG), the review found that most were not reported to either. In fact, nearly two-thirds of assaults were not reported to the OIG. At four selected VISN offices, the review found that anywhere from 0%-47% of assaults were correctly reported:

The GAO hypothesized that assaults were underreported overall, both to VA police and the higher-level offices, due to inconsistent definitions of sexual assaults requiring reports and unclear expectations for incident reporting. At five selected VA facilities, five different definitions were found:

Beyond the trouble with reporting and tracking procedures, the GAO found significant problems with prevention measures at facilities. Veterans entering a facility for service were often not adequately screened for potential for violence, with clinician’s often relying on the patient’s self-report. Clinicians themselves reported that these assessment tools were often incomplete or inaccurate.

Physical security precautions are required to be in place at all residential programs and inpatient mental health units for the security of both patients and staff. A review of these precautions, such as closed-circuit cameras and panic alarms, found “significant weaknesses”. These included:

When the report was presented to the House Committee on Veterans’ Affairs, the chairman Rep. Jeff Miller (R-Fla) said that he was “aghast” after reading it. He went on to say:

“It reminded me of a 1950s prison system — lawlessness, lack of security and reporting, and outright disregard for human dignity.”

Rep. Miller also stated an intention to force the VA to make improvements. In a response from VA officials, they stated their intention to follow-up on the recommendations, along with improving the reporting system and physical protection measures.

Read SWAN’s response to the GAO report and stay tuned for more updates on holding the VA accountable for protecting patients and veterans.

VA Health Care: Actions Needed to Prevent Sexual Assaults and Other Safety Incidents – US Government Accountability Office
GAO Slams VA Sex Assault Reporting, Prevention – Air Force Times

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