The Phoenix VA Health Care Center in Phoenix, AZ
The Phoenix VA Health Care Center in Phoenix, AZ (AP / Ross D. Franklin)

An Arizona veteran died of a heart attack after seeking treatment for chest pain from the Phoenix Veterans Administration medical center, where he was told he had to wait nearly seven weeks for a basic diagnostic test, a lawsuit settled by the government earlier this month for $800,000 revealed.

The Department of Veterans Affairs faces intense criticism for long wait times and fraudulent recordkeeping at its Phoenix facility, but the agency’s acting inspector general said that, to date, he’s found no evidence that delays in care led to fatalities.

“It’s one thing to be on a waiting list, it’s another for that to be the cause of death,” Richard Griffin testified before the U.S. Senate on May 15.

However, the lawsuit by Leonard Kitzinger’s widow, which has not previously been reported, indicates that at least one man died because he was unable to obtain prompt and appropriate treatment from the facility.

The suit, filed by Brewster Rawls of Rawls McNelis & Mitchell, alleged a series of missteps by V.A. medical personnel. Kitzinger, a U.S. Navy veteran in his early 60s, first sought treatment for chest pain in February 2011. His blood pressure was high—181/85—his electrocardiogram was abnormal and a chest X-ray indicated “atherosclerotic changes” to his heart, suggesting hardening and narrowing of his arteries. He was a smoker and his cholesterol was high, but he was sent home without medicine or a referral for further evaluation.

A week later, he was back. A physician’s assistant determined that his chest pain was due to reflux. She prescribed medicine to treat that and a drug to lower his cholesterol, but no cardiac workup.

Six months later, Kitzinger’s chest pain wasn’t better, so the physician’s assistant referred him to a gastroenterologist, who concluded “there were no findings to explain his chest pain or reflux,” according to the complaint. The gastroenterologist suggested a stress test to look for cardiac causes.

“The consult request form indicates that Mr. Kitzinger would be scheduled for the ‘next available’ stress test,” the complaint says. “However, the appointment was scheduled for Jan. 4, 2012, almost seven weeks later.” A stress test typically involves walking or running on a treadmill while the person’s heart rate is monitored.

On Nov. 21, Kitzinger suffered a massive heart attack at work that left him brain-dead. Four days later, his wife elected to remove him from life support.

“If his heart condition had been recognized and treated in a timely fashion … there’s not much doubt Mr. Kitzinger could have survived,” Rawls said in an interview.

Based on scant docket entries, the U.S. attorney’s office in Phoenix did not put up much of a fight before settling the case, arguing without elaboration that the injuries “were not proximately caused by the negligence of any employee of the United States.” A spokesman for the office declined to comment.

U.S. Treasury Department records show the government issued a payment of $800,000 on May 9.

Reports of substandard care at V.A. facilities have triggered a major scandal. President Obama on May 21 said, “when I heard allegations of misconduct—any misconduct, whether it’s allegations of V.A. staff covering up long wait times or cooking the books—I will not stand for it, not as commander in chief, but also not as an American.”

He continued, “The inspector general at the V.A. has launched investigations into the Phoenix V.A. and other facilities, and some individuals have already been put on administrative leave. I know that people are angry and want swift reckoning. I sympathize with that. But we have to let the investigators do their job and get to the bottom of what happened.”

White House deputy chief of staff Rob Nabors was in Phoenix on Thursday meeting with leaders of the Phoenix V.A. health care system.

On Wednesday, the House by a vote of 390-33 passed the Department of Veterans Affairs Management Accountability Act, which would make it easier to fire senior V.A. officials.

The suit by Kitzinger isn’t the only one to allege that delayed care led to a veteran’s death in Arizona. In December 2012, the government agreed to pay $600,000 to the wife of a man who died of liver cancer.

Alphonse Coronado sought treatment from the Southern Arizona Veterans Administration Health Care Services hospital in July 2008, complaining of right-side abdominal pain. He was diagnosed with a liver lesion. Over the next year, he followed up with his primary care provider, a registered nurse, but “no effort was made … to identify the source of the liver lesion.”

In October 2009, he was diagnosed with liver cancer, and he died nine months later. Negligence by the V.A. “resulted in significant delay in Alphonse Coronado’s care and treatment and more likely than not resulted in his death and/or the loss of a chance at an improved result,” according to the complaint by Barry Davis and Amy Hernandez of Piccarreta Davis.

To date this year, the V.A. has spent more than $50 million on medical malpractice claims, according to an analysis of Treasury Department records.

Contact Jenna Greene at or on Twitter @jgreenejenna.