A staffing issue delayed a deadly lung cancer diagnosis for at least one veteran
Key Takeaways
The Omaha VA Medical Center’s tracking system for lung imaging abnormalities went unmonitored for over a year between 2019 and 2021. It’s unknown how many patients were affected by this error.
In 2019, a radiologist spotted a 2 cm mass on a veteran’s CT scan, but no follow-up was conducted. By the time the veteran was diagnosed with lung cancer, the tumor had more than doubled in size and was present in both lungs.
The veteran's family filed suit against the Omaha VA in September 2021, alleging that the VA was medically negligent in its treatment of Hansen. The VA has not objected to these charges.
The Omaha Veterans Affairs (VA) Medical Center has a registry that collects lung scans to check for nodules and other findings that indicate a need for follow-up.[] However, in 2019, the nurse previously in charge of maintaining the Omaha VA registry retired. The position was left vacant for over a year.
Without eyes on the registry, concerning results, such as the growth spotted on Vietnam veteran Micheal Hansen’s July 2019 post-surgery scan, were missed. By the time Hansen’s tumor was diagnosed in October 2020, it had nearly quadrupled in size and progressed from stage IA2 to stage IV. Citing medical negligence, Hansen's family filed suit against the Omaha VA in September 2021, just 2 months before his death on December 30, 2021.
A failure to follow up
Micheal Hansen was born in Nebraska. After his time in the army, he made a living selling insurance. Married since 2004, Hansen was a father and grandfather. He lived in Las Vegas, NV, for almost 2 decades before returning to his hometown of Omaha in 2016. Hansen received regular medical treatment within the VA system and was reportedly happy with his care.[]
Hansen had an in-patient procedure to treat digestive and intestinal issues in June and July 2019.[] During his stay, he had a CT scan that revealed a 2 cm mass in his right lung. Radiologist Jack Vonk, MD, noted the mass as a “possible malignancy,” and reported his findings to Hansen’s surgeon.
However, no follow-up was ever conducted, and Hansen was not informed about the findings. In October 2020, Hansen returned to the VA Medical Center with multiple respiratory complaints. Scans at this time revealed a 4.0 cm mass in his right lung and a 3.5 cm mass in his left lung. A biopsy confirmed a diagnosis of stage IV adenocarcinoma.[]
VA admits fault
Hansen’s case was medically complex. The digestive and intestinal issues that led to his 2019 hospitalization and surgery weren’t the only reason he was under the care of medical providers. Hansen had end-stage renal disease and had been receiving dialysis three times a week since 2006;[] he was also managing coronary artery disease, diabetes, and rheumatoid arthritis. By 2019, he was reportedly under the care of nearly a dozen doctors, but none of them followed up about his CT results.[]
The Hansens initially filed suit against the Omaha VA in September 2021, alleging that the VA was medically negligent in its treatment of Hansen and that it demonstrated “negligent failure to warn.”[]
The VA has not objected to these charges. In fact, the Omaha VA admits to an error and a fault in its registry system. However, it disputes the extent of the damages. The VA alleges that, although it is liable for failure to warn, Hansen’s medical complexity limited his cancer treatment options. They also argue that Hansen was a heavy smoker who, reportedly, continued to smoke both nicotine and cannabis after his lung cancer diagnosis, thereby contributing to his shortened lifespan. The Omaha VA Medical Center contests the allegation that Hansen’s lifespan would have been significantly longer had he received his diagnosis in 2019.
VA cites hiring issue as root cause
Lisa Hansen and her legal team are seeking more than damages: They want to know how many similar cases exist and what can be done to avoid the VA’s error in the future. The Omaha VA has dedicated eyes on its registry again and has added new safeguards to the system; however, the full effects of the 2019 to 2021 gap in monitoring are unknown.[]
The Omaha VA knew that its registry system wasn’t working as intended. The system, called a lung nodule registry, is designed to make sure that test results like Hansen’s don’t fall through the cracks. When the system is working as designed, radiologists enter a code flagging any concerning findings and alerting others that follow-up is required. A designated nurse then manages those flags in the registry and ensures that follow-up action is taken.
The registry was unmonitored for a period somewhere between 15 to 22 months. The Omaha VA claims that a hiring issue was the root cause of the error.
According to records, the medical center’s pulmonology department wanted to upgrade the qualifications needed to fill the position after it was vacated in 2019. The department needed approval before it could recruit someone with advanced qualifications, which left the position open for over a year until an advanced practice registered nurse was hired in March 2021.
Omaha VA Medical Center Chief of Staff Dr. David Williams said that providers were informed of the gap in monitoring but acknowledged that missed follow-up care was likely. It’s unknown how many veterans might have been affected by this gap in monitoring, but it is clear that Hansen isn’t alone. In July 2020, a separate complaint filed against the same doctors that Hansen had at the Omaha VA alleged that a lack of follow-up after lung nodules were spotted on a scan resulted in lung biopsy and death of another patient. Records indicate that the complaint was settled.
A trial date of December 12, 2023, was set, but on December 11, Lisa Hansen and the United States government reached a tentative settlement agreement.[] The settlement amount is unknown. Hansen’s legal team previously estimated that had Michael Hansen lived to be 83 years old, “his death would be worth nearly $1 million,” not including damages for pain and suffering.