Families allege military medical mistakes killed their loved ones. They want reform.

CAMARILLO, Calif. – Patrick Vega shouldn’t have died.

The 21-year-old recruit’s chest stopped rising and falling shortly before midnight on March 23, 2018, as he lay in his bunk at the Marine Corps Recruit Depot in San Diego.

Vega, of Oxnard, California, had been vomiting on and off for four days, and declined into incoherence. Not long before he had failed to run 1.5 miles in 13 minutes, 30 seconds. He had to make the pace to graduate from a physical conditioning platoon for struggling recruits and move on to boot camp, one step closer to his lifelong dream of becoming a Marine.

Upon realizing the recruit had stopped breathing, one of his platoonmates who had been told to check on him throughout that night ran to roust a drill instructor who tried to resuscitate him. About 35 hours later, Vega was pronounced dead at the Naval Medical Center San Diego, surrounded by his father, mother, sister and friends who were once his water polo teammates at Oxnard High School.

 Vega was buried two weeks later in his father’s Marine uniform.

“There’s so much wrong about what happened with Patrick,” Manny Vega said four years later, poring once again over redacted medical investigation reports that conclude his son died of natural causes. 

As a former Oxnard police detective, Vega questions why the recruit was left under the watch of other scared young recruits, why he was allowed to continue to train when he could barely walk, why he wasn’t transferred earlier to the hospital and given the dehydration treatment his father contends would have saved him.

“If he had gotten an IV, he wouldn’t have died,” Vega said. "His body was shutting down in front of all these people."

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The saddest part of this nightmare is that Vega and his family aren’t alone. He texts with the others, the parents whose daughter died of sepsis after not being given an antibiotic, the Army recruit who lost his leg and endured 43 surgeries after becoming sick during a Strep A outbreak at basic training, and the mother who was pulled into a janitor’s broom closet in an airport and told her son died during Marine training in Twentynine Palms, California.

Scattered across the nation, the families have formed the nonprofit Save Our Servicemembers. They’ve met with generals and members of Congress. Some have told their stories in hearings on Capitol Hill.

They’re fighting to change a military medical system protected against malpractice lawsuits by a 72-year-old Supreme Court ruling known as the Feres Doctrine. They want faster investigations, discipline for doctors and corpsmen who make mistakes, changes to military training and answers to the questions that torture them.

“You know how painful it is to read all this and try to figure out the details of my son’s death?” Manny Vega said. “What happened to my son is not what they say happened.”

'Died in excruciating pain'

Derrick Luckey wore his daughter Danyelle’s dog tags as he fidgeted with a microphone in a congressional hearing room last month. His wife, Annette, sat a row back wearing a T-shirt showing Danyelle in her Navy uniform.

They were stunned by her decision to enlist six years ago but won over by her dreams of doing something bigger than she’d ever done before. They planned to fly around the world and visit her wherever she was stationed.

“We were so excited,” Annette Luckey said.

Danyelle fell ill less than a week after leaving Guam aboard the USS Ronald Reagan on her first assignment. She asked for medical care and was given Motrin and Tylenol for seasickness, her parents said. She grew so sick her shipmates carried her back and forth to her bunk.

Five days after she first asked for help, she was admitted into the ship’s hospital. She died of sepsis a day later, on Oct. 10, 2016. Danyelle was 23.

Her life would have been saved had she been prescribed antibiotics, Derrick Luckey said in a House Armed Services subcommittee hearing on patient safety in March. 

“I’m here today to share with you the tragedy of Danyelle’s death," Luckey said. "She did not die in combat or in any military operation. Her death was very preventable. Instead, she died in excruciating pain.”

It’s unclear how often allegations of medical malpractice in the military occur, partly because the Feres Doctrine prevents service members and their families from suing the federal government over injuries. The doctrine arose from a 1950 Supreme Court ruling over malpractice litigation that included the family of Lt. Rudolph Feres, who perished in a barracks fire caused by a defective heating system.

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The court ruled litigation wasn’t necessary partly because the military already provides death and disability benefits. The justices also objected to having a civil court system overrule decisions by military commanders.

Three years ago, Congress passed the Richard Stayskal Military Medical Accountability Act, named for an Army sergeant stricken with lung cancer that went undiagnosed. The law allowed service members and their families to file compensation claims, but not lawsuits, for alleged malpractice that have occurred in noncombat setting since 2017. 

Since the law's regulations took effect in June, 355 claims have been made, according to a Defense Department report in February. Two have been paid out, for $10,000 and $20,000, though the law permits compensation up to $500,000.

Luckey, Vega and others contend the military-written rules for processing claims limit or exclude many cases of alleged malpractice.

The Luckeys were told Danyelle died a year too early. She also does not qualify because she was treated on a Navy ship abroad rather than a medical facility in the United States.

“That is like the home team getting to be their own referee at a football game,” Luckey testified. “Without these changes, the military will continue policing itself. The military will decide if they are right or wrong.”

Rear Admiral Bruce Gillingham, surgeon general for the U.S. Navy, testified that Danyelle’s death has been investigated and, as a result, a sepsis screening program has been launched throughout the Navy. He didn’t reveal any disciplinary action taken against health care workers but said accountability issues have been addressed.

Lt. Gen. Ronald Place, director of the Defense Health Agency that oversees military hospitals and clinics, said he makes the final decision on malpractice claims and defended the ways they are processed.

“It’s clear you suffered tremendous losses and I apologize for those losses," Place said, speaking directly to Luckey and others in the audience. "I take it very seriously when there are bad outcomes from the medical care provider within our system. I’m deeply committed to assuring that we learn from your losses so that we can better our health care system so we can have fewer losses.”

After the hearing, Derrick and Annette Luckey flew 2,400 miles home to Pittsburg, California, where their daughter’s room remains exactly how she left it: dresses in the closet, makeup stacked atop a chest of drawers and inspirational post-it notes plastered on a bulletin board. “What is coming is better than what is gone,” says one.

The Luckeys said military leaders know their daughter and others died needlessly but want the criticism and the grieving parents to go away.

“They know but they don’t care,” Derrick Luckey said. “They keep kicking the can down the road.”

Lisa Lawrence, a spokesperson for the U.S. Department of Defense, praised the military medical system.

“DoD is confident in its processes for ensuring quality care and proud of its performance as measured against peers in American medicine,” she said in a written statement.

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Pushing for change

As a Marine corporal and sniper team leader in 1989, Manny Vega pulled injured Marines out of a burning helicopter in South Korea, earning him the Navy and Marine Corps Medal for heroism.

Decades later in Oxnard, he sued the Archdiocese of Los Angeles and later the Vatican over molestation he and other altar boys said they endured from Father Fidencio Silva-Flores, then a priest at Our Lady of Guadalupe Church in Oxnard.

Now, the former police detective is deploying his investigative skills to help lead a fight against the nation’s military medical system. He said family members aren’t told details or how or why their loved ones died and have to file a Freedom of Information Act requests to gain investigation reports that come heavily redacted.

Military inquiries into Patrick Vega's death concluded there was no misconduct but said emergency medical services should have been provided sooner. One unidentified staff member was removed from his position supervising recruits, according to a Marine report.

Manny Vega said the death should have brought criminal charges and contends the records don't come close to the truth.

He said the Feres Doctrine barricades his quest for more information, barring a lawsuit  that could force the Marines and the Navy to divulge more information about the training and health care provided at boot camps.

“There is no way forward,” he said. “If you were able to move forward in court there would be depositions, discovery and all sorts of things. It's blocked."

Vega’s daughter, Kate, used Google to collect stories of other families who have lost loved ones and allege medical malpractice or negligence. The details differed but the accusations ran a common thread of missed diagnoses, denied care and lack of information about investigations. The families decided to band together.

“There’s more of a voice in numbers,” said Lynda Kiernan of Dartmouth, Massachusetts. “When one mother can’t go on there are others that can.”

Kiernan’s son, Becket, died during training at the Marine base in Twentynine Palms. An infection that started as a sore throat but went untreated grew into flesh-eating bacteria, she said. Kiernan flew out to be with her son but was greeted at the airport by officers who pulled her into a broom closet.

“He died two hours before I got there,” she said.

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The families plan to travel to Washington, D.C., in June to fight for legislation that opens the door wider to claims and allows lawsuits for malpractice in noncombat settings.

They want changes in military insurance to cover recruits in delayed entry programs. They want non-military doctors to provide screening exams before training. They want mandatory and immediate care for recruits and service members if they develop fever, chills or start vomiting.

Most of all, they want doctors and corpsmen who make mistakes to face consequences. 

“The military isn’t accountable for their actions,” Dez Del Barba said in the March congressional hearing. “When you’re sick and you need medicine, you should not be denied.”

Del Barba, 24, of Stockton, California, tested positive for Strep A during Army basic training at Fort Benning, Georgia, in 2019. Testifying independent of the nonprofit family group, he said that when he asked for care, he was accused of being weak. His infection grew into necrotizing fasciitis, better known as flesh-eating bacteria. He went through 43 surgeries and his left leg was amputated at the knee.

“It only took 35 days for the military to ruin my life,” he said.

Credentialing questioned

The service members and their families have gained support from veterans advocates and members of Congress including Rep. Julia Brownley, a Democrat. She has helped Vega gather information from the Marines and Navy.

“It’s been honestly shocking to me,” she said. “It’s absolutely unacceptable that families can’t determine what happened to their sons and daughters.”

Lt. Gen. Ronald Blanck said the military medical system is more accountable than critics contend. Blanck, now 80, served as the Army’s surgeon general and leader of its medical system for four years ending in 2000. He pointed at review systems used when allegations of medical errors surface, including a National Practitioner Data Bank that lists disciplinary actions taken against doctors and other providers.

When he was commander of the Berlin Army Hospital in Germany, Blanck agreed to assume responsibility for a patient's medical care that ended with an "adverse outcome." He said it's an action that is rarely taken.

“We don’t tell people — for fear of God knows what — when we make a mistake. We need to,” he said. “You have to do more than say we’ll look into it.”

U.S. Rep. Jackie Speier, a Democrat, led the March hearing on patient safety as chair of the House Armed Services subcommittee on military personnel.  She authored the Stayskal Act that allows people to file claims and is working to amend the law to cover more cases of alleged malpractice.

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A preliminary report on patient safety by the U.S. Government Accountability Office hints at other problems. Investigators surveyed four military medical facilities, finding 16 out of 100 doctors and other health care providers with credentials that had not been verified. They reviewed 19 investigations into alleged medical errors and found less than 20% were completed in six months as required. One lasted 546 days.

The investigation delays mean some doctors accused of medical error are not being listed in the National Practitioner Data Bank, the system used to alert other hospitals of possible malpractice, Speier said. More changes may be needed, including using an outside monitor to watch over credentialing and other patient safeguards, she said.

“It’s inconceivable you would hire someone to be a physician and not verify a credential,” Speier said.

Vega said the families in Save Our Servicemembers will continue to fight for change by telling their stories. He said they share not only tragedy but also bitter frustration over deaths and injuries they believe never should have happened.

"I need to bring the absolute truth out," he said. "I am an angry destroyed man but I have a mission. The Marine Corps did one thing right. They trained me how never to give up."

Follow Tom Kisken on Twitter: @tomkisken.