JusticeforLt.Col.Sutton.

Berta "Probably 95-99% of us here have received denials, and we just kept fighting back. " Yes, I am so fiercely ready for this fight. "I think they would have to send you a copy of it now because the claim was denied." Do you have any ideas on who to contact to request this Peer Review. Should I call the Chief of the Spinal Cord Center at the VAMC of Memphis, ???? I would like to point out a few issues I have initially after going over the decision letter. Any guidance would be very appreciated. Under the evidence: 1. The Peer Review is not listed. (Though I gave my POA to the State Veterans Office last week thus I am suppose to view my C File on Wed. 3rd. and am hopeful it might be in there) 2. They listed " VA medical records, Memphis VA Medical Center, received March 25 2019 for the period of March 13, 2018 to September 13, 2018". This is not the accurate time of hospital admission nor what was submitted to them. The correct dates in which were submitted by me should be March 12 2018 to September 13, 2018. (The reason the medical records dated to Sept 13, 2018 (date of death March 22, 2018) is the VA providers continued to make late entries into his medical record). 3. Listed as evidence was "VHA Residents and Trainees and Extraordinary Circumstances submitted by Claimant received October 18, 2019". "VHA Residents and Trainees and Extraordinary Circumstances" does not exist. There is not a VHA publication nor one I submitted. In addition, I did submit multiple VHA publications in which were violated during this admission. I submitted the following as evidence: VHA Handbook 1176.01 Spinal Cord Injury and Disorder System of Care VHA Directive 1352 Prevention and Management of Pressure Injuries VHA Directive 1232 (2) Consult Processes and Procedures VHA Handbook 1401.01 Resident Supervision VHA Directive 2009-058 Pain Management VHA Directive 1400.01 Informed Consent VHA Directive 1004.03 Life Sustaining Treatment Decisions: Eliciting. Documenting, and Honoring Patients Values, Goals, and Preferences VHA Directive 1177 Cardiopulmonary Resuscitation VHA Directive 1157 Out of Operating Room Airway Management I also submitted the all of the below as evidence. All of which are pertinent to establishing they there medical malpractice. I do not see any of the below listed on the Decision Letters Evidence. Therapeutic Monitoring of Vancomycin: A revised consensus guidelines and review Vancomycin Drug Insert Meropenem Drug Insert Sepsis Clinical Practice Guidelines Order Summary Medication Administration Record (MAR) Surviving Sepsis 1 Hour Bundle Clinical Practice Guidelines Morphine Drug Insert Bumetanide (Bumex) Drug Insert Versed Drug Insert Etomidate Drug Insert Diprovan (Propofol) Drug Insert Blue Alert Record American Society of Anesthesiology Difficult Airway Algorithm Department of Veteran Affairs Emergency Airway Management Initiative Vancomycin Administration, Vancomycin blood levels, BUN, and Creatine Chart Echocardiogram on 21 March 2018 Advanced Cardiac Life Support (ACLS) Guidelines, 2015 Karen Curtis, MD late entry to medical record on 5 May 2018 at 11:40 from Blue Button Health Record State of Tennessee Board of Nursing Rules and Regulations State of Tennessee Board of Respiratory Care Rules and Regulations

Berta, "t says they had VA medical records from March 18, 2018 to September 13, 2018 ,but he died on March 22,2018- " They listed " VA medical records, Memphis VA Medical Center, received March 25 2019 for the period of March 13, 2018 to September 13, 2018". This is not the accurate time of hospital admission nor what was submitted to them. The correct dates in which were submitted by me should be March 12 2018 to September 13, 2018. (The reason the medical records dated to Sept 13, 2018 (date of death March 22, 2018) is the VA providers continued to make late entries into his medical record). "We had no idea the cause of death was MRSA , but the decision clearly states he was admitted at a routine exam, with ulcers and infection- I assume the ulcers he means are from the pyoderma-gangrenosum, which causes ulcers on the skin.. " The autopsy copied the cause of death word for word from the discharge diagnosis of the VA Providers. The VA Providers failed to document many things in there efforts to cover up the true events that my husband endured. With that being said it was true that he had MRSA. However, I can absolutely prove they give him MRSA. On second day of admission he was taken to surgery where wound cultures were collected. They were negative for MRSA (March 13, 2018). On March 15 2018 a second set of wound cultures were collected at bedside. These were also negative for MRSA. On March 17 2018 a third set of wound cultures were collected. The wound cultures collected on March 17 2018 were positive for MRSA. Thus, the VAMC give him MRSA. In addition, Yes he had the wounds for three weeks prior to admission. We had this exam set up already and he did not want to leave our autistic son so he waited for the annual admission. However, upon admission the wounds had zero infection. (Per the wound cultures collected twice). Pyoderma Gangrenosum is a rapid progressive wound with an over production of white blood cells. There was no infection until he got MRSA. Yes vancomycin does treat MRSA. They did not start the vancomycin until the fifth day of admission.

Berta, I expected the denial. I am ready to fight. One of my first concerns about this is the evidence list. It contains only about 1/3 of the evidence I submitted. ???? Should I re submit everything I submitted that is not on the list.

Berta Here's the decision letter and report.

I have gotten my decision letter about an hour ago. Everything was denied. I am still trying to calm down and make it through the letter. I will upload it very soon.

HamSlice, "When was he born, or how old was he, etc." He was born in 1956. He was 62 when he died March 22, 2018. I had to correct my initial post. My husband was in the United States Army for 13 years (entered in 1985 and honorably discharged 1998.) and in the Army Reserves for 12 years ( entered in 1998 and honorably discharged in 2010). My appoligies for my critical error on the initial post. With that being said, did my husband still have reserve retirement coming at age 60? "After twenty years reserve time, which could be more if there is a minimum requirement in the reserves, like the National Guard (last 8 years must be in Guard) however, even with that, your husband would have a reserve retirement coming at his age 60. Now, when he got his, Notice of Eligibility for age sixty retirement, he would have had to elect A, B or C on a DD 1883 or similar. Not sure what the reserve uses and I see this form has changed since I did mine. A, service member only. This means the service member only gets retired pay at age sixty. The spouse has to sign for this option. Not as rare as you would think, I had some chose this when I was a clerk in the NG. If you have a lot of money and are not worried about you spouse if you die, then people select this option as you make more money, as SBP is taken out post retirement pay, i.e., out of you retirement pay. B, when the service member passes, the spouse will get a portion of his retirement when the service member would have turned age 60. C, immediate portion of retirement when service member passes. And then, you can buy (from your retirement when paid) additional percentages. So, I believe the OP, (original poster), needs to find the DD 1883 Survivor Benefit Plan Election Certificate that her husband would have completed. She may be entitled to a portion of his retirement right now. FWIW, Hamslice I selected option C, and selected the highest percentage. So, if I was to pass right now, my wife would get 85% of my retirement immediately, even though, I won't get my retirement for a couple years yet." Thank you for explaining this in such detail for me. I am hopeful that I will be seeing my C File this coming week at the State Veterans Office. I signed a POA this week and they are suppose to go through it with me on Wednesday. I will be looking for the DD 1883 and also be requesting it from the military.

Berta, "I have a concern over the error they might have made in the pension denial You had stated: "My husband served in the United States Army for 18 years followed by 12 years in the Army Reserve. My husband was a skillful, highly sought General Surgeon, a life-saving Trauma Surgeon" That means he surely received a pension from the DOD, in addition to SSA, and if so, was that info included on the VA Pension form? All I could see on the letter regarding the pension was his SSA annual award. It my or may not include the Medicare amount." This is the first time that I have re read my initial post. I am so very sorry. The above is not accurate. I must have made this error talk typing through google. With that being said, to my embarrassment, I must correct my information so hopefully you, Hamslice, Oceanbound and all others will continue to help me. My husband entered the United States Army in 1985. He was honorably discharged in 1998. This is a total of 13 years in the Army. He then entered the Army Reserves in 1998 and was honorably discharged in 2010 for a total of 12 years in the Army Reserves. "That also means , as a retiree, he might have paid into the SBP program, which would have garnered you an annuity payment, monthly." What is the SBP program? Is this still possible given the above accurate facts? "I did not see anything on the one page letter you posted above regarding the pension matter, with any accounting for his Military Retirement Pay." The above accurate information may explain why he did not receive Military Retirement Pay. He received Social Security monthly. This was his only income. He received nothing from the military at all.

Berta "LHI was contracted to give him a C & P exam. I ca hardly read it even when I magnify it- You got it recently, but but what is the date of that exam.? What I see here is that he applied for a Pension ( far different from a service connected claim) If he did not appeal this decision and point out their errors, the date of the decision tells me the only way to get this changed is to file a CUE claim. But I do not know if pension's involve accrued benefits-will try to find out- Was there anyone ( like DAV- VFW- AL ) mentioned as his POA on the pension denial?" Berta Yes it was recently. The letter is dated 10/19/2019. My husband died 17 months prior to letter on 03/22/2018. This is what stumped me when the letter arrived. Yes it appears he had applied for pension on the letter from the Department of Veteran Affairs dated January 18, 2018. It also states on page three, "If you do not agree with our decision, you should write and tell us why. You have one year from the date of this letter to appeal the decision. The enclosed VA form 4107, Your Rights to Appeal Our Decision explains your right to appeal." It is my intention to Appeal the decision very soon. It will be next week before I am able to go to the Social Security Administration Office to obtain all proof I need from them to submit with the appeal. There was no POA listed. I am quite sure he did this himself. He was bound to his wheelchair so if he had gone to a VSO I would have taken him. I am sure we did not do this. Did you find out if pension is involved in accrued benefits?

On Thursday I was informed by my new legal representation for the FTCA claim that not only would I be filing out the form 95 but that they would be contacting my husbands adult children (whom I have no contact with and my husband had very little contact with) to sign a retainers contract and sign Form 95. It is essential that the FTCA claim be correctly. I am not sure that this above is correct. I have spent the entire weekend searching for the statue, the code, the rule, the regulation as to whom must file the FTCA claim. Can anyone help me find this information?

Berta, would you please give me your opinion on the attached additional letter in which I received recently on October 23, 2019. I have no idea what this is. I called the company. They informed me it was a review of medical records?????

Berta, I believe you guided me to the right track. I now believe my husband did have an ongoing claim. I am not quite sure how the "catastrophically disabled". However I wanted to show you my new discoveries. I discovered two additional letters after sifting through four banker boxes. This time I have slowly read each and every word of all Department of Veteran Affairs letters. The first dated January 2, 2018 (my husband died March 22, 2018). It appears this was the letter from the VA letting my husband know they received his claim. The second dated January 18th, 2018. Is informing my husband that his claim for Veteran's Pension has been denied because he is over the income limit for a "married veteran". When you first read it you would assume it is true and that he did not qualify. I am assuming this is what he must have thought in January when he received the letter. However, there are multiple errors. #1 They used the allowed income limit for a married Veteran (17,241). They should have used income limit for married Veteran with one dependent (17241). Plus one additional dependent (for our minor son) ( 2250 )=19,491. In addition, with the catastrophically disabled" just may mean he qualified for Aid and Attendance (which would put income limit at 26,036+one depend 2,250 =28,286. Or it may mean he qualified for Housebound with one dependent (20,166) plus one dependent (2250)= 20,416. No matter what the case maybe be they calculated the income limit wrong. #2 The VA did not have the correct income per Social Security Administration. My husband reported receiving 2,225 monthly. The VA said SSA reported monthly income as 2,412, thus annually 28,944. I called SSA then went to local office. I obtained proof from SSA that in fact my husband made less than even he reported making, only 2,199 per month or 26,388. Most importantly, thank if you had not continued to tell me that he may have had a claim open I would not pursed this. The letter from the VA said I only had till January 18, 2020 to submit new evidence and appeal the decision. So I did not have much more time. Again thank you.

Berta I believe my husband did have a pending claim though I still am not sure what this means exactly. The entire letter read exactly as follows: "Mr. X Based on a recent review of your records and examination, the Department of Veteran Affairs (VA) has determined that your disability, injury, or condition meets the criteria of a catastrophic disability. As a result you will be you will be immediately enrolled in Priority Group 4, unless you are eligible for enrollment in a higher Priority Group. Official notification of the changes in your enrollment status will be sent by separate letter. Veterans enrolled in Priority Group 4 are eligible for all needed services included in the Medical Benefits Package. Veterans who are determined to be catastrophically disabled are not required to pay inpatient, outpatient or prescription copayments that would otherwise apply. If you have any questions feel free to call the enrollment office at 1-800-636-8262 or 901-523-8990 extension 7972. Putting Veterans First. Michael Harper Chief/Business Office"

Thank you so much. I wish I had found this website much much sooner. I am stunned at the moment. I just check my claim status online and.....a decision was rendered today for my 1151 Claim? Are there any other options for finding out the decision other than waiting for it to arrive by mail?

Oceanbound, You rock. I want to contact Dr. Todd do you by chance know his first name or where I can locate his information. Also, do you know the answer to my 1151 offset question above. Just call me MIKE! Thank you so much for your help.

Berta I used the link to search for all providers involved in the care of my husband. They are all VAMC employees except for the many residents. (I am not sure what the residents fall under). I also emailed a copy of the post to my attorney. In regard to the 1151 offset factor..... My husband and I have a son whom is now 9 together. My husband also has five other adult children from his first wife whom died. It is my understanding in the State of Tennessee any settlement or award recieved who be distributed as follows after attorney fees: 1/3 goes to the surviving spouse, 2/3 would be divided equally between the total of 6 children ( despite my son being a minor and a minor with a disability). In regard to the offset of the 1151, would I be responsible for the entire award/settlement or only what I received.

Oceanbound Thank you so very much for your helpful advise. I had heard about Dr. Bash before however Dr. Todd and Dr. Anaise are new to me. With your and Berta's recommendation of Dr. Bash my intention is to contact him immediately if my 1151 claim is denied. I have hopefully obtained an attorney for my FTCA Claim on Friday. I say hopefully because I have not received the contract yet. The law firm told me on Friday that in fact they planned to use a lot of the "1300 pages of medical evidence" to pursue the case. I did want to mention that the "legal nurse review" in which I obtained was actually a review from a lady whom is a registered nurse, Family Nurse Practitioner, Acute Nurse Practitioner, and has a Doctorate Degree in Nursing. Not sure that this changes anything. I will not be speaking with anyone from the VAMC of Memphis nor any other VA employee at all. Can you believe I actually had an attorney tell me only last week "If I were you I would call one of the doctors who might remember you and see if you can get them to admit the mistakes." Our conversation ended shortly after that and I knew they were not the right attorney for me. Again thank you for everything. I hope to continue to have interaction from you.

Berta, Thank you so much for all your great efforts to help me. I have been following you on this website. Your knowledge and kindness to share your knowledge is very commendable. It is clear ly a passion of yours and now mine. I have hopefully obtained an attorney for my FTCA Claim on Friday. I say hopefully because I have not received the contract yet. The law firm told me on Friday that in fact they planned to use a lot of the "1300 pages of medical evidence" to pursue the case. I did want to mention that the "legal nurse review" in which I obtained was actually a review from a lady whom is a registered nurse, Family Nurse Practitioner, Acute Nurse Practitioner, and has a Doctorate Degree in Nursing. Not sure that this changes anything. I would like to answer all of your questions? -The statue of limitations in the state of Tennessee is two years. -The autopsy results mimicked almost word for word the discharge diagnosis of the VAMC medical provider. With that being said...…… the discharge summary, and discharge diagnosis were false and attempts by the medical records to ...As well as all other providers whom made entries into the medical record after death copy and pasted the MICU doctors discharge summary. The legal nurse review details the inaccurate documentation into the medical record in attempts to cover up their failures. It goes over each diagnosis followed by proof of it not being true. -"Memphis VA has been plagued with malpractice issues- " Yes the Memphis VA Medical Center of Memphis has plagued with malpractice issues. They have been dubbed the "House of Horrors" in the below USA Today article. https://www.usatoday.com/story/news/politics/2017/09/07/memphis-va-botched-surgery-veteran-patient-safety-threats/637497001/ The Office of Inspector General release a report about Memphis VAMC in March of 2018 (Days after my husbands death). See Below https://wreg.com/2019/09/05/report-faults-care-at-memphis-va-medical-center/ I could go on and on about the VAMC of Memphis however lastly I will say Memphis is rated one star out of five stars on the VA's official quality-of-care ranking. -"Mine went first to Regional Counsel and then, (now they are called District Counsel)after a very obvious attempt by VA to deny the FTCA, it went to the General Counsel, in DC. The Peer review they did caused the RC to want to settle with me within months of getting my SF 95. Then the Peer review, the RC, and the doctor who did the review 'disappeared and VA said that review never existed. I had to start all over again with the OGC. I found the Review many years later at the bottom of my C file and used it for my AO IHD Nehmer claim. If I had been able to find any lawyer who would help me, that BS would not have happened. " Could the Peer review your speaking about be the same type of investigation I was informed of. When the director of the Spinal Cord Injury Unit called me the second time, I asked her if I could receive a copy ( I knew the answer was No but just wanted to say I asked). She told me since it was Peer Reviewed it was protected. Tomorrow I am going to go back to Regional Office and attempt to view my C File. I have requested a copy of the C File under the FOIA certified mail but do not have a reply yet. When I went to the Regional Office located in Jackson TN the first time to view the C File they wanted me to sign a "limited" power of attorney form. I was told this would be the only way they could access this information for me to view. I left until I could find out what to do about this. Is this normal? To sign a power of attorney? Seem untrue? What steps should I take from here. I know I must see the C File. -I admire you Berta because I too have spent endless hours, days and night research medicine (I am lucky because I had access to doctors, nurses, my husbands medical library, and access to his online memberships to different medical specialty websites). Making a timeline, finding their failures and medical errors, research VA law ( I work part time for a criminal lawyer this gave me access to a wealth of information). Then I research at least 100 VHA Policies, Manuals, and Directives. I highlighted their violation of the policy as it applied to my husbands care followed by the entry into the medical record where the violation occur including direct quotes and citiation's from the medical record. I found violations of 31 of the VHA Policies including placing my husband on mechanical ventilation then removing the mechanical ventilation all without my knowledge more importantly my consent. -"Reading all of this over, I realize it is possible that you sent enough info to the RO to decide the 1151 claim. Are they aware of the internal investigation the VA did? Have you tried to obtain it under FOIA? (Freedom of Information Act)" No I did not mention nor make them aware of the internal investigation. I assumed they would have it. Should I send in a letter to them immediately to make them aware and request a copy via FOIA? -"You have certainly focused on the Vancomycin toxicity very well. There is plenty of info on the internet regarding this med to reveal that you have a basis for malpractice charges. Does the autopsy reveal a toxicology report? and if so does it reveal the vancomycin amount in his system? The toxicology as well as the entire autopsy did not contain a vancomycin level however the medical records last Vancomycin Level was done about 12 hours before his death. -"When did you file for DIC under 1151 and did you use the 21-534EZ application? You mentioned Accrued benefits and that form is 21P-601. That form is for accrued benefits, meaning benefits the veteran applied for prior to his death, that you have substituted yourself for as the claimant." When I filed for DIC under 1151 I did use the 21-534EZ for at the top it states "NOTICE TO SURVIVOR OF EVIDENCE NECESSARY TO SUBSTANTIATE A CLAIM FOR DEPENDENCY AND INDEMNITY COMPENSATION, SURVIVORS PENSION, AND/OR ACCRUED BENEFITS ". Should I have filed the 21P-601 form also for Accrued Benefits? With that being said, should I even be applying for accrued benefits. I received a letter on March 2018. "Based on a review of your medical records and recent examination, the Department of Veteran Affairs has determined that your disability, injury, or condition meets the criteria for a catastrophic disability. " I did not even know that my husband had received an exam for this nor that a form had been filled out. This is, however, what prompted me to apply for accrued benefits. Any help would be much appreciated. -TCA- I hope you are aware of the 1151 FTCA offset factor. That is explained in the FTCA forum here. This is really important to me at this point. My sitituation is this. My husband and I have a son whom is now 9 together. My husband also has five other adult children from his first wife whom died. It is my understanding in the State of Tennessee any settlement or award revieved who be distributed as follows after attorney fees: 1/3 goes to the surviving spouse, 2/3 would be divided equally between the total of 6 children ( despite my son being a minor and a minor with a disability). In regard to the offset of the 1151, would I be responsible for the entire award/settlement or only what I received. -"An IMO doctor should have expertise in the filed of this deceased veteran's disability ( we don't know what his prime disability was) and should be given copies of all VA and private medical records. " My husbands primary disability was an incomplete spinal cord injury he sustained in 2013 after falling while walking down a movers ramp hitting his forehead on the foot plate of the front door thus sustaining a incomplete spinal cord injury at C 3. He could stand in place for about 45 seconds, pivot, transfer himself, and could move his legs around when in a sitting position but simply could not walk. As well as losing the dexterity in his hand. For example, he could pick up a cup a pencil but not a penny off of the table. -"It is possible that VA would give serious consideration of any medical opinions the nurse gave, if their was a full description from his VA medical records, of the medical errors that occurred, and a strong rationale as to how any (or all) of these medical errors contributed to or caused his death. " She did amazing. She did all of the above extremely meticulously. A mind boggling amount of errors occurred within the ten days. Errors by nurses, errors by medical staff, failure to review diagnostic studies after ordering , administration of wrong med, failure to treat Acute Renal Failure for five days till death, fa Also I would like to say that when my husband situation became emergent a total of 14 physicians respondent and were present. Each and every provider documented an entirely different sequence of events. In addition in ten days he had a total of 36 resident physicians and a grand total of physicians on the record providing care without almost zero communication between providers. -"Malpractice can create a vast paper trail- every single notation , medical entry nurses notes, Blood chem profiles ,CT scans, MRIs, etc etc, have to be studied. And if any medical notation was crossed out that has to be determined as to what it said. " About one week after my husbands death, through the attorney I work part time for I requested a copy of the ENTIRE medical record from March 12 2018 (admission)- March 22 2018 (death). I discovered numerous documents images , lab studies, consultation notes, event notes, physician orders, pages to the medication administration record, the Blue Alert Record, and etc that were not included in my three different request for the entire record. Each of the above I request as soon as the discovery of not receiving it was made. "You also need to determine if the doctors were VA employees or federal contractors. The multiple federal contracting doctors VA has employed in the last few years are exempt from FTCA. " How do I truly know? Who do I ask? Where do I request this information? Lastly, Thank you for the links to IMO . If my claim is denied I plan to contact Dr. Bash immediately.

I have filed an 1151 Claim. I have finally found an attorney to represent my FTCA claim. We are going to submit Form 95 this This attorney informed me that he would need to submit separate Form 95's for myself, my son, and all 5 of my husbands previous children. My husband had a total of six children. Five of the children are by his previous wife whom died. And he and I have a son whom is now 9. If successful at the FTCA it is my understanding that the laws in TN will mean an award in the FTCA would be divided this way after attorney fees: 1/3 to the surviving spouse, 2/3 divided by 6. Each child the would receive 1/6 of the remaining 2/3 of monies. So with that being said. If my 1151 claim is successful will the offset amount be the 1/3 that I received or the entire amount of the FTCA award.

Okay. Here goes my first response and thank you.

I asked a question. Then people submitted a post. How do I respond to the person trying to help me. For example, I asked a question, Berta responded . How do I respond to each post. Thank you so much in advance.

On March 12, 2018 my husband was admitted to the Veteran Affairs Medical Center of Memphis, Tennessee for a prescheduled three-day admission. Subsequently, he tragically died on March 22, 2018 at 10:14am due a mind-boggling amount errors and failures of the providers of VAMC of Memphis. I am alleging that the VAMC of Memphis, Tennessee and the medical providers failed in their duty of care to my husband by their: failure to monitor and administer Vancomycin properly and safely, failed to recognize and correct Vancomycin toxicity which lead to Acute Renal Failure, failure to recognize and treat the Acute Renal Failure leading to fluid overload, failure to treat new onset Congestive Heart Failure caused by fluid overload , then failure to assess or render treatment respiratory distress. In addition, failure to have the proper equipment available to provide airway management, inappropriate administration of anesthesia by resident(far out of scope of practice), failure to intubate in a timely manner causing hypoxia leading to cardiac arrest. As well as, failure to follow the Advanced Cardiovascular Life Support (ACLS) guidelines for Cardiopulmonary Resuscitation on my husband. About three months after his death, I called VAMC of Memphis and asked to speak to his admitting physician/spinal cord attending doctor. I was transferred to her voicemail. I left a message. About a week later, I received a call from a lady identifying herself as the Chief Director of the Spinal Cord Center. She informed me that the hospital was conducting an internal investigation about all the events that occurred surrounding my husbands death. She stated that the admitting physician could not talk to me until this investigation was over. At the end of the call I ask her if I would be privy to the investigations findings. She told me no because it was peer review and they did not have to disclose it to me (which I already knew but thought I would just ask). I myself am a nurse. For me as a nurse, I could not believe the things I read in the medical record. I spent many months piecing the puzzle of the events, in which my husband endured, back together. The medical records were sent to me is true disarray. It was as though they hit the shuffle button then sent them. Once I got them in chronological order I began going through it highlighting all import facts as well as all standards of care to research. While reviewing the records I discovered many, many documents in which I had not received despite requesting ALL medical records. Each time I discovered I was missing documents I requested them (for example the Blue Alert Record, EKG's, Anesthesia records, etc.). After a total of 11 months, some help from other nurses and physicians I know, I had 1300 pages or so of medical peer reviewed literature to support all of my findings. I then consulted an independent legal nurse. I have a complete legal nurse review/chronology of the medical record including supporting peer reviewed medical evidence for each finding and failure to provide the duty of care in the medical record. I then enlisted a group of friends and we meticulously read through all VHA policies I felt might have been violated. I created a report citing each VHA policy/directive violated and citing the medical record where the violation had taken place. My husband had no choice but to receive his medical care at the Veteran Affairs Medical Center of Memphis. I clearly remember his first admission. As it began an endless battle with them to provide him dignified, safe , appropriate care. Each time I had to allow VAMC to render care to my husband I feared he might not make it home. I feared they might literally kill him. I have spent many drives home crying for this reason alone. I have witnessed many negligent acts of the staff and at times very dangerous care. I have battled with many nurse managers for change and at times refused to leave him. This was my greatest fear that came true. I am prayerful and seek to make VAMC of Memphis, Tennessee be accountable for their horrific, negligent care in which they rendered to my husband causing his death, taking him from my son (who is autistic and now 9) and me. This is what I have done so far. I submitted a claim for 38 USC 1151, Accured Benefits, and Pension. I submitted it just three days prior to my husbands one year date of death. I included all required documents for the 1151 Claim, copy of autopsy, death certificate, copy of all medical records, the legal nurse review. And approximatley 1300 pages of medical evidence to support all opinions of the legal nurse consultant. When I last checked the status of my 1151 Claim on the website it states it is in the review period with an estimated completion day of Dec 31 2019 (for what that is worth). I have obtained a certified legal nurse review which states my husband died due to no fault of his own, was not foreseen and died due to multiple VAMC providers medical negligence. I am having a lot of trouble obtaining an attorney for the Federal Tort Claim I am going to file. I have not filed Standard Form 95 as of yet. As my statued continues to run out I am faced with filing Standard Form 95 on my own. My husband served in the United States Army for 18 years followed by 12 years in the Army Reserve. My husband was a skillful, highly sought General Surgeon, a life-saving Trauma Surgeon, a teacher to many in West Tennessee, a father to our son whom is now nine, and my soul mate. . I have been told my husband cause of death was not as clear as a medical malpractice attorney would like it to be, like a sponge left during surgery or etc. The events of his hospitalization may not be that clear however, I am confident that their numerous failures to follow clinical practice guidelines fell far below any standard of care one expects in America today and far below the standard of care one would receive in my community as a civilian and caused his death.