WASHINGTON – A special office created by President Donald Trump to investigate potential wrongdoing, hold senior leaders accountable and protect whistleblowers at the Department of Veterans Affairs failed in its most basic mission, an investigation by the VA inspector general found.

In two years, the office removed just one VA executive, conducted shoddy investigations, disrespected whistleblowers and “floundered” in its duty to protect them, according to the inspector general.

In one case, the Office of Accountability and Whistleblower Protection targeted an employee at the request of a senior executive who played golf with the director. In another, an office leader steered contracts worth more than $2 million – 15% of the office's budget in 2018 – to projects unrelated to the office's mandate.

“The former leaders of OAWP engaged in misdeeds and missteps that appeared unsupportive of whistleblowers while also failing to meet many of the other important objectives of the Act" that created the office, wrote James Mitchell, who oversees the inspector general’s special reviews.

VA Inspector General Michael Missal said the report “details deficiencies and derelictions in OAWP’s development that have undermined its credibility and ability to achieve its mission – the impact of which continues to be felt today."

In a response to the report issued Thursday, the VA said many improvements have been made since a new leader took over the whistleblower office in January.

"It’s important to note that this report largely focuses on OAWP's operations under previous leaders who no longer work at VA," the agency said in a written statement.

Tamara Bonzanto, an assistant VA secretary and the new head of the office, “independently identified” many issues highlighted in the report and instituted better training for its employees and investigators, among other improvements, the VA said.

A 'floundered' mission

Trump established the whistleblower protection office by executive order in April 2017 and signed a law making it permanent two months later. "We are sending a strong message: Those who fail our veterans will be held, for the first time, accountable," Trump said at the time. And for employees who expose wrongdoing, “we will make sure that they're protected."

The office went through a succession of leaders as it received thousands of reports of potential wrongdoing at the agency, which employs 350,000 and includes more than 1,200 medical and other facilities across the country.

The inspector general found the office investigated things it shouldn’t have, including criminal allegations like excessive force against patients, which should have been referred to law enforcement.

And the office failed to investigate matters it should have, including “misconduct and poor performance” that may have been reported by non-VA employees, including veterans, family members or even members of Congress.

When it did investigate potential wrongdoing, the reviews were often conducted by human resources professionals who lacked training in investigations and weren't guided by any written procedures.

The shortfalls “contributed to the failure to consistently conduct investigations that were procedurally sound, accurate, thorough and unbiased,” the inspector general concluded. One official quoted by investigators described the inquiries as “a (disciplinary) action in search of evidence.”

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In one case, an investigator with the Office of Accountability and Whistleblower Protection decided not to interview more witnesses because a “determination was made to not waste more resources.”

The lone executive who was removed under the office’s authority was the director of the Washington, D.C., VA medical center, Brian A. Hawkins. He was fired in 2017 after equipment shortages and other failures jeopardized patients. He was reinstated with back pay earlier this year after a federal court reversed his removal.

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Questions about personal ties, contracts

After receiving complaints that the VA's head of human resources at the time had created a hostile work environment, the whistleblower office’s director at the time, Peter O’Rourke, personally selected an investigator to look into the claims.

O’Rourke was friends with the personnel chief, Peter Shelby, and they frequently golfed together. The whistleblower office turned around and investigated one of the employees who had complained about Shelby, the inspector general found. The request to do so came from Shelby himself.

Meanwhile, a top adviser to O’Rourke, who also golfed with Shelby, emailed Shelby about personal retirement needs, at one point asking for assistance with an annuity because “it is a fairly large sum of money for me.”

Shelby and O’Rourke left the VA in 2018. The inspector general referred findings about the adviser, Kirk Nicholas, to law enforcement for further review. O’Rourke declined to comment, and Shelby and Nicholas, who left the VA earlier this year, did not respond to messages seeking comment.

Nicholas was involved in awarding contracts for leadership development and consulting that investigators concluded were unrelated to the whistleblower office’s mission. They obligated $2.6 million out of the annual budget of $17.4 million.

In one case, a contract went to a vendor "associated with an individual with whom Mr. Nicholas had a personal relationship." That award has been canceled.

Failure to protect whistleblowers

The inspector general concluded the whistleblower office didn’t do enough to protect employees who reported suspected problems. Among its failures: It didn't prevent complaints from being referred back to the employees who were suspected of causing the problems.

The inspector general found that a program created by the office to mentor whistleblowers and help them reintegrate into the VA workforce was ineffective. The program helped only one whistleblower in 18 months, and statements made by former office leaders created the impression the office sought to silence whistleblowers.

“Any such effort must be designed to support and value whistleblowers rather than characterize repeat whistleblowing as an unwelcome and recidivist behavior,” the inspector general concluded.

The program has been canceled. The employee who oversaw it, Brandon Coleman, is a former whistleblower at the VA hospital in Phoenix. He has since filed for whistleblower protection himself with another agency that protects federal employees who speak out, the Office of Special Counsel.

The inspector general recommended that the Office of Accountability and Whistleblower Protection establish written guidelines for investigations and operations, create a process to ensure they are followed, and assure “accuracy, thoroughness, timeliness, (and) fairness.”

The VA said in its response that the whistleblower office plans to have all the improvements in place by the end of the year.

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