facility. the bipartisan senate homeland and governmental reform committee found, for example, dsa agents were remaining for relatively short periods, often no longer than a month. the independent accountability review board concluded that the utilization of temporarily assigned agents in benghazi was problematic. i'm quoting from their findings. the short-term transitory nature of benghazi staffing to be another primary driver behind the inadequate security platform in benghazi. staffing was at times woefully insufficient considering the post security posture, considering the high risk, high threat environment. the end result was a lack of institutional knowledge and mission capacity which could not

>> it is critical. your first 30 days on the ground, you are just trying to figure out where you are, how things are operating, where the threats are. we absolutely concur with that recommendation of taking steps to ensure that the personnel we put on the ground are there for longer periods of time. >> and has the department been able to achieve those requirements in its practice? >> yes, it has. the fact is we don't actually have any temporary facilities at the moment. i request give you an example, though, when we just entered

bengi, we have mobile security agents on the ground with u.s. marines that are there. those agents are going to stay for a much longer period of time. probably up to 90 days until we're sure we have the proper security that we can then start replacing them with permanent personnel we're going to have on the ground. the 30-day rotations as the arb pointed out were not conducive to the security operation. >> are there any other incentives that the department can provide or think to provide for personnel to undertake those longer assignments? >> i don't think it's a question of necessary or additional incentives. i think it's a question we needed to understand that constantly rotating like that was not in our best interest. i think my agents clearly understand that. and i think it really isn't about additional incentives.

it's about knowing that's not the proper procedure and we needed to change it. >> built a great practice. thank you for your forthright answers and i yield back to the chairman. >> the chair would recognize the gentle lady from the state of california, mrs. robey. >> thank you, mr. chairman. returning to the questioning of mr. jordan about the waiver process briefly. mr. starr, oversea security policy sets the physical security standards that must be met. it's also my understanding that they're either temporary, interim or permanent, correct? >> yes. >> and overseas diplomatic facilities can be further classified as residential office or other categories as well? >> yes. >> okay. >> and how was benghazi classified in 2012? my understanding from the reports is that it was the

temporary mission facility. >> and was that classification found in the ospb's standards? >> no. >> are there any ospb standards for a temporary office facility? there's not, right? >> our outlook on that is whether it's temporary or interim or permanent, that we should be applying the same security standards that the ospb has put in place. and that if we can't, then we need to look closely at what risks we run -- >> so that -- sorry to interrupt you. the office in the residential don't require a higher level of security if they're in that category? >> there are higher levels -- when we build offices, when we build facilities, they have higher level. >> the benghazi facility was used at both, correct? >> yeah, i'd say that's an accurate portrayal.

>> in the dual case where it's being used as a residential and an office, what standards apply? the higher standards, correct? >> correct. and so those ospb standards should have applied to the benghazi facility? >> that is the way that i would apply them now. i wasn't here, but if we had a similar situation, we would be applying the higher standards. >> i just want to make sure this is very clear. your policy is that any time a facility is being used for any purpose, whatever type of facility has the higher -- the highest level of physical security standards, those standards should be applied? >> that is correct. >> but that didn't happen in benghazi? >> i would have to say i can't answer that question. >> looking ahead, when you talk about in this era of expa

dishary diplomacy, is it possible for the facility to other a temporary facility? >> we don't have any at the moment. i can't imagine we would or that i would approve it. >>. >> okay. let's turn to marine security guard detachments. were marine security guard detachments ever deployed to the benghazi compound? >> no. >> the benghazi compound we already established by multiple questions here, it was a temporary facility. and marine security guard det h detachments are never deployed to temporary facilities, correct? >> not in my experience. >> the increase in marine security guard detachments as a result of the arb recommendation 11, therefore, would not have actually helped in benghazi, correct? >> i mean, if it's a temporary

facility and they can't be deployed, then it can't help? >> i just want to make the point, i'm not saying that additional personnel on the ground would not have helped, but, yes, you're correct, we would not -- in my experience, we would not have put a marine security guard detachment into a temporary facility. >> we've also already established here today there's currently 30 posts that are considered high risk, high threat. how many have benefitted, of those 30, of the marine security guard personnel? >> i'd have to get back to you with the exact number. i think about 20. we have opened four marine detachments in benghazi at our high-risk posts. there are still some that don't have marine detachments. there's a variety of reasons why. >> is it your goal to get to

marine security detachments at all the high risk, high threat posts? >> i would like to have marine security guard detachments at all of our high risk posts. some impediments cannot be overcome. >> at the ones that don't have the marine security detachment, how exactly does the -- without highly trained marine security guards? >> in some places we have made up by using diplomatic security agents. in some cases we have made risk managed decisions where we have taken personnel out and lowered our presence. some cases our families are not

there. or we lowered the number of employees to minimum numbers. in many cases we make representation with the host governments and we analyze whether the host government has both the capability and the will to provide the necessary level of protections. and if we find that we don't have those types of protections or we think the risks are too high, then we won't be there. >> okay. if an ambassador at a high risk, high threat post picks up the phone and calls the seventh floor of the state department today, asking for additional security, physical or personnel, who ultimately makes the decision to grant or deny that request? mr. starr? >> the last person in the chain would be me. the request would probably not go to the seventh floor. it would probably go to me on the sixth floor or the rso to our personnel. i can tell you that today i have available mobile security teams

to deploy. we work very closely -- >> ultimately i'm asking who makes that decision? >> it can be approved at lower levels. >> what's the lowest level it can be approved? >> i think the lowest level would be the regional director of the -- of diplomatic security. >> if an ambassador sends a cable, would it be the same, rather than picking up the phone, it would be the -- >> exactly the same. >> and would it -- would the decision-making process change if it were not a high risk, high threat post? >> no, it would not. >> okay. >> and was benghazi considered high risk, high threat or critical threat? >> pardon me. i actually don't know what the rating was of benghazi. we did not have the 30 identified high threat, high risk posts listed at that point. >> who denied the additional diplomatic security personnel requested in benghazi by those who were working and living

there and in tripoli? who was the person that denied that? >> i have to refer you to the results of the arb. i came back five months after the attack. >> what i'm trying to get at, is that same person who was also responsible for ensuring the physical security in benghazi, is that the same person that's vested with that responsibility today? >> i think the board pointed out that there were lapses in judgment on the part of the director and several others, including the director for international programs. >> if a ds agent at the post writes back to headquarters requesting additional security upgrades or increased personnel performing security duties, who is responsible for making the decision to deny or grant that request from a ds agent? >> i think the first thing that would happen is the discussion would go on, is this an individual request from ds? has it been vetted through the emergency action committee at the post? is this a post request?

>> okay. and is it affected by whether you categorized this as high risk, high threat? >> we pay more attention to our high risk, high threat bases on a daily basis, but i would tell you any additional request for additional security resources for any of our posts overseas is going to be met with immediate action. we would make decisions on how we can best fulfill those requirements. >> so, to get to the point, even if a post is not high-risk, high threat, we know in certain parts of the world things are very volatile and can unravel in a moment's time. despite threat assessment or not. what i'm getting at is, is the department now today, in light of what happened in benghazi, prepared to pay better attention when the folks on the ground are saying, we need help?

which is not what happened in the days and weeks leading up to the attack in benghazi. >> my answer to you is unequivocally, yes. that's what i've been spending my time since february 1, 2013 on, making sure that we have the resources, the programs, the knowledge, the capabilities, to respond quickly and effectively to any cry for help. more ever not just respond to the cries for help, but to try to better place ourselves before those come in and make sure that we're ready for these things. >> thank you. mr. chairman, i yield back. >> i thank the gentleman woman from alabama. we recognize the gentle woman from alabama, mrs. duckworth. >> as member of the oversight and government reform committee and armed services committee, i've spent a great deal of time working on all of the -- working through the reports on the attacks in benghazi. and as the committee begins our work here today, i think the

most appropriate way we can honor the brave americans who lost their lives in benghazi is to make sure we learn from those past mistakes and never make them again. i heard that from the family members again. let's never let their buddies down the way we let their family members down. and so i want to go back to t s this -- the discussion on the security and interagency cooperation. i was there the day admiral mullen testified. i have to disagree with you. you may question his professional integrity, but when admiral mullen, a man that served in vietnam, 43 years of military service, againing this great nation, comes before this committee and swears an oath of office and then testifies he was fiercely independent in the arb, i would tend to believe him inspect in fact, the arb was incredibly scathing of the state department in its report. and i want to go to that report. mr. starr, i want to follow up on what my gentle lady from

alabama, her line of questioning about the marine security guard details. so, if you don't have -- if you have a post that does not have a detail because they're not at a temporary facility, for example, can you talk about other details that can be there? are there other military options that can be assigned to those temporary details? you talk about the mobile security teams, marine augmentation units. are there other options if there are -- if the marines can't actually be assigned there full time? >> yes, there are other options. we currently are trying to expand 35 more detachments. it should be noted that at the moment we have 270 -- more than 275 diplomatic facilities counting the embassies, consulates and consulate generals. we have only 173 marine security guard detachments. we have never had enough

marines, nor we will to cover every single post. many of our posts around the world f we put a marine security ky2k1éñ have ent w more marines than foreign security officers. so we carefully look at where we need to use this scarce resource. we have had excellent cooperation from the marine corps in terms of augmenting different units and getting more detachments. as i say, we have opened 17 more detachments since benghazi on our way to opening 35 totally. we should be done by the end of next year. additionally marines have made marine augmentation units where we can send additional marines under the ruberick where we have different situations. but your question, what do we do where we don't have marines or don't have permission to send marines. we have different capabilities. we have diplomatic security agents that are high risk, high

threat, highest trained, mobile security officers. we have the ability to request from the department of defense, and they have never let us down, for things like fast teams to come in and protect our embassies and consulates when we need that. >> we have a robust program where we have security contractors. many times they're americans, sometimes third country national contractors but we have used contractors for many years. there are some downsides to that and some countries won't allow them and we've learned some very painful lessons over the years about contractors, that we have to have incredible amounts of oversight and make sure we're using them properly. but it is still a tool. we have local guard forces and local elements we hire directly from the country we're in. and i would tell you some of these units in some places around the world have done amazing acts of heroism protecting our people. ultimately we have host country

services which we evaluate whether they have the capability to protect us. additional funding congress has given us is the ability to start a program where we can train host country forces, whether it be police or national guard directly around the embassies and increase their capabilities. so, we have a number of different possibilities.)63j4pzi >>. >> you had said the state department. i have to say i was disappointed with the risk management process that was undertaken leading up to the benghazi attacks. assessment and mitigation process has become morrow bust. i want to speak specifically to enter agency cooperation,

between d.o.d. and state. you said the d.o.d. has never let you down. on that night, the arb in various reports, including armed services committee has stated there was no way those f-16s, those u.s. military forces could have made it there in time to save our americans lives. what have we done to make sure in the future they can be present in time to save american lives? as these special dates come up, september 11th, these anniversaries or as you hear more chatter going on and you think there might be the potential for greater risk, what trip wires are in place? what processes are in place for you to call the d.o.d. and say, hey, maybe you need to help us and reposition some forces so that if we do have another benghazi, we can call -- and that those f-16s can be there in time in the future so we don't lose american lives? what process is happening between d.o.d. and the department of state at this point? >> the department of defense has

put together a program they refer to as the new normal. we have looked closely at what capabilities d.o.d. can bring for defensive use of american embassies and consulates overseas. there has to be realization that we don't have bayh bases everywhere in the world. in many cases while we would like to say the department of defense could respond to any one of our embassies within four hours, physical distances, just the amount of distance between where our diplomatic stations are make it impossible. even if they could respond in a certain amount of time, this idea that we're magically going to get paratroopers out of the back of the plane and land on the embassy isn't realistic. we still have to go through airports, go through host countries to get personnel in, transport them from the airport to the embassy somehow. in the midst of a crisis, this isn't realistic about what's

going to happen. what we've worked with d.o.d. on is making sure that we're better prepared to predict what's going to happen. looking at instability. as d.o.d. said, we would rather be on the ground in advance of something happening then trying to react after something happens. now, it doesn't mean in certain cases that they haven't been on a very close leash with us. i can give you the example of tripoli recently, where we had in many cases special forces and helicopters and marines on less than one hour notice to respond to the embassy. and a high, high threat, critical threat situations, those are the types of things we're working with d.o.d. on, to make sure they have very close at hand respond capabilities. i can tell you with 275 locations around the world, we can't do that ofsh. we can't do that every place. d.o.d. is seeking increased base options. i would highly recommend a discussion with d.o.d. on this

about where they're going in terms of basing closer and more closely to u.s. embassies and facilities. they have excellent plans. working closely with the state department on this. ultimately, we've got to do a better job of making sure we have the right preparation on the ground in advance. in those situations that are absolutely critical, we'll have d.o.d. very close to us. they've worked tremendously with us in places like tripoli and sana and other places. i have to tell you i have the utmost respect for the way the department of defense, u.s. marine corps, army and air force -- and navy have responded to our needs. >> in the last minute i have left, can you talk about at what level at the state department does that request for d.o.d. have to take place? for example, in the case of tripoli recently where you said that they had them on a one-hour leash to respond. does that come from you or can it come from lower? if an ambassador determines that through his risk analysis assessment with his diplomatic

security team that's there, that he needs this, how far does he have to go before you can have something like a fast team, that's ready to come in or something along those lines. how far up the state of bureaucracy does he have to go? >> the commander will call the nearest combatant command. they meet awe the time, talk with each other. in an emergency situation, he can pull the string immediately. in a less than emergency situation, in the way we're looking tat to pry to preposition ourselves, he would state something or make a request or we may make the request and say, we think you need this. we work through the office of executive secretaries. we send an exec sec back and forth. i can instigate it, assistant secretary of the regional bureau can instigate it. in the most extreme cases, the ambassador can go directly to

the combatant commander closest to him and request support and then even notify us afterwards. >> thank you. yield back. >> . >> i would like to clarify two points miss duckworth said. you cannot discuss the proceedings outside of the arb. admiral mullen admitted he did that. it's fact. >> in law that's called exparte communications. >> sorry. i didn't go to law school. from our review under-secretary kennedy in authorizing that made up that term in order to avoid the ospb security standards.

>> it's an interesting thing. yesterday in our office we did a ne nexus lexus search of special compound, not benghazi. there may be different ways to look, ways to look ought over the landscape. the result of looking for that term yielded nothing. throughout all those data files, all across the fruited plain, absolutely nothing. so what does it mean if simply is redefined? if they declare this as something other than that which is to be regulated. that means have you no regulations, right? >> correct, sir. >> mr. sullivan, you mentioned in your opening statement one of the regrets you have as a member of the panel that the department of state didn't adopt your recommendations as it relates to waivers. what is your recommendation as it relates to waivers? >> we think -- we believe

waivers are needed. we want to see those waivers. because when you have a waiver, what that will do and set in motion standards and people recognize once have you those standards, have you to meet those standards. what we saw in this particular instance, since there was no standards, was no waiver, there were really no standards set, and i think somebody brought up the fact before that there were a lot of people coming in tdy, and some very dedicated people, some very hard working people, and some extremely well-intentioned people and dedicated people. however, these were people that were extremely inexperienced and they were coming in for 30-day periods. and they would come in for 30 days. they would identify vulnerabilities, take care of that vulnerability. the next person would come in and that process would continue. >> so, you're saying you need an orderly process by which things are waived, not declarations on the part of the department of state, that it's all waived, is

that right? >> right. it goes back to what we talked about before, risk management. risk management is all about identifying the threat, identifying the vulnerability and then coming up with the mitigation for that threat. we did not see that formalized process ongoing. >> secretary starr, question, you said earlier in an answer to congressman smith, on benghazi they didn't get the threat information. now, i understand that threat information may be a term of art, but to mr. west moreland's testimony earlier, certainly a bomb blowing up on the side of a wall. the whole litany of events that took place beginning march 18, 2012 until the first time there was a communication from ambassador stevens, those -- isn't that enough information? you're not saying, nobody was aware of the nature of the threat. is the threat a term of art?

>> congressman, thank you for the question. i think the distinction is -- that i was trying to make is that there was no specific threat information that had been developed by the intelligence community. >> in other words, these people are coming over the hill top at this moment in time? >>y correct. >> we don't normally get that. i think your point that there were a number of different thins going on. i think people were aware of the overall level of instability? >> here's my point. the senate intelligence committee report, they reported on june 6th of 2012 ambassador stevens recommended the creation of teams and so forth. the team was never created in benghazi despite the ambassador's recommendation. there were other events subsequent to that. then ambassador stevens reaches out again, sends a cable to the state department headquarters requesting a minimum of 13 temporary duty personnel and the state department never fulfilled his request and headquarters never responded to the request with a capable.

then they follow up on august 16th of 2012, a month before these events 37 again, a cable to the state headquarters. stevens raised additional concerns, et cetera, et cetera, et cetera. now, go to the arb. the arb says one thing two times about ambassador stevens. and it's worth noting. they said this about him. his status as the leading u.s. government advocate on libya policy and his expertise on benghazi in particular caused washington to give unusual deference to his judgments. they said that on page 6 of the report. they cut and pasted -- they liked it so much, they put it on page 34 of the report. and yet ignoring the ambassador, who by their own admission is the expert in the area, and ignoring his request for support, that's not giving unusual deference to his judgments, is it, mr. secretary?

>> gill question, mr. congressman. >> no, it's very straightforward. >> no, i don't think it is. it's a difficult question. i think chris stevens was a tremendous ambassador with a tremendous -- >> look, there's no question that he was tremendous. there's no question that he was a hero. he made specific requests of the department. the department in the arb said this person is uniquely qualified, secretary, and he was ignored. >> and i think this is why the arb recommendations are what they are. >> well, this is why the arb recommendations and the panel say, you can't have this kind of waiver authority. when miss robey asked you the question, are there any plans for temporary facilities in the future, you were pretty clever in how you responded. you said, we don't have any plans for it, and i'm not likely -- i'm paraphrasing now -- i'm not likely to approve it. you know what that tells me?

that tells me you can do it all again. that tells me you can take the special mission compound, you can call it something else, can facility. you can take two adjectives, put it in front of a noun and call it some other thing. and do it all again. so, here's the question. if madeleine albright signed off on certain recommendations, if the best practices panel makes certain recommendations, why is it that the state department is clinging to this legacy of power that has failed? why are you grasping on it so much? why not walk away from it? and nobody here is criticizing a very tough job. but the nature of the job, mr. secretary, means that this, to mr. cummins point, needs to be the transformational moment. why not be the transformational moment to say, we're not going to just choose to redefine things and we're going to visit

how we do these waivers and we're going to do everything we can in cooperation with congress to honor chris stevens' legacy, to honor the legacy of those who suffered and you know, but why cling to this old thing that just isn't working? are you the only one that doesn't see it? >> congressman, i think i have a distinct view having served 29 years with the state department, four years with the united nations and i'm back again. i think that in accepting all of the recommendations of the accountability review board, i think in accepting 38 out of 40 recommendations made by the best practices panel, i think the department has made tremendous progress and efforts in the time that i have been back and -- >> but the opportunity -- you want to knock it out of the park right now. >> not every recommendation is gold. every recommendation needs to be

looked at from the recommendation standpoint, but then from the organization as well. >> okay. take your argument, a couple of minutes ago you made this point as it relates to the responsibility of a foreign service officer. ha to be mindful of their own security. that was in response to miss sanchez. every foreign service officer must understand they have a role in their own security. i agree with that wholeheartedly. yet when ambassador stevens played a role in his own security on cable number one, cable number two, and cable number three, that responsibility was not absorbed or reflected in the state department. and you're not offering anything as it relates to fundamental change. based on what the rules are right now, mr. secretary, you have the authority,ç you have e capability and you've got the flexibility to do the benghazi structure again. am i wrong? >> the rules have been changed.

who is responsible is clearly defined. >> who is responsible is fourth down on the food chain. by your own -- >> no, sir, i will disagree with that. i am responsible. >> yeah, but i'm telling you -- >> the latest example. when we're trying to open a facility, in southern turkey. we had a request to put personnel in on the ground for start operations, for humanitarian operations. they're in their tdy. we need a facility. we are in the process of leasing a facility. we know where it's going to be. a request came to me from the people on the ground saying, can we use it in advance of the security upgrades being done, being accomplished. my answer, no. >> okay. that's beautiful. and in light of mr. cummings' response, you're going to be there for a season. and in another season, someone is going to succeed you. and in that new season, when

someone with your judgment and your deference doesn't have that level of capacity and they don't have your kind of stick and background, they'll be under tremendous pressure and they're going to say yes. i yield back. >> chair thanks the gentleman from illinois and recognizes himself. it strikes me there are at least two issues at play. two major issues. one is the efficacy of the arb process itself. whether or not it is in our best interest to allow any entity to essentially grade its own papers. we don't do that in any other category of life. we don't get to sentence ourselves when we're in court. we don't get to grade our own papers in the classroom. the other aspect of the arb is who they interviewed and didn't interview. whether or not they have to accept recommendations or don't have to accept recommendations. that's a separate issue, whether

the arb works, whether or not it has shortcomings. let's assume that the arb works. let's just make that assumption for the sake of argument. is anyone following the recommendations of the arb? mr. secretary, i want to read something to you. we are disturbed at the inadequacy of resources to provide resources against terrorist attacks. we are disturbed at the relative low priority of accorded security concerns. we praise the ambassador for seeking security enhancements long before the attack. do you know what that comes from, mr. secretary, what i just read? >> i believe it's part of the accountability review board report. >> from 1999. >> nairobi, correct? >> that was the arb from 1999. and you can lay it almost perfectly over what happened in

benghazi. one other point, the 1999 arb went really clear, they went out of their way to make it clear, they were disappointed that the recommendations that came after the bombings in beirut were not being implemented. something called the inman commission. the '99 arb criticizes existing state department employees for not following the inman commission from 14 years prior. that's a quarter century's worth of recommendations. and yet, here we sit. so, what i want to do, because i -- honestly, i commend mr. schiff. this was a wonderful idea. i thank each of you for coming. but giving the inescapable, inner connective with recommendations made after beirut, eastern africa, benghazi, we're going to look

past some of those arb recommendations. inman being beirut bombing. not meeting inman standards, essential physical security upgrades should be made immediately. that was the recommendation of the 1999 arb. mr. secretary, i'm going to read you another one. this goes to mr. cummings point, which was a great point. diplomatic situations should be made to all governments with whom we have relations to remind them they have security obligations to our embassy. who in libya were we to call? who? mr. cummings' point was so good. the 1999 arb makes a great point. who did we call in libya? >> question, sir?

>> when i pause, that's generally an indication i'm waiting on you to answer. but i'll make it more clear in the future. >> i think this is the heart of the question. there are times when -- for the national interest of the united states, we are going to have to have diplomats, humanitarian programs, rule of law programs and other things in places where the host country is -- >> mr. secretary. >> -- does not have a government. we must take lessons from -- >> was there a government in libya for us to contact? >> no, not at that time. >> so that recommendation of the 1999 arb we were not able to do. let's move to one perhaps we were able to do. also a recommendation from the 1999 arb. again, the arb is presented to us as a panacea. i mean, that's the evolution of what happens, is there's an attack, there's a blue ribbon panel, we're going to study, make recommendations and this is never going to happen again. back to the 1999. the secretary of state should

personally review the security situation of facilities closing highly vulnerable or threatened. why do you think the 1999 arb went out of its way to use the word personally. >> no comment, sir. >> is the answer privileged? i mean, that's a recommendation from the 1999 arb. the secretary of state should personally review. i'm skug with all due respect -- we're not going to get to the word review. we have to get to the word that modifies the word personally. why did the secretary of state himself or herself personally review? >> i think ultimately the secretary, who bears the responsibility for the security, has to be brought the information that's necessary for him to make decisions.

that is my job. >> okay. >> i have gone to the secretary of state on different occasions and we have talked specifically about the security of different places. tripoli was one of them in particular since i have been back. but we have also looked at sana, we've talked about kabul, we talked about the other locations as well. where i have concerns about the safety of our personnel and if we're not doing the things we need to do, then it's my responsibility to bring it to the secretary. >> and i appreciate that, mr. secretary. was it done on september 10th of 2012? was it done prior to benghazi? because this recommendation has existed for more than ten years. >> i was not here at that time. i'm sorry, i cannot tell you. >> well, your answer is -- mirrors what the 1999 arb further said, which is first and foremost, the secretary of state should take a personal and

active role in carrying out the responsibility of ensuring security of u.s. diplomatic personnel. is that being done now? was it being done prior to your tenure? >> in the time that i was here previously and i have served under multiple secretaries of state, i have heard every secretary talk about the importance of security. i have heard every secretary state to personnel of department that security is their function, their personal security has to be their function. that goes from madeleine albright, that goes through secretary clinton, secretary rice and with secretary kerry, who has also made those statements and has made statements that the safety and security of our personnel is absolutely one of our highest priorities. >> and i appreciate that, mr. secretary. again, i think words have consequences and they have meaning. most people use words intentionally. the 1999 arb intentionally used the words personally and active.

that to me does not mean talking about something. a personal review is not simply talking about it. is the personal review ongoing? is that arb recommendation still accepted, i guess, is my question? does the state department still accept these recommendations from the 1999 arb? and is it being done? >> yes. i think the best and clearest example that i can give you today is a new process we put into place. the vital presence validation process, where we, again, look at what are our vital national interests and why should we be in these high threat locationses. we put this process up and it goes all the way to the secretary. >> and that is a great point, which leads very nicely into the next point i was going to make, or ask you about. what is it about that recommendation that is so

talismatic that it couldn't have been made prior to the attack in benghazi? >> i think the department of state has practiced risk management from the day -- >> risk management we're going -- we know the risk of being in benghazi. can you tell us what our policy was in libya that overcame those risks? in other words, why were we there? >> these questions, i think, have been fundamental to the department for over 30 years. it is the reason why in many places we have evacuated or we have shut down operations or we've taken our families out. or we've gone down to essential personnel only or we've asked for marines to come in and support us while we're there. >> right. and my point being, mr. secretary, none of that was done in benghazi. so, what -- we know the risk in benghazi. my colleagues and you and others have done a wonderful job of highlighting some of the trip wires, i think is the diplomatic term. what policy were we pursuing in

libya that was so great that it overcame all of the trip wires and all of the rifbs? >> not being here at the time, sir, i cannot answer that question for you. i do believe personally, with my time at the united nations, that many of us understood that if we lost the eastern half of libya, that if we lost the confidence of the people after the revolution in libya, that we were going to pay a terrible price. and i don't want to put words into chris stevens' mouth. i think he was the -- an immensely talented diplomat. and i was not here at that time. but i think it was clear in chris's mind why he needed to go to benghazi and what he was trying to accomplish. i think today we have more normalized processes to make sure those decisions are documented, the vpvp process makes us go through a process that i don't think was there

prior to benghazi. i think the results of the accountability review board and the best practices panel and the recommendations that we've forward, we've got a clearer, more precise, more mandated process for risk management. but i would tell you, sir, that every singleag664kmsg6vñi day i was with the department of state, we were weighing the safety and security of our personnel. i think that's a fundamental tenet you will find everybodyçn the department agrees with. >> i appreciate you bringing the hearing toward its conclusion back to chris stevens and back to the other four who lost their lives. but mr. stevens was equally clear that he needed help. he was equally clear that the situation was getting worse in benghazi. he was equally clear in asking the people who sent him there to represent us, to provide adequate security. and none was forthcoming. with that i would recognize the

ranking member for his closing remarks. >> i want to thank you all for being here today. i thank all of you. one thing i want to remind all of us is that we are americans. everybody trying to do the best they can to protect our people. when we look at what happened in benghazi, there are a lot of lessons to be learned. the question is, not only have we learned them, but then how do we address them? and, you know, quarterbacking -- what do they call it,

monday-morning quarterbacking, i think when you look back on it a lot of times, you realize the things you could have done differently. that probably would have made things better. but, you know, we cannot bring back the past, but i think we can make a difference right now. it's clear that our diplomats are in some very dangerous situations. i think we all agree on that. and so now we've got to figure out how we go about protecting them even better than we have in the past. and so that's why, secretary starr, i asked you about coming back to us and letting us know

exactly, you know, what you're working on, those things that you still have to do. and reporting back. it is so important, because after -- when all the dust settles, the question is, what do we accomplish? you know, i've been here 17 years and i've seen a lot of arguments back and forth, but i think we must concentrate on being effective and efficient and getting something done. the arguments that have been made, and the frustration you hear from both sides, trying to figure out what happened. i believe everybody is acting in an honorable way, with great intentions, but i want you all to understand we're just trying to figure out what happened so

that we make sure, if there were things that went wrong, that it doesn't happen again. that's what it's all about. so, mr. chairman, again i want to thank you for this hearing. and i want to ask you to do something for me. i want to bring mr. starr back in either december or january. he's already told us that in 45 days or less he can tell us about what he's working on and give us some kind of timetable. but i want him to come back and tell us what has been achieved. and that's very, very important for me. and i'm sure for the whole committee. mr. chairman, if you will,

that's your call but i think it would be unfortunate if when all of this -- this committee ends, that we have not addressed these recommendations and addressed them in a way that would make -- that would please the families of the deceased. and that brings me back to them. four great americans who lost their lives. and i think we all made a commitment in one way or another to them, that we would do everything in our power to find out what happened. and at the same time, to make sure we did the best we could to protect our folks overseas, to tighten up security, if that's appropriate. and we've got to do that.

and so with that, mr. chairman, i want to thank you. >> i want to thank the gentleman from maryland for all of his help and, frankly, getting ready for this hearing. and the cooperative nature with which he has always worked with me. and i think it's an excellent idea. we will work with the secretary. i don't to want pick a date that's inconvenient with his schedule. december suits me better than january. i would rather do it sooner rather than later. but we will work with the secretary and i will work with you on the nature of whether or not that will be a hearing with all of our colleagues, whether or not that would be with just you and me. we'll work all that out. but i will pledge to you it will be done. and it will be done in december, if it suits his schedule. also, i just want to say this. we were given two different tasks. i say we. the house voted for us to be in existence. find out everything that happened before, during and after the attack in benghazi. and then do everything. and the speaker has been very clear in my conversations with him about this. do everything you can to make

sure that it never happens again. part of that is taking recommendations that have been made in the past and asking whether or not they've been implemented. the other part of that, frankly, frankly, is anticipating things that might possibly happen. we do not have to wait on a tragedy to make recommendations. i noted, mr. cummings, during the secretary's opening statements -- i'm not minimizing this at all. if it comes across as me minimizing it. i am not. he mentioned they were partnering with the new york fire department. that's a great idea. but it does necessarily lead some of us to conclude, why could that not have been done previously? fire's been around for a long time. it's been a weapon for a long time. why now? and it's not fair of me to ask him, which is why i didn't ask him. but the notion that we have to wait on something bad to happen before we can act to do something that all 12 of us

agree ought to be done. so, again, i thank all of my colleagues. i want to thank mr. schiff again for giving me this idea. i'll hope he'll share some others with me. again, as we adjourn, i want to adjourn in memory of chris stevens, sean smith, woods and y and pledge a process that is worthy of their memory and one that our fellow citizens can respect regardless of their political ideations. with that, we are adjourned. >> the family of cia contractor glenn doherty who was one of the four americans killed in the benghazi attack is seeking damages from the state department according to the associated press. a wrongful death claim was filed

by the family last week seeking $1 million from the two agencies . the executor of his estate filed a separate claim seeking a little over $1 million. the family argues that the u.s. post that came under attack in libya lacked adequate resources and personal despite repeated requests for more. >> the student cam video competition is underway. minutea five-seven documentary on the theme "the three branches and you." how action by any branch has affected you and your community. there are 200 cash prizes for students and teachers totaling $100,000. for the list of rules and how to get started, go to studentcam.o rg. >> terry branstad is running for a fifth term in iowa against jack hatch. the candidates will be facing

off tonight in a televised debate. here's a look at several ads running in that race. ago, 114,000 iowans were out of work. unemployment was the high west -- the highest in five years. terry branstad came back and so did i want. we have 140,000 new jobs. unemployment has been reduced to nearly 3%. and governor branstad is just getting started. iowa is back. he is honest, compassionate, a visionary. he is always looking forward. where we can go next to do better. we are seeing that. the jobs are there. we are seeing young people moving back.

i am really optimistic about the future. he definitely has a passion for this estate. after 20 years, iowans are tired of terry branstad. deals andls, bad political favors. there is the $110 million bad deal. taxpayer money given to an egyptian billionaire. they call it the dumbest economic decision made in iowa. he even tried to abolish preschool funding. aren't you tired of terry? it's time for a fresh start. >> there are two men running fry was governor. branstad supports tax breaks for corporations. giving wayanstad was to hundred million dollars in taxpayer money to a wealthy egyptian company. jack hatch was rebuilding neighborhoods, putting iowans to

work. there is only one thing that branstad and have in common. or jack, that's one thing to many. >> i'm ready for a fresh start. >> the debate between terry airstad and jack hatch live tonight at 8:00 eastern here on c-span. now, a house veterans affairs hearing that looks at the findings of an inspector general report on the phoenix v.a. health care system where 40 patients were alleged to have died while awaiting appointments. the report found there was no conclusive link between the delays and care -- delays in care and veterans death. those testifying include sam foot. other witnesses include veterans affairs acting inspector general richard griffin and secretary robert mcdonald. we will take your phone calls on the issue a and about 2.5

hours. >> good afternoon. this ring will come to order. i think everybody for attending this hearing which will examine the oig report on the phoenix issue. i would also like to ask unanimous consent, he is not here yet, but that our colleague david schweikert from arizona be allowed to join us here to address this issue. without objection, so ordered. also members, we do have a series of votes that will start at 1:00. i apologize for that. this hearing was moved from its original schedule time because of the joint session of congress to th the president of the ukra. what we will do is immediately after the final vote move back as quickly as you can. we will resell him the hearing as quickly as we possibly can -- resume the hearing. so we do not keep the witnesses

waiting any longer than absolutely necessary. on the 26 of august, the office of inspector general released its final report on the phoenix va health care system, which vaulted to national attention after our hearing on april the oig confirmed that 9. inappropriate scheduling practices are a nationwide systemic problem and found that access barriers adversely affected the quality of care for veterans at the phoenix va medical center. based on the large number of va employees who were found to have used scheduling practices contrary to veterans health administration policy, the oig has opened investigations at 93 va medical facilities, and it found over 3400 veterans who may have experienced delays in care from wait list manipulation at the phoenix va medical center alone.

the oig concluded by providing the va with 24 recommendations for improvement to avoid these problems from recurring. these recommendations should be implemented immediately, and this committee will work tirelessly to ensure that they are. mr. griffin, i commend you and your team for your work and continued oversight on these issues in the months ahead. with that said, and as we've discussed, i am discouraged and concerned the matter with which the oig report, the final report, was released, along with some of the statements contained within it. notably, prior to the release of the report, selective information was leaked to the media, apparently by a source internal to va, which purposely

misled the public that there was no evidence at phoenix linking delays in care with veteran deaths. as the days progressed, people actually read the report, not falsehood actually became obvious. what the oig actually reported, and what will be the subject of much discussion today, is this statement by the oig. we are unable to conclusively assert that the absence of timely quality care caused the deaths of these veterans. what is most concerning about this statement is the fact that no one who dies while waiting for care would have delay in care listed as the cause of death, since a delay in care is not a medical condition. following the release of this report, which found pervasive problems at the facility regarding delays in care and poor quality of care, committee

staff was briefed by the oig regarding its findings and how specific language was chosen throughout the drafting process. prior to this meeting, we requested that the oig provide us with the draft of the report in the form it was originally provided to va three weeks before the release of the final report. after initially expressing reservations, the oig provided us with the draft. what we found was that the statement i just quoted was not in the draft report at all. another discrepancy we found between the draft and final reports arose with statements to the effect that one of the whistleblowers here today did not provide a list of 40 veterans who had died while on waiting lists at the phoenix va medical center. first, the oig stated in the briefing to committee staff that va inquired why such a statement was not in the report, and the oig ultimately chose to include

it. further, additional information provided by the oig to committee staff shows that, based on the numerous lists provided by all sources throughout the investigation, the oig in fact accounted for 44 deaths on the electronic wait list alone, and an astonishing 293 total veteran deaths on all of the lists provided from multiple sources throughout this review. to be clear, it was not and is not my intention to offend the inspector general and the hard-working investigators he employs. however, i would be remiss in my duty to conduct rigorous oversight of the department of veterans affairs if i did not ask these questions. i would also like to point out that no one within the department, or any other federal government employee, including the members of this committee,

is beyond having the records scrutinized. as such, the committee will continue to ask the questions that need to be asked in order to perform our constitutional duty. it is absolutely imperative that the oig's independence and integrity in its investigations be preserved. full and transparent hearings like this one will help ensure that remains the case. with that i now turn to the ranking member, mr. michaud, for his opening statement. thank you very much, mr. chairman for having is the important hearing. i would like to thank all the panelists for coming today as well. today's hearing provides the opportunity to examine the va inspector general's final report on the patient wait times and scheduling practices within the phoenix va health care system. this report did not state a direct causal relationship between long patient wait times and veteran deaths. for some, that is a major concern, and accusations of undue influence by the va on the

ig report will be discussed at length today. what the ig did find is that the cases included in this report clearly show there were serious lapses in va's follow-up, coordination, quality, and continuity of health care to veterans. they also concluded that the inappropriate scheduling practices demonstrated in phoenix are a nationwide systemic problem. i do not need any more evidence or analysis. there is no doubt in my mind that veterans were harmed by the scheduling practices and culture at the phoenix facility and across the nation. the bottom line is this behavior, and its detrimental effect on veterans, is simply not acceptable. my heart goes out to the families of the veterans who did not receive the health care they deserved in phoenix and around the country. rest assured, we will understand

what went wrong, fix it, and hold those responsible for these failures accountable. as such, my questions to the va today is straightforward, what went wrong, what are you doing to fix the problem, how will you ensure that this never happens again, and how are you holding those responsible accountable? i applaud secretary mcdonald for taking forceful action to begin to address the systemic failures demonstrated in phoenix. we need serious, deep and broad reform, the kind of change that may be uncomfortable for some in va, but so desperately needed by america's veterans. i believe that such reform must be guided by a higher-level national veterans strategy that outlines a clear vision of what america owes its veterans, and a set of tangible outcomes that every component of american

society can align and work towards. earlier this week, i sent a letter to president obama asking him to establish a working group to engage all relevant members of society in drafting this national veterans strategy. we know from experience that va cannot do it alone. we must develop a well-defined idea of how the entire country government, industry, non-profits, foundations, communities and individuals will meet its obligation to veterans. va needs to become a veteran-focused, customer service organization. it needs to be realigned to become an integrated organization. it should do what it does best, and partner for the rest. it needs to be the government model for honesty, integrity, and discipline. we need to complete our investigation of the problems, and provide oversight on the solutions.

i look forward to today's additional testimony about what happened in phoenix, and how the va is working to ensure it never happens again. so once again, trying to i want to thank you for having this hearing at i yield back the bowels of my time. >> i would ask all members way their opening statements as customary in this committee. thank you to the witnesses that are here at the table, and those who agreed to set behind the principles. today we're going to hear testimony from acting inspector general richard griffin who is accounted by dr. john day, assistant inspector general for health care inspections, ms. linda halliday, assistant inspector general for audits and evaluation, maureen regan, counsel for the inspector general and transit, director of the kansas city office of audits for the office of inspector general. we are also going here from doctor samuel foote, former va

physician at phoenix the health care system, and doctor catherine mitchell, current whistleblower and medical director for the iraq and afghanistan post-deployment center at the phoenix va health care system. i would ask the witnesses now to please stand so that we may swear you in. if you would, raise your right hands. [witnesses were sworn in] >> and thank you. you may be seated and let the record reflect that all of the witnesses affirmed that they would, in fact, tell the truth, the whole truth and nothing but the truth. all of your complete written statements we made a part of this hearing record, and mr. griffin, you are not recognized for five minutes. >> mr. chairman, ranking member michaud, and members of the committee, thank you for the opportunity to discuss the results of inspector general's extensive work at the phoenix va health care system.

our august 26, 2014, report expands upon information previously provided in our ma may 2014 interim report, and includes the results of the reviews of the oig clinical staff of patient medical records. we initiated our review in response to allegations first reported to the oig hotline on october 24, 2013, from dr. foote, who alleged gross mismanagement of va resources, criminal misconduct by va senior hospital leadership, systemic patient safety issues, and possible wrongful deaths at phoenix. the transcript of our interview with the dr. foote has been provided to the committee, and i requested that it be included in the record. >> without objection. >> we would like to thank all the individuals who brought

forward your allegations about issues occurring at phoenix and other va medical facilities to the attention of the ig, the congress, and the nation. on august 19, 2014, the chairman of the subcommittee on oversight and investigation sent a letter to the ig requesting the original copy of our draft report prior to the a's comments, and adopted changes to the report. on september 2 a committee staff member at a summit request for a written copy of the original unaltered a draft as first provided to va on behalf of the chairman. concerns seem to come from our conclusion of the following sentence at a subsequent draft report that was not in the first

draft report we submitted to va. the sentence reads as follows. while the case reviews in this report documents poor quality of care, we are unable to conclusively assert that the absence of timely care caused the death of these veterans. this sentence was inserted for clarity to summarize the results of our clinical case reviews that were performed by our board-certified physicians, whose curricula the day are an attachment to our testimony. it replaced the sentence, the death of a veteran on a wait list does not demonstrate causality, which appeared in a prior draft, not the first draft that was requested but in a subsequent draft this change was made by the oig strickland on

her own initiative, neither the language nor the concept was suggested by anyone at va to any of my people. in the course of our many internal reviews of the content of our draft report, on july 22, almost a full week before the draft was sent to the department, one of our senior executives wrote this question. this is key, gentlemen and ladies. and i quote, did we identify any deaths that she needed to significant delays? this is on july 22. if we can't attribute any deaths to the weightless problems, we should say so and -- waitlist problem. we should say so and say why. the draft wording in the draft report was, were the deaths of many of these veterans related

to delays and care? this type of deliberation to ensure clarity continued, as it should, after the initial draft was sent to the department. in the last six years with issued more than 1700 reports. this same review and comment process has been used effectively throughout oig's history to provide the va secretary and members of congress with independent, unbiased, fact-based program reviews to correct identified deficiencies and improved va programs. these reports have served as the basis for 67 congressional oversight hearings, including 48 hearings before this committee. during these same six years, and our work has been recognized by

the ig community with 25 own words for excellence. we are scruples about her independence and take pride in the performance of our mission to ensure veterans receive the care, support and recognition they have earned through service to our country. i va secretary has acknowledged the department is in the midst of a serious crisis, and has concurred with all 24 recommendations, and has submitted acceptable corrective action plans to a recent report cannot capture the personal disappointment, frustration, and loss of faith that veterans and their family members have with the health care system that could often not respond to their physical and mental needs in a timely manner. although we did not apply the standard of determining medical negligence during our review,

our findings and conclusions in no way reflect the rights of a veteran, or his or her family, from filing a complaint under the federal tort claims act with va. decisions regarding va's potential liability in these matters lies with the va, the department of justice, the judicial system, under the federal tort claims act. ..

in december, 2013. while i have views on many aspects of what has come to be known as the scandal i would like to use this statement to comment on the downplaying and frankly inadequacy of the inspector general's office that continues in the report issued august 26, 2014 that i fear is designed to minimize the scandal and protect its perpetrators rather than to provide the truth to the veterans and families that have been affected by it. all the employees receive training on their duty to report waste, fraud and abuse to the inspector general whose job it

is to investigate these allegations. i did this in february, 2011 that resulted in the indirect debate director placed on leave in which two weeks of receiving my letter and then his resignation in lieu of resignation. i sent a separate level rate cut later in 2,013th against the chief administrative services brad curry for creating a hostile workplace and engaging in personnel actions and discrimination against certain classes of employees. as far as that could help committee ig never investigated this complaint. and it appears they turned it over to the veterans integrated network director susan bowers who is both superior. susan bowers could take action against him without running the risk that the entire waiting list scandal would be exposed. in late october, 2013 ice and a third letter to the ig informing them of access to his.

i include allegations of the actions by senior staff. and i advise them of the second hit in backlog of patients contained in the schedule with primary care consulates list. i came to phoenix to investigate all of the above. i get a response from the office and december, 2013 to join a conference call with them on december. the team came up to investigate the december 16 through the 20th and at that time i and others told them about the on address scheduled appointment convoy and showed the northwest electronic folding clinic which was being used to mask the true demand for the return patient appointments. we updated them on the secret electronic waiting list summary

report showing that 22 patients had been removed because they had died. we only had the names of the two deceased because none of the employees who were working with me had the electronic keys to print the names of the deceased. we asked the inspectors if they could do it but they responded that they could not. the last response that i had from them was on december 21, 2013 when i received him out of the office until december 31, 2013 reply. i offered to fax or mail the names that we had at the time that they were unable to give me a working fax number or address to mail it to. facts and a standard mail but not encrypted e-mail are appropriate methods to transmit sensitive materials. i said far more send far more e-mails in january asking if they would like the names but i got no response. i also got no response when i advised them that several more veterans have died.

finally february 2, 2014 out of frustration with a lack of action by the ig even though we were informing them of more and more deaths i sent a letter number four with copies to everyone that i could think of who might be able to help. the only response i got was a confirmation that they have received my letter. a friend suggested i contact the house veterans affairs committee and there i found the help i needed. during this process i was advised by several people that the only way that i could get the office to investigate my allegations was to make them public which reluctantly, i did. in my opinion, this was a conspiracy. possibly criminal perpetrated by the senior leaders. of the many scandals from the performance made in the top administrators by supposedly supposedly at the time goals to the harassment of employees trying to rectify the situation to the destruction of the documents and electronic records to the very real harm done for the thousands of veterans unable to receive timely medical care

nothing is more than the facts that's 293 veterans died in phoenix. the inspector general tries to minimize the damage done and the culpability of those involved by stating that none of the deaths could be conclusively tied to the treatment of uas. i've read the report many times into several things bothered me about it. throughout the case reports, the authors appeared to downplay the effects and minimize the harm. this was true in the cases six and seven where i have direct knowledge. after reading the cases it leaves me wondering what really happened in all of the rest. for example, in case number 29, how could anyone conclude that conclude but that wasn't related to the delay when the patient that needs a defibrillator to avoid sudden death did not get one in time and why was the case excluded from the ig review. a critical element proving this is a conspiracy as a potential tampering with the reporting

softball where the electronic waiting list from the beginning there 01 data showed that there is a difference between the number reported to washington and what the numbers actually were on the secret electronic waiting list. they minimized the significance of the crucial point treating it as a trivial clerical error and touting how quickly the department corrected it. rather than exploring who tampered with it in the first place. they stayed for thousand 900 veterans were waiting for the patient appointments at the phoenix va. 3,500 were not on any official list and 1,400 were on the not reporting secret electronic waiting list. 293 of the veterans are now deceased. this exceeds my original allegation that up to 40 veterans may have died while waiting for care. the ig says it isn't charged with criminal conduct.

but neither is it charged with producing reports to downplay the potential criminal conduct designed to diffuse and discourage potential criminal investigations for its diminished the public outrage. at its best to this it's best to this report is a whitewash and it's worse it is a feeble attempt to cover the report deliberately uses the language to invent the standards of proof and ignore the wide waiting list was not reporting accurate data and makes misleading statements. and i think that by outplaying the damaged information thereby protecting the officials responsible for the scandal reinforced the long-standing to delay committing i can't let the claim by that they've had to suffer with frontiers. >> you have gone three minutes over the five. i would like to say that the rest of your testimony will be entered into the record. i apologize, but i let you go

little bit longer then once we all had agreed to. if you could wrap it up in the next 20 seconds. >> secretary mcdonald said he was going to try to increase the transparency of the agency and that wouldn't comply. they didn't get the memo. the report failed miserably in the areas with of a conspiracy = to the redline concrete wall. >> doctor mitchell, you are recognized. >> i'm deeply honored by the committee's invitation to testify today. we were unable to conclusively assert that the timely club of the care cost veterans. as a physician reading the report i disagreed. specifically come a minimum of the five cases, i believed there was a very strong actual or potential causal relationship between the delay to care or proper care and a veteran death. in addition, the health care is contributed to the quality of life and for five other veterans who are terminally ill and and shorten the lifespan of one of

them. in the looking at the report, there are four cases where there is no cause of death listed and it's unclear to me how that relationship may or may not exist if there is no cause of death given. it's unclear if the veterans who are on the electronic waiting list were aware of the self referral process to the primary care clinics if they were not aware of the process, and the recently believed waiting on the waiting list was the only way to get medical care even if the symptoms were worsening. in the two cases, they gave evidence that the veterans accused or had a cute and stability acute instability to the medical disease that required repeated visits to the er and hospitalizations. iab leave that those likely contributed to the death began they didn't give a cause of death for those veterans. in terms of mental health treatment, there were eight veterans from electronic waiting list waiting for primary care who apparently just wanted a mental health mental-health referral.

two of the veterans committed suicide before they got the appointment. it was unclear if anyone told them that it was a self referral process and they could have done so any regular business day and in the mental-health care. and case number 29 there is a veteran that needed life-saving medical device implanted under his skin that would immediately shock his heart into a normal rhythm of his heart stopped. the community standard would have been to implant the device immediately. at the va, he waited for four months and still did not have happened. unfortunately, the veteran targeted stock and without the device he had to wait precious minutes for the paramedics to arrive to restart it. he was revived by but unfortunately, the family had to withdraw life support three days later. they stated that this device might have forestalled death. it is apparent that it would have forestalled death because the device is exactly what is used to treat heart rhythm that he had.

he died from complications of prolonged heart stoppage without the device that could have restarted his heart and seconds. he was denied access to specialty care. case 39 and veteran with risk factors came to the e. r. with stressors like being homeless. he was discharged back to the street and committed suicide at 24 hours later. the community standard would have been to admit this unstable veteran. the oig admitted that it would have been a more appropriate management plan to admit the patient but didn't draw the connection between an appropriate mental health discharge and death from suicide in 24 hours. case number 31 he died of prostate cancer that wasn't treated during a seven-month period the va failed to act on the lab. it couldn't have been cured of that earlier detection would have started the treatment that would have slowed down the progression of the disease significantly and slowed the puzzles were cancer to his bone

but because of the unavailable urology appointment and domestic labs he was denied access to care that would have forestalled his death by months if not longer. in case 36 the veteran didn't receive quality care for evaluation of unrelenting severe pain that served as the impetus for suicide. case number 40 is a premature discharge for an unstable patients with multiple suicide risk factors that enabled the death from suicide 48 hours later. there are many other cases they reviewed in a written testimony. i did not discern a difference between death that on the electronic waiting list and death waiting for appropriate mental care for those already in the system. death is death and there is no way to get them back. the purpose of my testimony is not to undermine the va. it's to get the va to examine its practices and in order to improve the club of the health care for veterans they have to repair the cracks in the system so no more veterans slip through.

thank you for your time. >> thank you everybody for your testimony. mr. griffin, and the information that you provided to the committee chose 28 veterans died while on the list were the new endpoint and request essentially meaning they died while waiting to get their foot in door and since they were not yet in the system your staff briefed us that they used social security records which only show that the individual had died, not how they died is that correct? >> i would say we saw a lot of additional information from social security and we sought to find death records from the coroner's office. we explored who might have been getting treatment under medicare

programs but as far as the specifics i would defer to doctor day. >> can you answer that question? to make the determination was by and large made by the medical records and the death certificate was mostly however able to identify the patient had died and records was correct and by reading the medical record and in several cases the records of the care at local hospitals. anyone that is on the list that doesn't make it through to be seen and it doesn't have a medical record i can't look at so those folks i am not able to examine.

>> if that is true then how can you conclusively or otherwise whether these were related to deaths of care. >> indicates is that we identified that we were able to actually review. his back the report says conclusively this is where we have some problems, there were people that were looked at in the report and your report says conclusively that there is no link to the delays in care yet there are individuals that you were not able to go back and look definitively out of their medical records to determine what the cause of death was or if there was a delay in care; is that correct? >> in the reports we are trying to address the patients that we identified who had a delay in

care, and then subsequently received the poor quality care as a result. >> but if you were on the list, is that a delay in care if you did not get into the system is this system is that a delay tax >> yes. >> okay then how can you conclusively say that none of the delay is more a cause of death? >> we were referring to the patients that we were able to look at. >> i provided your staff with a breakout. >> did you -- were you able to book book includes a flea at all of those that were on the waiting list plaques. yes or no word you able to come come close if we look at all of the people that were on the wait list plaques i want to direct

you to a finding in the report regarding the veteran who died while waiting for care and it's already been talked about this morning in a staff briefing on the floor, you stated that the veteran was seen by a urologist within three days of presenting to the er so the case wasn't included in the 45 case reviews in the report. however, we have received notification from the oig yesterday stating that a mistake had been made and that this veteran was actually not seen after he was presented at the er and after informing us of this delay the oig still says it didn't contribute to his death. could you explain to me how they came to this conclusion? the >> of the patient in question has had bladder cancer for many years and he arrived at the va and was seen in the emergency room initially and received a

very reasonable evaluation. among the chief complaints is that he had blood in his urine. he also had rheumatoid arthritis and other disabilities including amputation of the leg. as a result of the business, he had microscopic -- he also didn't need to see a the physician asked that he had several consoles, oncology consult and urology consult primary care consult. the records come and this is the source of the confusion, the records stated that he had an appointment made for urology to be held on 10-22-13.

it says that they requested a rescheduling of the appointment i was then rescheduled for 11: 11:06. so some people would say the patient had an appointment to see urology and didn't keep his appointment. >> what we ask this question real quick and then i will let you finish. nobody here in this room has any faith in any of the appointments and scheduling that was going on at that time, so i have no belief that what may have been written was in fact true. >> i understand about. that. what i'm saying is this gentle man then died by what appears to be mh and a static cancer where he had it in his brain and also cancer in his lungs. so the assertion that having seen the primary care provider provider into six or eight weeks

before the emergency room visit and when he died, i don't believe that the primary care provider would have changed his death. and i refer you to page 75476 of the testimony that we provided from the transcript. >> if i may also interrupt the testimony was given as the hearing already started. we didn't have a chance to look at it we just got it handed to us. in the hallway after the gavel dropped. >> i am just saying that -- >> it was sent up to make sure that the truth was on the record having seen other witnesses testimony and needing to make sure that the committee was aware that we had a taped

transcript of the interview and people should take a hard look at the transcript. >> i appreciate it very much but your staff told us that there was a problem getting it to the committee and that's why we just got it. >> are you referring to the transcript? >> that's what i'm referring to. >> any other transcripts i need to be aware of? >> we sent about 48 hours in advance. >> of the original allegation was up to 40 veterans may have died while awaiting for care in phoenix and i think everybody knew he was referring to patients on the electronic waiting list and on the schedule. an appointment with primary care consoles so it was all

conclusive. between the two sources you've now found 83 patients, more than double the original allegation was. so i have a couple of questions and then my alternative over. but why was that information not included in the executive summary that the va, not you but the va leaked early? but you did find room to include that we, quote, pursue this obligation but the whistle blower didn't provide us with a list of 40 patients names? >> i believe that you as the chairman and received the same that we did. it stated that there were 22 that died on the electronic waiting list. and there were 18 who died on the consult list. succumb in our pursuit of finding out what happened here.

the pursuit is ongoing as you know because of the urology issues that we discovered. the obvious first question in the interview was give us to 40 names. we want to go after the records of these 40 people. and ensure that we don't miss any of the 40 because that was so definitive. now you were very careful in the hearing on april 9 to say potentially 40. as time passed others said that there were at least 40. so, that spawned 880 reports that 40 veterans died while waiting for care in phoenix. that was the story in the hearing. to not address that with the amount of coverage and the

amount of readers. so we didn't look at 40. we looked at 3400 records to make sure that we didn't miss any. >> so that was important that you draw the fact that doctor foot didn't provide you with a 40 names. that was very important. >> what was important is in the hearing in this room -- >> i'm talking about the final report. >> that was not something that was inserted in the final report. there were multiple drafts which was a very important point but it doesn't seem to be getting any traction. we were asked to provide the first draft report and that's what we provided. please provide the committee with the original draft copy.

you may have thought that it meant an unaltered copy and i have an e-mail that went to your staff that has original unaltered, we want the original draft. >> to requests from the committee. one from you and one from the chairman. one of them said unaltered into the other one said something different but there wasn't any confusion that you wanted the very first initial draft report. >> let me read this e-mail to you. you have a third one that came from the staff director of the subcommittee. to joann moffatt, chairman miller would like to know if the oig is going to provide the committee with a written copy of

the original unaltered draft copy of the phoenix report as it is first provided to the va. if so, when? >> i guess i don't see what the difference is. you asked for the first initial draft report and we provided it. >> did you ever indicate indicates to the committee or to the staff that there was more than one draft? >> we provided with the committee asked for and we also explained that in the last six years no committee has ever requested a copy of the draft report. >> here's the way that it works here. we want all of the information, we don't want you to use semantics about which copy of the draft we asked for. we asked for the draft that you

gave so the va could make their determination as to whether or not the draft was factual or not. that was the intent you knew that's what it was. >> you knew what the request was and what we were trying to get is how did that get inserted from the draft to final. now we've testimony that in fact they did not conclusively look at all the causes of death. so i still make the statement and then i'm going to yield. and i apologize to the members. we have to be honest and open with each other about what's going on and whether or not any other committee has ever asked for a draft report, shame on them. whether they've ever sat at a table with anybody other than

the office, tough. this committee is going to get the truth about all of the facts >> me i respond? this is the whole allegation. >> we were asked to provide the initial because you didn't want one that had been through two or three iterations. you you wanted the very first draft report and that was clear to us. you can did can gi about all you want. >> can you show me anywhere that it shows we asked for the first draft. >> can you tell me where we asked for the first draft report?

sumac let me find the e-mail and i will respond to your question. >> it showed a lack of awareness -- >> you are out of order. >> on the reports if i understand you correctly, you did provide the first draft of the report, but there might have been other additional drafts. >> that's correct. >> so the draft you provided was the first. but there was other drafts since the first one that came out is that correct? >> it is a deliberative process in order for us to get concurrence from the department. we have to put a draft in front of that. if we have factual errors in that draft that they can

convince us were factual errors and it would be incumbent upon us to make whatever is required so that at the end of the process, the report in its final issuance speaks the truth on all. >> when they do the reporting you could conceivably get information whether it's from the whistleblowers or the department that might not be factual and once you get information that you determine actually to be factual that's when you change the report before it gets -- >> there were some minimum changes on one of the case reviews we had numbers that were taken into different times and were reversed. to me that is not a substantive change.

we put them back the way they should have been. but that is not a substantive change. it wasn't a budget of 40 veterans. did you ever receive the list of names of those that were on that list? the interview addresses that very clearly and was even suggested that perhaps some of them might have been run over by a bus that he didn't know what the cause of death was. >> did he not give you a transcript yet? >> i apologize for arriving late but it needs to be read by everybody that has a serious interest in this matter because it was a taped transcript of the interview. >> can i respond to that interview?

>> of the 93 ongoing reviews, how many have been closed out and when do you use the leave the rest will be completed? >> at this point we have 12 that we have turned over to the department that i wouldn't say were closed because we would anticipate administrative action being taken from the standpoint that we have completed the work that would have addressed the specific allegations that we were looking at. in the department proceedings to make determinations concerning the administrative action if they come across additional information that wasn't part of our focus we may have to do additional work. we turned over 12 so far. the others are not being worked with any.

the other 81 are going to be all published. we will turn these over to the department. those that do not get accepted for any criminal action we will promptly turn those over to the department so that they can take administrative action. >> thank you. doctor mitchell, in your testimony you mentioned how good the phoenix pain management team is that as they lack the staff and supply to service the veterans how do they communicate to their staffing needs to the director? was ever communicated and if so, what was done? >> i don't have any direct knowledge between the pain management team and the senior administration official staffing. but i do have is erect knowledge from many providers who find their panels filled with patients who are on long-term

narcotics and patients need additional close monitoring and follow-up. those providers don't have enough time to get those patients in for the sufficient appointment to be able to review that. in the community patients that are on long-term narcotics are referred to a pain management specialist to treat the ongoing education and monitor for side effects. unfortunately the staffing does not allow for that. >> thank you for having this important hearing. doctor mitchell, briefly on page 15 you pointed out case number 45 and a special circumstance. please explain why you did so in this case. >> i didn't have access to the records however anecdotally i was told that this is the same

patient i was familiar with and the details are the same with one oh mission. in the report the history starts with the patient presented with his family seeking mental health care. he was evaluated and declined and was discharged home and committed suicide the next day. what wasn't in the report and i believe this is the same case and if it's not it should be reported anyway, he was having problems with depression and called his parents and they brought him to the mental health care clinic however because he he had been enrolled in the dag was diverted from their to the enrollment clinic where he waited for hours. by the time he was enrolled in the system he went back to the mental health clinic and it was too late in the day to be seen so that he and his family were diverted to the er where again they waited a link the amount of time before they were seen by a psychiatric nurse to evaluate and by that time the people

involved said that the patient was tired and wanted to go home, he declined to discharged and was discharged at that point to have a follow-up the next day in the same clinic that wouldn't see in earlier. >> thank you for that verification. when you shared your draft report did the da propose any changes or ask questions regarding what asked questions regarding what was or was not in the report? >> needed. they requested that we remove several of the case reviews that appeared at the beginning of the report and we refused to them. they suggested that we flip-flopped and put numbers that were out of order. of course we changed that. there were two other things one involving a data that was inconsequential to the outcome of the case reviews we fixed that. there were a couple of tenses

changed in the recommendation that in no way whatsoever affected the intent of the recommendations of those who changed. none of the case reviews were substantively changed and the secretary agreed to implement all 24 of the recommendations. >> how often do departments ask for changes before the release to the public? >> i suspect that there's probably never been a report where there wasn't some minor change in that request. >> if we implement what they found and what they are concurring with that they are going to scrutinize those things and make sure that they are in total agreement and also look for those miniscule types of errors that will make the report more accurate.

>> in the language that you couldn't conclusively asserted that there wasn't a connection do you know who leaked back to the press before the report was made public? >> i have no idea. >> was it someone in your office click >> absolutely not. >> i didn't think so. on the scale of one to 100 where does that fall on the spectrum? >> it's a reflection of the

professional judgment of the board certified physicians there've been a number of suggestions as to how we should do this and we have received one from the committee saying that we should unequivocally prove that these cause death. what is unequivocally programmed as we do a review of the quality of care that these 3409 veterans received. that's what we do in all of our healthcare reviews and with the charter calls for when they were created. >> that there could be a connection less than conclusive. >> i think in some of them we said it might have improved the course but to say definitively that this person wouldn't have died if they had gotten in sooner was a bridge too far for the clinician's. now can you expand on that?

>> the basic problem is it is difficult to know why somebody actually died, not clairvoyant you i would ask you to read the testimony submitted by doctor davis where he supported the methodology that we used in the report that would be death certificates, plus the review of the chart. in the case that was discussed previously pretty individual died after failing to get get the implants of all hearts device quickly and that report you said, and i will read exactly what we said we indicated that he should have gotten the device more timely. i don't know exactly why he died. you would like to think that he died and that if that device had worked maybe it would have saved

his life but i don't know that that's why he died. there are circumstances that are not included in this report and the reason that he came to our attention is that he was on a wait list. he wasn't on a wait list for the cardiology clinic. second he's not in the group of patients initially where we called those who are on a wait list of the delayed care is on the list of patients that got substandard care when reviewing these cases where the care did not meet veterans quality of care so this gentleman was delayed in getting care between phoenix and tucson. so the part of the draft where he belongs i cannot assert why he died.

>> i have to say i am trying to understand what the controversy is and i understand the charges that have been made by the majority impugning her integrity and i understand that it means you are forced to change language and persuaded to change the language and that is the heart of the allegations. can you help me understand what is the charge and what is the response? >> my response is that there is a lack of understanding of the processing of draft report and it's understandable because it is the first time that anyone has gotten one. when we send an initial draft report, that doesn't mean that my senior staffnd