US Government Failed To Spot Pedophile At Indian Health Service Hospitals
Since 2006, The U.S. Government Has Paid Out About $55 Million In Settlements In 163 Malpractice cases at Indian Health Service hospitals. US Government Failed To Spot Pedophile At Indian Health Service Hospitals
After Memorial officials suspended him permanently, citing “multiple serious deficits in judgment,” he tried to find work in Nevada, but a licensing board rejected his application.
Thrust into medical exile at age 52, Dr. Stachura turned to the Indian Health Service for a job. The federal agency, which provides health care to 2.6 million Native Americans, has given second chances to dozens of doctors with trails of medical mistakes and regulatory sanctions—sometimes to disastrous effect, a Wall Street Journal investigation found.
Before Dr. Stachura retired this August, the U.S. government made five malpractice payments totaling $1.8 million to settle allegations involving his care at the IHS, according to a Journal analysis of Treasury Department data and federal court records. Three of those patients died after he treated them.
“We trust IHS as Native Americans, and they should hire the best people for us,” said Jeanise Livingston, who was in a coma after her bile duct was cut during a 2006 gallbladder surgery Dr. Stachura performed, medical records show.
Dr. Stachura didn’t respond to requests for comment. In correspondence with the New Mexico medical board, he said a medical review panel ruled he wasn’t negligent in some of his malpractice cases, including the one that got him suspended from the Las Cruces hospital. He said other patients who sued over his care, including Ms. Livingston, recovered well. The IHS declined to comment on Dr. Stachura, citing privacy rules.
The Journal examined 163 malpractice claims against the IHS that the government settled or lost since 2006. One out of four doctors involved in those cases worked for the IHS despite a history that should have raised red flags by the agency’s own standards, the Journal found. At least 66 of the patients died as a result of the alleged malpractice, the analysis found.
Insurance actuaries say U.S. doctors typically have one malpractice claim every 20 years or so. Surgeons and other high-risk specialists have twice that rate. The IHS was willing to hire doctors with many more lawsuits in their past, in some cases more than 10 in less than a decade.
“Our tribal members are at the mercy of these federal health facilities,” said Tori Kitcheyan, a Winnebago Tribe of Nebraska council member and the chairwoman of the nonprofit National Indian Health Board. “There is no other choice.”
The IHS’s chief medical officer, Michael Toedt, said in an interview that the Journal’s analysis wasn’t representative of a broader IHS workforce he said is composed of “top quality physicians.” Asked about some of the doctors the Journal identified, he said that “it’s never appropriate to make a compromise on quality to fill a vacancy.”
The Journal found that IHS managers didn’t always make basic inquiries about physicians’ work histories. An official who approved Dr. Stachura’s appointment at the IHS’s Gallup, N.M., hospital, Floyd Thompson, said he didn’t know of the surgeon’s malpractice history. The cases were logged in a government database that IHS managers are required to examine. Mr. Thompson said he relied on a secretary at the hospital to perform such checks.
It isn’t clear whether IHS ever contacted Memorial Medical Center about Dr. Stachura’s history there, either. MaryAnn Digman, the former CEO, said she didn’t know he had landed at the IHS until a Journal reporter inquired.
“Hank Stachura is a lovely human being, and I recall having a conversation with him and encouraging him to consider another field of medicine than surgery,” she said.
IHS officials hired doctors whom state regulators had punished for transgressions such as drug addiction or sexual misconduct. One doctor who was sanctioned by a state medical board after a patient accused him of sexually abusing her during a surgical exam found work with the IHS, records show. Three IHS managers later vouched for him when he successfully petitioned a licensing board to lift the restrictions.
The agency allowed doctors with checkered pasts to recruit other troubled providers. In one case, an emergency-department chief who was fined by a licensing board over alleged patient-care failings pushed to hire a doctor whose license was restricted for prescribing narcotics to her boyfriend, emails show. The ER chief said in a deposition he thought the medical board’s allegations couldn’t be accurate, because the amount of pills involved was so large.
IHS leaders have vowed for years to overhaul their process of credentialing doctors before they treat patients at the agency’s two dozen hospitals. U.S. regulators require all hospitals to verify that physicians are qualified, competent and safe.
The IHS’s network of hospitals and clinics treats some of America’s poorest communities, beset by high rates of diabetes, alcohol-related deaths and other chronic diseases. The agency for decades has been criticized by Native Americans and government watchdogs for lax and dangerous care, including by the main U.S. hospital regulator.
Such failures have left IHS leaders with a conundrum: how to recruit badly needed doctors—often into remote areas where pay is low compared with private practice—without hiring people so troubled they endanger patients. The vacancy rate for IHS doctors was 29% as of May, agency data show. The industrywide average is 18%, according to medical-staffing agency AMN Healthcare’s most recent survey, from 2013.
Former agency leaders who struggled with the task of filling these slots said in interviews they resorted to compromises. Michele Gemelas, a former IHS official who wrote the agency’s guide to credentialing, said the agency faces situations where “you get three candidates who come through and they all seem not great. But what you do is choose the lesser of three evils.”
In 2016 the IHS hired obstetrician Bobby Ray Miller Jr. , who reported on his application five malpractice lawsuits resulting in settlements totaling $2.7 million, an internal agency review says. Dr. Miller also was sanctioned by the California medical board after a patient bled to death following a caesarean section, records show.
A baby died in the womb at the agency’s Crownpoint, N.M., hospital because Dr. Miller failed to treat the mother’s high blood pressure, the hospital’s medical staff found in the internal review. The review concluded that his history “foreshadows the tragic events that transpired in October 2017.”
He left the agency last year. In a text message to the Journal, Dr. Miller said: “I just did not address patients primary medical needs in a satisfactory way.”
The agency declined to comment on any specific doctors, but its quality chief, Jonathan Merrell, said he would review each of about a dozen cases the Journal raised with the agency. “I will take action and ensure that some of those things aren’t persisting,” he said.
The IHS’s oversight of doctors came under renewed scrutiny earlier this year when the Journal and the PBS series Frontline revealed the agency had long ignored complaints that a South Dakota pediatrician, Stanley Patrick Weber, sexually abused young male patients. Mr. Weber, who has been convicted in two trials and filed an appeal, was moved from one IHS hospital to another despite mounting allegations against him.
In 2011, Mr. Weber, by then the subject of accusations, led the committee that vetted doctors for the Pine Ridge, S.D., IHS hospital, his résumé says.
To examine how the IHS screened doctors, the Journal reviewed data from a Treasury Department fund that pays claims against the U.S. government. The Journal then matched those records to federal lawsuits that named 171 doctors—both full-time employees and certain contractors—who plaintiffs alleged were involved in negligent care at the IHS.
At least 44 of those doctors had histories that should have caused concern based on the IHS’s own guidelines, according to medical-board documents, court filings and other records. The guidelines urge managers to screen doctors for multiple past malpractices cases, medical-board sanctions and criminal convictions.
Among them is Franklin Wolf, a surgeon who was sued for malpractice at least 11 times in Pennsylvania over an eight-year period. One patient claimed Dr. Wolf left a leak after a colon surgery, leading to a serious infection and a long hospital stay. The case settled for an unspecified amount without Dr. Wolf responding to the allegations, court records show. At least three of the lawsuits were either dropped or dismissed with regard to Dr. Wolf.
After being hired at an IHS hospital in Shiprock, N.M., he allegedly cut a tube connecting a patient’s liver to his stomach and punctured the man’s intestines during a 2008 gallbladder surgery. That led to a $170,000 settlement after the man died, court and Treasury records show. Dr. Wolf said in a deposition he didn’t believe he had caused the injuries.
In at least a couple of cases, more than one doctor with a history of problems operated on the same patient. Jordan Fleishhacker assisted Dr. Stachura in the 2006 gallbladder surgery on Ms. Livingston that led to a lawsuit costing the U.S. government $175,000, according to medical and Treasury records.
In that case, a gash made in her bile duct spilled at least four liters of digestive fluid into her abdomen, and she suffered from septic shock, according to a report by a third doctor who was involved.
In 2003, a Massachusetts hospital suspended Dr. Fleishhacker, and the state’s medical board alleged in 2005 that he had shown a pattern of “practicing medicine with negligence” in five surgical cases. Years later, after he had left the IHS, the Massachusetts medical board barred him from surgeries.
Dr. Fleishhacker said in an interview that a suspension like the one he faced from the Massachusetts hospital “is almost a death sentence for someone’s career,” and that he disagreed with the medical board’s conclusions. He said the IHS offered him a position after he told them “my side of the story.” He said he didn’t remember the Livingston case.
Dr. Wolf didn’t respond to requests for comment. A lawyer for Dr. Wolf said in a letter to a medical board that his client’s problems were a byproduct of a time when “[l]awsuits were commonplace and the very best physicians and surgeons suffered.”
Over the past decade, on average, less than 1% of doctors a year were sanctioned by their state medical boards, according to a report by a medical-board association.
Depending on the offense, sanctions can include fines, restrictions on what doctors can do and the revocation of medical licenses. A quirk of the piecemeal licensing system, though, means that doctors who have been sanctioned in one state might still have a clean license in another.
The IHS requires its doctors have an unrestricted license, in most cases. But even when a doctor has been sanctioned, local IHS officials can decide to take a chance—out of sympathy or need.
When Annicol Marrocco was hired as a contractor at the Shiprock, N.M., IHS hospital in 2012, she had been disciplined by medical boards in Florida and New York for prescribing pain pills for her then boyfriend, board records say. On a single day, she prescribed 1,350 oxycodone pills, the records say.
Dr. Marrocco later testified in a Drug Enforcement Administration proceeding that the man’s pet monkey had thrown some of the pills into the pool.
In an interview with the Journal, she said she had refilled the man’s existing prescriptions, a one-time mistake for “a scumbag who misled me,” someone she said wasn’t her boyfriend. She said she typically prescribed fewer than 20 opioids at a time.
The Shiprock medical leadership worried IHS guidelines precluded them from hiring her as a result, until an administrator discovered Dr. Marrocco’s Pennsylvania license was clean at the time, according to internal emails. The staff concluded that allowed them to hire her, the emails show.
“I think this could be a win-win for our ED [emergency department] and for Dr. Morrocco [sic],” Shiprock ER director Thomas Burnison wrote in an email to the hospital CEO, medical director and other officials. Dr. Burnison, himself sanctioned by the Florida board of medicine years earlier in connection with a patient’s death, said portions of the Journal’s account are incorrect, but he declined to specify what.
The IHS’s Dr. Toedt said agency policies on how to deal with doctors who have both clean and restricted licenses are unclear, and that he would revise the policy to eliminate any uncertainty. “Our view is that the individual should not have a restricted license,” he said.
At Shiprock, Dr. Marrocco sent home 18-year-old Lydell Begay, who was complaining of dizziness, with a diagnosis of pinkeye in March 2014, according to a later malpractice lawsuit. Within a week, he suffered brain damage from a stroke.
Before the stroke, his youth baseball teammates had nicknamed him “Flash” for his speed, according to his father, Marty. Now 23, Mr. Begay is confined to a wheelchair and unable to speak. He communicates by pecking out texts on a cellphone. “I wish I could play,” he typed, while watching a recent football game.
Dr. Marrocco disputed the malpractice allegations, saying Mr. Begay didn’t have “any kind of neurologic sign” when she examined him. The government settled for $1 million last year. Hospital officials said in interviews that the doctor’s background made the case hard to defend.
Doctors who have had multiple malpractice claims can face huge premiums for insurance in private practice, even if they win cases, insurance actuaries say. Because the U.S. government covers malpractice claims, IHS doctors don’t need to carry their own coverage—nor will they pay any settlements out of their own pockets, in most cases.
That can make the agency an attractive destination for physicians with past claims. A 2011 survey of IHS doctors by a physician-recruiting firm found that many considered those malpractice rules a top perk of the job.
Surgeon Juni Femi-Pearse was hit with almost a dozen malpractice lawsuits by 2006, according to court and licensing records. His malpractice insurer, at one point, said in a letter that it would discontinue his coverage in part “due to prior claims activity,” including one case that later settled for $675,000. That case involved a routine surgery that went awry, leading to a double amputation and, months later, a patient’s death.
Dr. Femi-Pearse had the kind of conduct issues that trigger medical-board sanctions. In 2004, Norton Community Hospital, in Virginia, suspended him after a patient complained he sexually abused her during a checkup after surgery.
“All he wanted to do was kiss me and pull out his penis and show it to me,” said Michelle McCracken, the patient, in an interview.
In letters to regulators, Dr. Femi-Pearse said that he had a previous consensual sexual relationship with Ms. McCracken, which she denied in an interview.
He was acquitted of a criminal charge, but medical boards in Virginia and Kentucky, where he also practiced, required his visits with female patients be chaperoned. The boards also cited him for prescribing diet pills to nurses.
In early 2008, Dr. Femi-Pearse started work for the IHS in Arizona. He was sanctioned by the Kentucky medical board around that time. He later told the board he couldn’t find work in Kentucky because of the sanctions. “The hospitals all say they do not want a ‘Flagged’ Physician,” he wrote.
Several IHS officials, including Stephen Waite, wrote to the Kentucky board several years later to vouch for Dr. Femi-Pearse, who at the time was asking for the restrictions to be lifted. Dr. Waite himself had lost one of his licenses, in Ohio, in 2006 over an alleged pattern of misdiagnosing critically ill patients, records show.
Dr. Waite, who couldn’t be reached for comment, was named in a 2017 malpractice lawsuit that alleged a 6-year-old girl suffered brain damage after she suffocated on a misplaced intubation tube at an IHS facility. In September, the government admitted negligence and agreed the girl’s “past reasonable and necessary medical expenses are $500,000,” court filings show.
After Kentucky lifted its restrictions, citing his colleagues’ support, Dr. Femi-Pearse became a full-time employee at an IHS hospital in Claremore, Okla., in 2012. The government last year paid a $618,890.64 judgment over a colostomy the doctor performed that spilled fecal matter under a patient’s skin. Last month, it paid a $500,000 settlement after he allegedly botched a hernia repair, leaving a debilitating injury despite additional surgeries.
Dr. Femi-Pearse said in a deposition he was later fired by the IHS over a privacy violation that he denied. In the deposition, he denied having been sued for malpractice before joining the IHS, other than the one case that settled. He referred questions from the Journal to the IHS.
Patricia Lowery said an IHS hospital in Fort Defiance, Ariz., was down to one surgeon—her—when she helped recruit Dr. Femi-Pearse in 2008. She didn’t know then about his history of malpractice allegations, Dr. Lowery said. “I would not have hired someone like that if I had known,” she said.
The Journal found that multiple reports had been submitted about Drs. Femi-Pearse, Stachura and several others, before their hirings by the IHS, to a government-run database meant to alert hospitals of malpractice claims and sanctions. The IHS’s policies require managers to check that clearinghouse—the National Practitioner Data Bank.
IHS officials said the agency’s leaders don’t check whether local officials comply with that requirement.
By the time obstetrician Robert Zabenko was hired by the IHS in early 2012, he had accrued at least seven databank reports, a review of the databank shows, including some referencing North Carolina medical-board sanctions over an alleged sexual relationship with a patient.
In 2011, Augusta University Medical Center, in Georgia, also reported to the databank that it had barred Dr. Zabenko from treating patients after a series of surgical complications, a copy of the report shows. In a response to the hospital’s allegations, he acknowledged his complication rate was higher than other doctors in his department, but said it was within normal bounds.
At least one prospective employer asked the Augusta hospital for more information about him, emails reviewed by the Journal show. A hospital clerk said the facility could find no record of correspondence with the IHS about him.
In July 2013, Dr. Zabenko struggled to deliver a baby at the IHS’s Belcourt, N.D., hospital, with a vacuum extractor, as the fetus’s heart rate grew irregular. The baby died soon after birth. A medical-board reprimand later said Dr. Zabenko should have resorted to a C-section “hours earlier.”
The U.S. government paid $900,000 to settle a claim by the baby’s mother, the Treasury data show.
Dr. Zabenko, who left the agency in 2014, didn’t respond to requests for comment. His wife, Tammy Zabenko, said in a brief phone call: “He is a great doctor, and doctors make mistakes.”
IHS medical leaders at times moved quickly to remedy hiring decisions they came to regret. For some patients, that came too late.
Craig Copeland briefly lost his Illinois medical license in 2004 over “gross negligence” when a surgical patient died, resulting in a $925,000 malpractice settlement, records show. It was the third malpractice payment on his behalf, licensing records show. Soon after, he closed his practice because he could no longer afford malpractice insurance, he said in an interview.
The Shiprock staff accepted Dr. Copeland’s explanation that he had become a better doctor through additional training, former colleagues said.
Two months after he arrived as the hospital’s chief of surgery in 2014, he allegedly punctured a patient’s intestines during a surgery, a malpractice lawsuit says. The next month, officials confronted him about four major complications at Shiprock, according to an IHS review.
Less than four months after Dr. Copeland arrived at Shiprock, hospital leaders stripped him of his privileges, and he soon quit, agency records show.
Dr. Copeland said that his problems in Illinois were due to personal issues at the time spilling over into his practice. He said the 2014 intestinal injury could have been a ruptured ulcer, not the result of a surgical mistake. He said he felt singled out, since colleagues with similar complications faced no punishment.
“It is easy to scapegoat people,” he said. “It is harder to change the system.”
Vernita Scott, the patient, said she had more than a dozen surgeries at a non-IHS hospital before finally recovering after a four-month stay. The government paid $475,000 to settle her case.
Dr. Copeland now teaches high-school biology in North Carolina.
Six CEOs and No Operating Room: The Impossible Job of Fixing the Indian Health Service
Rear Adm. Michael Weahkee, nominated to lead the troubled agency, struggled to turn around a South Dakota hospital.
Three years ago, the U.S. Indian Health Service needed a savior for its hospital in Rosebud, S.D.
The federal health-care agency was forced to shut down the emergency department under pressure from federal regulators. Capt. Michael Weahkee seemed the man for the job, having run the IHS’s flagship hospital in Phoenix.
He launched quality-improvement efforts and got the hospital’s emergency department running again, before departing later that year to resume his Phoenix post. He signed off with a laudatory email to the Rosebud hospital staff: “For those of you who have weathered this storm, I salute you.”
His rise since then has been rapid. After running the agency on an acting basis for two years, now-Rear Admiral Weahkee—an officer in the U.S. Public Health Service Commissioned Corps—was nominated in October to be permanent director of IHS. His Senate confirmation hearing is scheduled for Wednesday.
Rosebud, however, continues to struggle. The operating rooms, which Adm. Weahkee shut in June 2016 in what was supposed to be a short-term disruption, remain closed. That is despite extensive efforts at renovation and hundreds of thousands of dollars paid for surgeons who couldn’t do their jobs because they had no place to operate. The hospital can’t deliver babies or do colonoscopies.
The turnaround stalled at Rosebud in part because of local mismanagement. Also to blame were the kind of enormous, agencywide challenges Adm. Weahkee will face if confirmed to the top job.
“Our hospital is like a MASH unit,” said Russell Eagle Bear, a Rosebud Sioux Tribe council member. “When people go to the emergency room, they basically fly them out.” Mr. Eagle Bear said he wasn’t speaking on behalf of the tribe.
Jerry Dale, an owner of Medical Air Rescue Co., said his company often flies at least three or four patients a week from Rosebud to regional hospitals. Each trip costs more than $8,000, he said.
For decades, policy makers in Washington have promised major improvements to the IHS, which is responsible for providing free health care to 2.6 million Native Americans under U.S. treaties. For many, the IHS is their sole source of health care.
Rosebud and some of the 23 other hospitals in the IHS system suffer from systemic problems, including leadership turnover, staffing shortages and facility breakdowns. There have been few signs of an overhaul under Adm. Weahkee, whose style is described as conciliatory by people who have worked with him.
While at Rosebud, “I achieved what I was sent there to do—to reopen the [emergency department] and move toward recertification [by regulators], which we have since successfully accomplished,” Adm. Weahkee said in a written statement.
IHS said Adm. Weahkee as acting director filled senior positions, created a quality-assurance arm and won funding for capital projects. The agency said Rosebud remains a priority and it has worked to improve the facility.
The president of the Rosebud Sioux Tribe said he endorsed Adm. Weahkee’s nomination, citing his qualifications, in a statement relayed by a tribal official. The tribe is also suing the IHS, alleging it provides inadequate care.
Adm. Weahkee’s job is a difficult one. He and his predecessors have struggled to gain attention in Washington. The agency has gone without a Senate-approved director since 2015. Many of its facilities are in remote areas where it is difficult to recruit skilled staff. Historically, local IHS leaders have operated with autonomy, making oversight from headquarters more difficult.
Overall, IHS spent about $4,078 per patient each in 2017, according to a report from the Government Accountability Office. That was about one third of what the Veterans Health Administration and Medicare spends per person.
Kerry Weems, a former official at HHS, said fixing IHS would require bringing per capita spending closer to the rate at Medicare, along with other changes. Neither Congress nor federal health officials have pushed for such major changes. Everyone shares culpability, said Mr. Weems.
President Trump nominated Adm. Weahkee to be the IHS’s permanent head after the first nominee, Oklahoma insurance broker Robert Weaver, withdrew early last year after a Wall Street Journal article showed that his résumé had misstated his experience. Mr. Weaver disputed the Journal’s reporting at the time and said that he was forced out.
After that, HHS officials contacted nearly a dozen executives who had overhauled large private-hospital systems, said a former Trump administration official. None were willing to raise their hands for the IHS job, the former official said.
“We conducted a search process, and have nominated the best candidate,” HHS said in a written statement. It said Mr. Weaver had withdrawn for personal reasons.
Several Native American groups have expressed support for Adm. Weahkee’s nomination, saying he has done a good job working with tribes. Adm. Weahkee, a member of the Zuni Tribe, has spent most of his career at the agency and was born at an IHS hospital in Shiprock, N.M.
“He’s very collaborative. He’s very thoughtful,” said Lynn Malerba, chief of the Mohegan Tribe, chairwoman of an IHS advisory committee. “It’s very difficult for any director to fulfill the treaty obligations of the Indian Health Service given what the structural and budget challenges are.”
Earlier this year, an investigation by the Journal and the PBS series Frontline showed IHS officials had long suspected that a pediatrician, Stanley Patrick Weber, was a pedophile. Mr. Weber had been transferred from one facility to another after coming under investigation. He has been convicted of abusing six boys in two states, and is appealing.
In the wake of that report, Adm. Weahkee said problem employees no longer would be moved around. He overhauled abuse-reporting policies and required all workers to complete new training by September. It isn’t clear how much effect his efforts have had on the front lines.
In October, an agency hospital on the Standing Rock reservation in North Dakota failed a regulatory inspection after a cancer patient repeatedly accused a nurse of physically abusing her, including by punching her in the back. A video showed the nurse, Maria Wilkie, entered the patient’s room alone while a second nurse paced outside, according to the inspection report.
Ms. Wilkie’s supervisor, the hospital’s nursing director, told inspectors she “had no idea what to do” about an allegation of patient abuse by staff, had never received any training on the topic and that the hospital had no policy on it, the report said.
Ms. Wilkie denied abusing the patient and was suspended. She didn’t respond to requests for comment. She is now being considered for a nursing position at an IHS facility serving the Zuni reservation in New Mexico, people familiar with the matter said.
IHS said it is trying to do everything it can to protect patients and that its message is being heard in its facilities around the country. Training and policies at Standing Rock “may not have been specific enough,” it added.
The Rosebud hospital has changed CEOs at least six times since Adm. Weahkee departed in October 2016, including this Thanksgiving week. Many of them worked at Rosebud on only an interim basis. The agency has struggled to find people willing to accept the job full time.
Rosebud’s chief quality officer temporarily lost her nursing license in 2001 for drinking on the job at a prison where she then worked. Last month, just before an important quality-assurance inspection at Rosebud, the nurse, Carin Greenhagen, was charged with driving under the influence of alcohol or drugs in Arapahoe County, Colo., police records show. She missed the inspection, which Rosebud passed.
Ms. Greenhagen, who is scheduled to appear in court later this week, and the agency didn’t respond to inquiries about those events.
“We are making every effort to make staffing stability a priority” at Rosebud, the IHS said. The agency said funding nursing positions and recruiting in rural South Dakota remains difficult.
In May, Rosebud had a 40% vacancy rate for nurses. Last year, it had fewer than four patients on an average night at the 35-bed hospital. Nine other IHS hospitals had fewer than 10% of their beds filled on the average night in 2018, Medicare data shows. Nationwide, rural hospitals’ average occupancy rates are about 40%, according to the American Hospital Directory.
Scarce funds also mean that when IHS patients are referred to outside facilities for medical care, the agency can’t always pay for it, especially in cases not considered emergencies. In fiscal 2018, the agency estimated that its outside-referral program denied or deferred an estimated $677 million in care, or 163,058 services.
T.J. Heinert, a 25-year-old Rosebud Sioux Tribe member, went to the Rosebud emergency room on Aug. 11 after hurting his left ankle during a rodeo competition. An IHS doctor told him a major ligament was probably torn.
A physician assistant later asked the agency to authorize referrals to an outside hospital for a magnetic resonance imaging scan and to an orthopedic specialist, according to Mr. Heinert’s medical records.
Mr. Heinert said he was warned the requests probably wouldn’t be approved because of limited funds. “He said, ‘it’s not life-threatening,’ ” said Mr. Heinert, whose father is a South Dakota state senator.
Adm. Weahkee was sent in to fix things in May 2016. At that point, Rosebud had flunked a regulatory inspection and its emergency room had closed and the Rosebud Sioux Tribe had filed its suit arguing its health care was inadequate, a claim the government disputed.
At Rosebud, Adm. Weahkee’s five-man leadership team worked 12-hour days and lived in a government housing unit, said Adam Archuleta, one of the team members.
A few weeks after Adm. Weahkee arrived, a nurse anesthetist died. That forced the agency to close the operating rooms and stop delivering babies, saying it aimed to “resume these services as quickly as possible.”
Adm. Weahkee made a one-page list of goals dated June 22, 2016, including restoring emergency operations, regaining the trust of the Rosebud tribe and reopening the operating rooms. That July, he checked off a big one: The emergency department began taking patients again, using doctors from a staffing agency.
The operating room defeated him. Shannon Hopkins, who was deputy CEO at Rosebud in 2016, said she repeatedly brought the problems there to Adm. Weahkee’s attention. “He kept saying [the operating room] was a priority, but there was no action in place to follow that up,” she said.
The agency said its staff was working toward reopening the operating room.
At one point, agency officials realized they didn’t have proper climate controls in the operating room, which could increase infection risks, so workers attached monitoring sensors to one operating room wall with squares of surgical tape, according to a photo viewed by the Journal, staff notes and a July 2016 internal quality audit.
The next week, the team figured out that the tape could itself pose a sanitation risk. “[W]e need something more permanent,” an official wrote in an August 2016 work order. Later, officials realized they needed an estimated $1.2 million upgrade to the hospital’s dated HVAC system, a report by an outside monitor shows.
The agency disputed this account, but didn’t say which aspects were inaccurate. The IHS said it is replacing HVAC equipment throughout Rosebud.
That September, with the climate issues unresolved, Rosebud hired a general surgeon. Adm. Weahkee’s temporary stint in Rosebud ended the next month. The agency paid at least $420,000 over the next year for surgeons who had no place to operate.
“They got paid to sit around a lot of the day and not do anything,” said Ruth Thomas, a former Rosebud physician assistant.
The IHS said the surgeons saved money by screening patients before sending them for agency-paid treatment elsewhere.
In mid-2017, Adm. Weahkee moved from Arizona to IHS headquarters in the Washington area to become the agency’s acting director.
Back at Rosebud, the latest hold up in the operating suite came when it tried to install cabinets, a project that dragged on for more than six months.
“ ‘Oh my God,’ I would think. ‘You’re IHS. You’ve got the full weight of the federal government behind you. You can’t get that a little sooner?’ ” said Kevin Coffey, the CEO of Winner Regional Healthcare Center, a nearby private hospital who visited Rosebud during the construction.
By August 2017, more than a year after the closure of the operating rooms, new cabinets had been installed, according to people with knowledge of the matter. Then a surgical technician realized a new sink was too small to fit an instrument tray for cleaning, according to documents and people with knowledge of the matter.
Construction work had to resume. Staffers made plans to do the first colonoscopy on Oct. 18, 2017, according to internal planning documents.
It never happened. The operating suite still wasn’t ready.
The agency said it addressed the sink issue quickly and disputed it had immediate plans to reopen the operating suite at that time.
The U.S. hospital regulator returned in July 2018 to find the emergency room had again run afoul of federal rules. Among other errors, an intoxicated 12-year-old girl had attempted suicide while left unattended by hospital staff despite a previous effort to take her own life.
The agency made little effort in 2018 to reopen the operating suite, according to people with knowledge of the matter.
“The priority has been ensuring patient safety and establishing a sustainable foundation before” reopening the operating room, the IHS said.
By then, hundreds of thousands of dollars of equipment had been purchased for the suite, including a $230,000 endoscopy tower for which Adm. Weahkee had helped find funding in 2016, according to the goal list.
At the time, staff expected the operating room to open soon and wanted to prepare, the IHS said.
Current and former staff members say the endoscopy tower has never been used.
Indian Health Service Effort To Protect Patients From Abuse Needs Work, Report Says
Inspector general office’s criticism comes after a rush to overhaul practices following a sex-abuse scandal.
The U.S. Indian Health Service’s latest effort to protect patients from abuse falls short, federal inspectors said in a report to be released Friday, despite a rush to overhaul policies this year following a sex-abuse scandal.
The new policies are too narrow and haven’t been implemented at some facilities, according to the Office of Inspector General for the Department of Health and Human Services, which oversees the health care agency. Obstacles remain, including fear among some IHS workers that they will be punished for reporting abuse and confusion over who is responsible for monitoring allegations, the report says.
Ruth Ann Dorrill, a regional inspector at HHS, said in an interview that top IHS officials had acknowledged they were in the early stages of implementing the new policies and didn’t feel they were fully integrated into how the agency operates.
“There are few issues more urgent than this one,” she said.
The inspector general’s review was announced by HHS Secretary Alex Azar days after an investigation by The Wall Street Journal and the PBS series “Frontline” showed that officials mishandled the case of an IHS pediatrician, Stanley Patrick Weber, who sexually abused boys in his care for decades.
Mr. Weber has been convicted of abusing six Native American boys in two states while working for the agency. He is appealing the conviction.
The day the Journal-Frontline investigation was published, the IHS announced new child-protection policies. The agency later required employees nationwide to complete a new training program.
The new policies require employees to report any incident or suspicion of child sex abuse to law enforcement or child protective services within 24 hours, as well as to their supervisors the same day. An IHS official said agency leaders are now “finding out about things much more rapidly than ever before.”
Nevertheless, inspectors found that IHS staff at some facilities continued to fear retaliation over reporting and didn’t trust that their supervisors would respond appropriately if they spoke up. Agency officials also continued to grapple with confusion over how abuse cases are tracked and with concerns about the effectiveness of the system used to report those incidents.
Ms. Dorrill said the IHS clearly faces challenges in implementing the changes. In particular, she said, the agency continued to be hampered by leadership and staff turnover, which makes training difficult to coordinate and sustain. The agency also still needs to have more open and candid conversations among employees when patient abuse problems arise, she said.
She said her team interviewed 45 agency officials, mostly at IHS headquarters, and planned a second report examining whether employees at IHS facilities were adhering to the policy changes.
The IHS said in a written response to the inspector general that it will replace the software used to report and analyze patient safety incidents early next year. Top officials are trying to shift the agency’s culture so that employees are encouraged to report such incidents, with an emphasis on praising employees who speak out, the IHS said.
Inspectors also said the agency’s policies for protecting children from sex abuse by medical providers were sufficient at least on paper. However, they said they focused too narrowly on that particular type of abuse, causing workers to remain uncertain about how to handle other situations.
The inspectors cited the example of an adult patient who complained that a nurse repeatedly physically and verbally abused her. Regulators who investigated the incident found that staff were “not trained on how to recognize, report, and investigate abuse,” the report said.
The Journal detailed that incident, which occurred at an agency hospital on the Standing Rock reservation in North Dakota, in an article last week. The nurse in question didn’t respond to requests for comment.
The inspectors also said the IHS policies should cover all types of staff, citing another Journal report that detailed a 2016 incident at a youth substance abuse center in North Carolina where a maintenance man was accused of sexual misconduct. The maintenance man declined to comment but later denied the allegations in a Facebook post.
The agency said in its response to the inspector general that it plans to expand its policies by next May.
The IHS’s response to its patient-abuse crisis has become a major focus for its acting director, Rear Adm. Michael Weahkee, whom President Trump has nominated to lead the agency on a permanent basis. Adm. Weahkee has repeatedly faced questioning by lawmakers in Congress over his handling of the situation, including at his nomination hearing last week.
At that hearing, he said the agency would continue to take steps to prevent a repeat of the scandal over Mr. Weber. He also criticized the media for focusing too much on negative news about the agency and vowed to promote more positive stories.
Kate Miner’s Tragic Journey Through the U.S. Indian Health Service
An X-ray found clear signs of cancer. What happened next showed the federal agency’s systemic failures.
Kate Miner walked into the Indian Health Service hospital, seeking help for a cough that wouldn’t quit.
An X-ray taken of Ms. Miner’s lungs that day, Oct. 19, 2016, found signs of cancer.
What exactly the IHS doctor said to Ms. Miner about her exam remains in dispute. Notations in her medical file indicate the doctor told her to come back for a lung scan the next day. Her family says they never were given such instructions and weren’t told of the two masses the X-ray revealed.
What is clear is that no further tests were done. And no IHS provider followed up when Ms. Miner returned twice more to the hospital, the only one on the Cheyenne River Reservation, over the next six months, medical records show.
Finally, on May 7, 2017, as the 67-year-old Ms. Miner lay crumpled on a hospital cot, the right side of her body shaking, a physician assistant ordered a CT scan, after her family insisted, according to the records and family members.
“You have two very large masses in your right lung. It’s probably a malignancy,” Ms. Miner’s daughter Kali Tree Top recalled the physician assistant saying.
Ms. Miner reached for her daughter’s hand and started to cry.
Ms. Miner’s encounters with the IHS, and her family’s repeated efforts to get her help there, illustrate how the federal agency can fail the patients who need it most.
At the Cheyenne River Health Center in Eagle Butte, a succession of IHS medical providers treated Ms. Miner’s symptoms but never followed up on initial concerns about her condition, making each visit effectively her first, medical records show.
Operational problems such as mismanaged patient chart systems affected her care, those records show. When hospital staffers discovered serious health problems, the results weren’t clearly communicated to Ms. Miner or other providers to ensure the right testing was done, according to the medical records and her family.
“The sad thing is, our people don’t have a choice. That’s all that is there,” said Harold Frazier, the Cheyenne River Sioux tribal chairman.
In recent years, tribal leaders, health experts and federal regulators have identified widespread problems with the IHS. Ms. Miner, like many of the agency’s patients, was let down by the care she got there, not because of one catastrophic medical mistake, but by a cascade of shortcomings that the agency has failed to fix despite years of promises from its leaders.
IHS hospitals, including the one in Eagle Butte, have been cited by regulators time and again over the past decade for dangerous medical care, including haphazard record-keeping, negligent follow-ups and sending home patients who turned out to be critically ill.
In October, Ms. Tree Top sued the government over her mother’s care, alleging that the IHS never informed Ms. Miner of how sick she was and failed to treat her illness.
The IHS declined to comment on Ms. Miner’s case because of the pending litigation. In a court filing Friday, lawyers for the Justice Department denied the allegations. In a written statement, Charles Fischer, the Eagle Butte hospital’s top official, said the facility has a “sound medical records and records management program” and had improved the consistency of its care in recent years.
The IHS provides free health care for 2.6 million Native Americans under treaties between the U.S. government and tribes. The agency is supposed to help a patient population often in desperate need of medical attention, with high rates of chronic illnesses and deaths related to substance abuse.
On much of the Cheyenne River Reservation, life expectancy is 67.6 years, according to data from a University of Wisconsin research group, more than 10 years less than the U.S. average and lower than in North Korea.
The Wall Street Journal reviewed hundreds of pages of medical records provided by the IHS to Ms. Tree Top about her mother’s case. They describe Ms. Miner’s multiple visits to the Eagle Butte facility in 2016 and 2017.
Kate Miner’s family wasn’t used to seeing her feeble and helpless. She stood 4-foot-11 and weighed barely 120 pounds, but her knack for small talk and storytelling, her sharp tongue and her spectacles gave her an air of authority.
She grew up in one of the tiny Cheyenne River communities scattered across this isolated reservation roughly the size of Connecticut, learning to run cattle as a little girl from her rancher father. She dropped out of high school, working construction and other jobs before becoming a nurse at the IHS hospital and then a detox coordinator.
She raised three daughters and a son by herself in Eagle Butte—at about 1,300, the largest town on the reservation.
Ms. Miner knew most everyone in Eagle Butte, friends said. After retiring in 2002, she would wake at 5 a.m. and drive around town to see what was happening before heading home to entertain visitors over cigarettes and coffee.
In the fall of 2016, Ms. Tree Top noticed her mother had a bad coughing bout while returning from shopping for groceries at Walmart in Pierre.
Ms. Miner had smoked for many years before cutting down, and she had interstitial lung disease, which causes lung scarring. She also suffered from scleroderma, a painful rheumatic disease affecting the skin. She occasionally saw non-IHS specialists in Rapid City, 170 miles away.
She hadn’t visited a pulmonologist there in over a year, but more recently had seen a cardiologist who ordered tests on her heart. Ms. Tree Top worried the cough was bronchitis contracted from one of Ms. Miner’s great-grandchildren. She made an appointment for her mom at the IHS.
For her own care, Ms. Tree Top tried to avoid the IHS. As a girl, she had to get her broken arm reset at a Pierre hospital after an IHS doctor hadn’t set it properly, leaving her in pain, she said.
With no other nearby options for her mother, Ms. Tree Top took Ms. Miner to the Eagle Butte hospital, which opened in 2012 to replace a 1950s-era facility one-third its size.
A nurse checked Ms. Miner’s vital signs but couldn’t do a throat culture because the hospital had run out of the long cotton swabs used to do them, records said.
Saira Khan examined Ms. Miner and ordered an X-ray. A radiologist noted a “pleural-based mass” in the right lung—meaning a likely cancerous tumor—and a second mass in the same lung, records show. The radiologist suspected a “neoplasm,” an indication the second tumor was also likely cancerous, and recommended a CT scan.
According to Dr. Khan’s medical notes, she shared the X-ray results with Ms. Miner.
Ms. Tree Top said Dr. Khan didn’t mention any masses or tumor to them. She said Dr. Khan reported some “cloudiness” in her mother’s lungs that could be causing the cough and wanted a closer look.
It was getting late in the day. “Would it be all right, if we need to, could we call you back in?” Ms. Tree Top recalled Dr. Khan saying about scheduling the scan.
Dr. Khan sent Ms. Miner home with a prescription for cough syrup and antibiotics, records show.
Ms. Tree Top remembered her mother elbowing her as they left the hospital, saying: “See? I told you all they were going to do was give me antibiotics and cough syrup.”
“Well, at least it’s nothing serious,” Ms. Tree Top replied.
Dr. Khan’s medical notes indicate she thought she had been more explicit with her patient that day. “Would order a CT, patient will come to get CT tomorrow. Patient verbalizes understanding and agrees with the plan,” her notes say. Further down in her notes, Dr. Khan wrote, ambiguously: “Follow up in months.”
Dr. Khan didn’t speak with Ms. Miner or her family again, family members said. According to Ms. Tree Top, nobody from IHS ever contacted them about needing Ms. Miner back for a lung scan.
Dr. Khan, who left the IHS in August, didn’t respond to requests for comment.
The confusing records, and the seeming lack of follow-up, wasn’t a new problem at the Eagle Butte facility. The hospital was cited in at least nine reports between 2005 and 2009 by the Centers for Medicare and Medicaid Services, the U.S. hospital regulator, for failing to properly document patient information, for poor follow-up and unsafe care. (In the years that followed, its inspections were conducted by the Joint Commission, a health-care nonprofit that accredits hospitals. Its reports are confidential.)
Mr. Fischer, the hospital’s top official, said all employees must undergo annual training on records management, and that any allegations of problems are “seriously and swiftly addressed.”
Cindi Pochop, one of the doctors who treated Ms. Miner, said patients’ records at Eagle Butte are sometimes mislabeled, often disorganized and difficult to locate quickly. She said there is no clear system to ensure that providers view important findings, and serious problems can get missed. She declined to comment on Ms. Miner’s case because of the litigation, and said the agency had been trying to address the issues, with minimal success.
As recently as October, a Department of Health and Human Services report found the IHS’s record-keeping systems continued to cause problems, saying the transferring of patient information was “burdensome, error-prone, and time-consuming.”
Over Christmas 2016, as family gathered at Ms. Miner’s home, her daughters noticed she ate less. Ms. Miner smiled at the police scanner Ms. Tree Top bought her so she could trail the emergency vehicles around the reservation the way she liked. She soon retreated to her room, saying she was exhausted.
Several days later, she called Ms. Tree Top.
“Kali, my girl, I’m not feeling well,” she said, explaining she was nauseated, with body cramps.
On Dec. 30, Ms. Miner returned to the IHS hospital. A nurse checked her vital signs, and her Oct. 19 visit was referenced for comparison, records show.
Mr. Fischer said if a patient doesn’t show up for a CT scan, “the order remains outstanding in the system until the patient contacts the department.”
In Ms. Miner’s chart from that day, which included her medical history, the staff didn’t list any outstanding orders for a CT scan, nor was there any reference to the X-ray results showing tumors.
A physician assistant examined Ms. Miner, wrote her a painkiller prescription and sent her home an hour after she arrived, the records show.
Over the next several months, Ms. Miner grew more fatigued and withdrawn. In early spring, she contracted what seemed like a stomach bug. When she didn’t get better, Ms. Tree Top and her brother, John, took their mother to the hospital on April 7.
That day, Ms. Miner vomited six times, medical records show. She had lost nearly 14 pounds since her last visit and was now down to 87 pounds. The physician assistant who examined her, Martin Katambwa, described her as “well-nourished,” records show.
Mr. Katambwa was the third different provider Ms. Miner saw in three visits—meaning he, like the others, had little familiarity with her or her family’s medical history. IHS facilities long have been hampered by high staff turnover and a lack of continuity of care. In 2017, the Eagle Butte hospital had a vacancy rate for doctors of 50%. It now stands at 27%.
Neither Mr. Katambwa nor the nurses who saw Ms. Miner mentioned in her charts that day the masses found months earlier. It isn’t clear whether they ever saw them in Ms. Miner’s records.
Mr. Katambwa diagnosed her with gastroenteritis and sent her home with antinausea medication.
A few days later, Ms. Tree Top gave her mom a hug.
“You’re just a sack of bones,” she said.
“I’ll still kick your ass,” her mother shot back.
By May, Ms. Miner was in near-constant pain, family members said. One morning, she cried out to her son that her right side was hurting and shaking. Panicked, John called Ms. Tree Top and his other sister, Lisa, telling them to meet him at the IHS emergency room.
During that visit the two masses in Ms. Miner’s lungs were spotted again—on a new X-ray and the CT scan her family requested. She was seen again by Mr. Katambwa, who consented to the scan despite misgivings that it wasn’t necessary, according to the family.
The tests allowed Mr. Katambwa to assess her ailment in her medical records as “right lung cancer.” He told Ms. Miner she needed to return the next day for outside referrals, the family said.
Mr. Katambwa didn’t respond to requests for comment.
Back home, the family gathered around the table. Ms. Miner began speaking in Lakota, which her own parents had spoken to her when she was little. Aside from a few terms of endearment, her children had never heard her speak the language before.
Her daughters strained to recognize words they understood. It sounded like their mom was talking about a dream she’d had where Lakota spirits visited her and told her the tumors wanted to take her.
Four hours later, Ms. Miner’s pain had grown excruciating. She wanted to return to the IHS hospital.
There, Ms. Miner reported a pain level of 8 out of 10, a nurse documented.
Robert Martin Jr. , the physician who saw her that night, wrote in her chart that Ms. Miner had come to the emergency room earlier that day and was “found to have a right lung mass which is probably Cancer.”
Ms. Miner’s daughters said Dr. Martin never physically examined her, instead popping his head into the exam room, saying she was very sick and needed to come back tomorrow for referrals. They said Dr. Martin had a nurse give Ms. Miner antipain and antinausea medication before discharging her.
Dr. Martin said in an interview he didn’t recall Ms. Miner’s case, but that he always examined his patients.
In 2015, Dr. Martin’s medical license in Arkansas was suspended, then restricted, after he allegedly prescribed painkillers to two patients with whom he was sexually involved, according to that state’s medical board.
The women were prostitutes at a Nevada brothel, board records show, and appeared on the HBO show “Cat House: The Series.” Dr. Martin also allegedly prescribed steroids to himself, the records show.
As part of the sanctions, he offered to practice only on Indian reservations or at Department of Veterans Affairs hospitals, Arkansas medical-board records show. Eight months after his suspension, the disciplinary order was dismissed, and the restrictions were lifted.
In an interview, Dr. Martin denied all the allegations, saying he was seeking to rescue the women from prostitution and was targeted by their pimp. He no longer works at the IHS. He provided the Journal with a 2018 letter from his IHS supervisor praising his work at Eagle Butte.
The next morning, Ms. Miner and her daughters returned to the IHS hospital to get cancer-specialist referrals.
Ms. Pochop, the doctor who treated Ms. Miner that day, spoke with her about getting an outside oncology appointment, writing in her chart that Ms. Miner’s treatment options were now likely limited because of chronic health problems and frailty.
She referenced in her notes the CT scan that Dr. Khan originally recommended after an “abnormal” X-ray the prior October. “Unfortunately, pt did not return the next day as directed,” Dr. Pochop wrote.
Dr. Pochop wanted to know why Ms. Miner didn’t return for the CT scan, her daughters said.
“She never told us to come back,” Ms. Tree Top told Dr. Pochop. Had they known about the masses in October, they would have rushed to get whatever treatment their mom needed, she said she told the doctor.
Ms. Miner, distraught about her diagnosis, just stared at the floor.
An oncologist who reviewed Ms. Miner’s charts at the Journal’s request said she likely was very sick already when the first X-ray caught the two masses seven months earlier, and that it was doubtful any treatment would have cured her.
Nevertheless, said Kathryn Locatell, a forensic geriatrician who specializes in examining medical records and also reviewed the charts, Ms. Miner should have been given the opportunity to seek treatment earlier—and to put her affairs in order, given that she was gravely ill.
Over the next several days, Ms. Tree Top said, she unsuccessfully tried to get specialist appointments for her mother at Regional Health Rapid City Hospital through IHS’s referral department. The IHS staff didn’t complete the correct paperwork, and it took more than a week for the agency to send out the proper forms, she said.
On May 24, less than three weeks after the diagnosis, Ms. Miner’s daughters drove her to the Rapid City hospital, where doctors told her she had small cell lung cancer. It had spread to her liver and brain. She died there six days later.
Doctor Sentenced to Five Lifetime Terms for Sexually Abusing Boys
An Indian Health Service pediatrician who was convicted of sexually abusing young Native American boys in his care over two decades and became an emblem of the federal agency’s long-term failures was sentenced Monday to five lifetime prison terms.
Stanley Patrick Weber, 71, groomed and abused Native American boys as young as about 9 years old on reservations in Montana and South Dakota between 1995 and 2011, according to court documents.
His supervisors in the federal government buried their own suspicions about his conduct, tried to silence others who raised concerns, and transferred the doctor from one reservation to another after managers concluded he might have molested his patients, The Wall Street Journal and the PBS series Frontline reported last year.
The agency’s handling of Weber revealed broader dysfunction at the U.S. agency that provides health care to 2.6 million Native Americans, often in some of the nation’s poorest and most remote communities. The Journal and Frontline later reported that the agency had hired dozens of doctors with track records of malpractice, licensure sanctions and even criminal convictions who went on to harm patients at IHS hospitals.
Weber was convicted in South Dakota in September of abusing four of his patients at the IHS’s Pine Ridge hospital and his government housing unit there. One victim testified at the trial that Weber had used narcotics to subdue him before sexually assaulting him, and another described escalating assaults during a series of visits in hospital exam rooms.
In delivering the sentence, Chief U.S. District Judge Jeffrey Viken described his four-decade legal career before pronouncing he had never seen anything like the “abuse of trust you have inflicted on these men.” Judge Viken imposed 45 years and an $800,000 fine in addition to the five life sentences.
Three of the victims he was convicted of abusing were present in the crowded courtroom and spoke of the impact of Weber’s crimes. “I need help, I try to get help,” said one of the victims. “But I refuse to go to the IHS.”
In 2018, Weber was convicted in a separate trial in Montana for abusing two former patients there, and sentenced to more than 18 years in prison. He appealed that conviction, but a higher court affirmed it Monday, hours before his South Dakota sentencing.
An IHS manager in Montana concluded in 1995 that Weber might be molesting his patients, and ordered his supervisor to fire him. But, just weeks later, Weber re-emerged with another agency job, at Pine Ridge. There, he survived multiple investigations and years of complaints by colleagues about the parade of boys who visited his home at night.
After hearing his sentence Monday, Weber had no visible reaction. His lawyer, Harvey Steinberg, declined to comment as he left the courtroom.
U.S. Attorney Ron Parsons said the case had focused the federal government’s attention on accountability for such abuses. “This has been a wake-up call for everyone, including us,” he said.
Rear Adm. Michael Weahkee, the director of the IHS, said in a statement, “The actions of this individual were reprehensible, and we sincerely regret the harm caused to the children involved.”
The investigation that led to the convictions began after a prosecutor at the Oglala Sioux Tribe, which is based at Pine Ridge, began looking into the case in 2015. The prosecutor, Elaine Yellow Horse, learned the name of one boy who had earlier told associates that Weber had abused him.
Ms. Yellow Horse, now a law student, attended the sentencing hearing Monday in Rapid City, at times looking down and wringing her hands as victims described the damage Weber had inflicted. She said, “I hope they can restart their lives now that they have had their voices heard.”
The tribe, which doesn’t have jurisdiction over non-Native American offenders, passed the lead on to investigators at the Bureau of Indian Affairs, which in turn enlisted the Department of Health and Human Services’ Office of the Inspector General. Those federal agents then identified a series of other victims spanning the two states.
The Oglala Sioux Tribe’s current president, Julian Bear Runner, addressed the court, saying Weber had told him when he was a teenager that he didn’t need to bring an adult for a return visit.
Reports by the Journal and Frontline about Weber have prompted at least five federal investigations. One of them, an independent review commissioned by the IHS, recently ended. A private contractor hired by the IHS reviewed three decades of agency records concerning Weber and interviewed about 50 people involved in the case, people familiar with the findings show.
But the agency has declined to disclose the report, arguing it is a confidential quality-assurance record that is not public by law. IHS told congressional offices it plans to eventually release a summary of “broad findings and recommendations.”
Mark Butterbrodt, a former IHS pediatrician who repeatedly accused Weber of sexual misconduct, said he was interviewed by investigators in that probe. He said they showed him records indicating an IHS official had signed off on renewing Weber’s patient-care privileges at Pine Ridge just one day after the disgraced doctor had submitted a form alerting the agency he was under investigation by the South Dakota board of medicine.
Dr. Butterbrodt, speaking at the hearing Monday, described his efforts over about 15 years to call attention to Weber’s conduct. “Not one physician stood with me on that medical staff,” he said. Instead, he said, they snickered about their colleague’s behavior.
A top medical official at the hospital at the time said her colleagues investigated allegations against Mr. Weber but found no hard evidence of misconduct.
At the height of the courtroom drama that unfolded Monday, the first victim, who now is incarcerated, shook his head and remained seated in shackles when a prosecutor asked if he wished to speak.
Then, two of his childhood friends—also victims of Weber—spoke to the court about their experiences. One turned to the shackled man who’d kept his silence and said, “I love you.”
The prisoner changed his mind. In a strained speech, he told the court he had lost his ability to trust anyone as a result of Weber’s abuse: “I look at each and every one of you as potential predators.”
And he turned to his friends seated in the audience and told them, “You gotta stay strong.”
Indian Health Service Managers Protected A Pedophile In Their Midst. Now the Agency Is Protecting Them
Senior officials failed to act on warnings that Stanley Patrick Weber was preying on Native American boys and even retaliated against whistleblowers, according to an internal report. The IHS has attempted to hide some of their identities.
After a doctor at the U.S. Indian Health Service accused a colleague of sexually abusing boys in 2009, a senior personnel supervisor at the agency named Paul McSherry quickly took sides, a new internal report obtained by The Wall Street Journal says.
The government should defend the accused, pediatrician Stanley Patrick Weber, and discredit the whistleblower by reassigning him to a remote outpost, Mr. McSherry wrote, according to the report, which the IHS disclosed after a legal effort by the Journal’s publisher.
“The sun is shining in Kotzebue this time of year,” wrote Mr. McSherry, who at the time helped run a human-resources office based at the agency’s Washington-area headquarters, referring to the northwest Alaskan town. Now retired from the IHS, Mr. McSherry said in a text message to the Journal: “This was over 11 years ago and I have no recollection of this communication.”
The accuser, pediatrician Mark Butterbrodt, was ultimately transferred to an agency hospital on the Canadian border, the report says, and quit a year later. Weber was promoted and stayed with the agency for another seven years, it says. After Weber resigned in 2016, he was convicted of sexually abusing Native American boys under his care at IHS facilities over two decades.
Despite pledges to hold its own accountable for their failures to stop Weber sooner, the IHS is still fighting to keep the names of officials like Mr. McSherry secret, citing privacy concerns.
The version of the report it released last week redacts the names of agency managers and leaders in hundreds of instances, including current and former officials at the IHS and its overseer, the Department of Health and Human Services, who the report shows did little or nothing when they were warned about Weber’s conduct.
The IHS said in a statement Sunday that it “sincerely regrets that this abuse went undetected for so long, and remains committed to preventing this abuse from happening again, regaining the trust of our patients, and providing safe and quality health care to all we serve.”
The Journal identified many of the officials based on other records and interviews with people familiar with the internal investigation, revealing for the first time just how widely sex-abuse allegations against Weber circulated in the agency.
The IHS commissioned the report in 2019 after an investigation by the Journal and the PBS series Frontline exposed many of the agency’s missteps in handling Weber’s case. Around that time, then-IHS director Michael Weahkee told U.S. senators the report would show exactly “where the breakdowns occurred and who should be held accountable.”
After the report, by contractor Integritas Creative Solutions LLC, was completed in January 2020, the U.S. government fought to conceal the findings from public view for more than 20 months. The IHS said the report was a confidential medical quality-assurance record, but federal judges repeatedly sided with a challenge by Dow Jones & Co., parent of the Journal, and the New York Times.
When the agency disclosed the findings last week following a court order, it cited the personal privacy interests of its employees, some of whom helped cover up for Weber, as the reason to redact their names.
Not every name was redacted. The IHS identified some managers who had already been interviewed for the Journal-Frontline report, for instance. Some officials’ names were redacted in some instances, and not in others. At times, the agency appeared to have missed names it intended to redact.
The IHS statement didn’t answer a written question posed to it by the Journal about whether the agency had taken any action against employees following the report’s findings. Instead, the agency argued that “due to elapsed time, individual examples and recollections may lack broader details, interpretation, or context.”
The redacted names and titles include a Denver-based HHS attorney who advised the agency on legal affairs and learned about the abuse allegations against Weber in March 2009. The current CEO of one of the Indian Health Service’s North Dakota hospitals was told of the allegations a few months later.
The top official now overseeing IHS’s Oklahoma City region knew of Weber’s alleged abuse as early as June 2010, according to the report and interviews.
None of them reported the abuse allegations to law enforcement, as required by law, the report notes.
Instead, Weber was promoted. He was named medical director of the IHS hospital in Pine Ridge, S.D., where he supervised potential witnesses to his crimes and maintained access to teenage patients even after agency officials were notified he was under federal investigation for sex crimes in 2015. He resigned the next year.
Weber was sentenced to five life prison terms in 2020 for a series of crimes that included raping a drugged teenager at his IHS housing unit and penetrating an 8-year-old boy in an IHS exam room. The agency faces several civil lawsuits by victims of the abuse. Weber’s lawyer didn’t respond to a request for comment.
The new report says that Weber’s conduct at the IHS was an “open secret.” Newly hired nurses were warned to keep track of how long Weber was in exam rooms with boys as part of their training, it said. One staff member recalled hearing Weber had been discovered playing videogames in the hospital bed of one of his patients.
On Monday, the Journal published a version of the report disclosed by the IHS. While the IHS concealed the names of its employees in many instances, it didn’t protect the identities of three alleged victims of sexual misconduct by agency workers.
The Journal has removed those names from the version it published.
The report shows how rare efforts by Weber’s colleagues to flag his abuse—at stints in New Mexico, Browning, Mont., and finally Pine Ridge, S.D., spanning more than 20 years—often hit dead ends. Sometimes they were met with retaliation.
In 2009, Jan Colton, an IHS dentist who then oversaw medical care at Pine Ridge, received a complaint from Dr. Butterbrodt, the IHS pediatrician, alleging Weber was engaged in misconduct with teens and cherry-picked adolescent males to be his patients, the report says. She sought advice from HHS’s Denver-based attorney, Jim Cribari, the report shows.
Health department lawyers and medical providers are required to report sexual abuse allegations to law enforcement. Mr. Cribari instead advised Dr. Colton to set up an “ad hoc Investigative Committee” to look into the complaint and suspend Weber pending the resolution, Integritas reported.
“You need to read it and understand that it is just one view point,” Mr. Cribari said of the report. He declined to comment to the Journal on his conversations with agency officials, citing attorney-client privilege.
The investigative committee appointed to look into Weber never interviewed any witnesses and didn’t pursue other evidence, the report says. Hector Burgos, a general surgeon who still practices at Pine Ridge, told Integritas he recalled only one meeting of the committee. It concluded the allegations couldn’t be substantiated, Dr. Colton said in an earlier interview with the Journal.
Drs. Burgos and Colton didn’t respond to requests for comment on the report.
At the time, Weber’s standard biennial application to be reappointed to the Pine Ridge medical staff was pending. On the application, Integritas found, Weber disclosed that he faced a South Dakota Board of Medicine investigation: “One of the complaints if (sic) that I am [a] child molester.”
Nevertheless, Dr. Burgos and other members of the medical staff and Pine Ridge management team, who faced a chronic shortage of doctors, signed off on his reappointment in May. Among them was Frankie Delgado-Canas, by then the facility’s medical director.
Dr. Delgado-Canas was charged in 2011 with federal felonies related to alleged sexual harassment of two nurses. He pleaded guilty to two counts of disorderly conduct.
Dr. Delgado-Canas, who now works for the Department of Veterans Affairs, couldn’t be reached for comment.
Few aside from Dr. Butterbrodt raised their complaints up the chain of command, in part due to a fear that managers would retaliate, the report says.
In June 2009, Ron Keats, one of Weber’s regional managers, emailed colleagues at headquarters that Dr. Butterbrodt “is still up to no good” and that “Weber has had a rough 3-4 months” fending off the allegations, the report shows.
At that point, Mr. McSherry, then the deputy director of the IHS’s Rockville, Md.-based Office of Commissioned Personnel Support, proposed a solution. Referring to Weber by his U.S. Public Health Service Commissioned Corps rank, he advised, “Move CAPT Weber to restore him. Move the other guy too so there is no implication that his actions or accusations have merit.”
“It does confirm my suspicion that people at the very highest levels of the Commissioned Corps were complicit in the cover up,” Dr. Butterbrodt told the Journal in an interview this past week. The Commissioned Corps is a group of uniformed health workers that includes many IHS medical providers. Dr. Butterbrodt, seen as an outsider in the Corps for rarely wearing his uniform and frequently bucking orders, resigned in 2011.
Mr. Keats sought support for the plan from the agency’s top regional official in South Dakota, Charlene Red Thunder, and her deputy Shelly Harris, emailing that Dr. Butterbrodt, “based on arbitrary information without any evidence or proof, accused CAPT Weber of non-professional behavior.”
Ms. Red Thunder approved Weber’s reappointment application three days later, Integritas noted.
Ms. Harris, who remains a senior official at the IHS, overseeing its Belcourt, N.D., hospital, declined to comment. Ms. Red Thunder, now retired, said she thought highly of Dr. Butterbrodt, but relied on the local hospital staff at Pine Ridge to determine whether to approve Weber’s reappointment.
A year later, Mr. Keats, who helped manage Weber, was forced out of the agency over a child pornography investigation that later resulted in his conviction on related charges. Mr. Keats’s lawyer didn’t respond to a request for comment.
Mr. Keats’s replacement, Travis Watts, also dismissed Dr. Butterbrodt’s reports of Weber’s misconduct, the report shows. Mr. Watts told a colleague he knew of allegations that Weber had “acted inappropriately with teenage boys,” but that law enforcement had looked into it and “came up with nothing,” according to an email cited in the report.
Mr. Watts, a pharmacist who is now a rear admiral in the Commissioned Corps and the head of IHS’s Oklahoma regional office, told Integritas he based this information on Mr. McSherry’s version of events and didn’t attempt to verify it. Integritas found no meaningful investigation into Weber had been conducted. Instead, HHS’s Office of Inspector General had just declined to follow up on a tip, the report shows.
Mr. Watts declined to comment.
The report says IHS failed to produce emails spanning 2010 until mid-2015. In an interview, Carl Caulk, Integritas’s leader, said the agency had fully cooperated with his requests, but struggled to locate records and appeared not to have documented important events.
Other health department units, including the Office of General Counsel, didn’t respond to requests for Integritas interviews or declined to make employees available, the report says.
In July 2015, a Bureau of Indian Affairs law-enforcement official informed IHS and HHS managers that it had opened a federal investigation into Weber.
Mr. Cribari, the health department lawyer, recommended that Ms. Harris and other officials suspend Weber’s clinical privileges and put him on administrative duty.
Instead, IHS officials did nothing for nearly four months, and Weber continued seeing pediatric patients, including making nighttime visits to hospitalized teens, Integritas found.
Officials finally barred Weber from patient care in October of that year, after the Office of Inspector General joined the investigation. But the IHS didn’t remove Weber from his other role as the hospital’s acting clinical director—one of the most powerful positions at Pine Ridge.
Integritas investigators say in the report that the move “allowed him continued access to the same adolescent Indian male population into which he had spent years ingratiating himself.”
Despite a restriction from treating patients, Weber continued seeing teenage boys in the administration office in plain view for months, the report says.
IHS officials finally suspended Weber in May 2016. Just beforehand, an administrative assistant told Integritas, she saw him shredding documents in his office. “He is shredding the evidence,” she recalled thinking, the report says.
Integritas said its investigators never found copies of key documents from Weber’s time at Pine Ridge, such as the ad hoc investigative committee’s report.
Weber quit days later, the report says.
A few days after Weber resigned, an HHS Inspector General’s agent visited Weber’s house to question him as part of the investigation that would ultimately lead to his convictions, according to the report and court records.
Weber wasn’t home, the court records show. In a sign of how open Weber’s conduct was, the report notes, “a young boy was at Weber’s house” at the time.
“For every known victim there are likely dozens of victims who endured their abuse in silence and will do so until the end of their life,” the report concluded.
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