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Dear Doug Collins

Barry Coates: The Colonoscopy That Took a Year — and the Testimony That Became the Face of the VA Wait-Time Scandal

He is the face of the scandal because he insisted on being one. Barry Coates was not killed by a secret list — that was Phoenix, and his case is older and in a way worse: his doctors wrote the right test in his chart, month after month, and the system simply never ordered it. By the time he fought his way to a colonoscopy, the cancer that a rectal exam could have found was in his lung and his liver. What he did with what remained of his life was testify — plainly, specifically, with dates — postponed his own chemotherapy to do it, and left a sworn record so complete that his page here can be built almost entirely out of his own statement. The institution he addressed promised reform in his name's season. He did not live to see two years of it.

The service and the promise

Barry Lynn Coates of South Carolina enlisted in the Army in February 1991, “anxious to serve my country,” as his sworn statement begins. Near the end of basic training he injured his back, and he was discharged around May 1, 1991. What followed was his first education in the system: a five-year fight to obtain service-connection for the injury before he “finally became eligible for medical treatment through the VA system.” The VA then managed his chronic back pain for years. He made himself useful inside the machine he fought — by his own testimony, he represented “a lot of other veterans around my community and my state,” helping them with compensation claims and tort claims.

The promise in his case was the ordinary one, the one the VA makes to every enrolled veteran: that the care will be there, and timely, when the symptoms come. His symptoms came on November 22, 2010, when severe abdominal pain sent him to the emergency room at Carolina Pines Regional Medical Center in Hartsville. The ER found blood in his stool and recommended follow-up, with consideration of a colonoscopy. He was forty years old, with blood where blood should not be, and a written recommendation for the one test that settles the question. The record of the next thirteen months is his own, given under oath, and it is reproduced here in its sequence because the sequence is the indictment.

What happened

January 20, 2011 — the ER follow-up at the VA’s Rock Hill Clinic, with Dr. Anuradha Verma. “No rectal exam was done,” Coates testified. “I was basically told to continue taking my medications previously prescribed and to come back if things did not improve or things got worse.”

February–May 2011 — he went back, repeatedly. On February 25 he asked to be seen by a doctor or referred to a GI specialist. On March 3, with increased pain and rectal bleeding, he reminded Dr. Verma of the ER doctor’s colonoscopy suggestion; “I was sent home with hemorrhoidal suppositories and the promise that a colonoscopy might be done at some point.” A May visit produced “the same.” In his oral testimony he put the chart’s own language to the committee: Dr. Verma’s notes said “may need colonoscopy” on the January, the March, and the May visits — “Never set a consult up for it.”

June 2011 — he transferred to the Florence Clinic, where Dr. Eric Naumann “agreed that a colonoscopy needed to be done.” It still did not happen. His first gastroenterology consult came in August 2011, nine months after the ER visit, with Dr. Sylvia Kim — to whom he reported “the ongoing pain, constipation, and bloody stools that I had been dealing with for over a year only to repeatedly have it dismissed as hemorrhoids. I was simply told to return in two months, still no referral for colonoscopy despite my request.”

Fall 2011 — on September 1 he messaged Dr. Naumann that he was “still bleeding every bowel movement”; by September 15 he had trouble urinating. Naumann requested the colonoscopy a second time on October 4, 2011. He saw Dr. Kim on October 12 — and “was finally scheduled to have a colonoscopy consultation in April of 2012, which would be approximately a year and a half after the beginning of this journey.” The consult queue at the Dorn VA system was running about six months out. The GI backlog behind that queue was not a rumor: the VA’s Inspector General later found that at the William Jennings Bryan Dorn VA Medical Center in Columbia, delayed colonoscopies and other screenings were linked to malignancies found in 52 patients, that six veterans had died, that critical nursing positions had gone unfilled for months while GI consults arrived electronically and “no one was looking at the consults coming in,” and that of $1 million given to Dorn to relieve the backlog, only about $275,000 had been used in a year. CNN put the combined GI backlog at Columbia and Augusta at roughly 7,000 veterans.

Coates did not wait for April. “Tired of living in constant pain,” he testified, “I persistently called on the chance that there might be an earlier opening or cancellation” — refused a cancellation call-back list, he called anyway, and a cancellation came. Consultation November 30, 2011; the colonoscopy itself on December 9, 2011, at Fort Jackson Hospital, performed by Dr. Steedman Sarbah. It found a mass with, in his words, “almost total luminal obstruction” — CNN’s report described a tumor the size of a baseball — and the diagnosis was stage IV colorectal cancer, with metastatic nodules on his right lung and lesions on his liver. He told the committee the point that still reads like a verdict: “because of the proximity of the nodules to [the] anal verge, a proper rectal exam would have easily found it and prompted treatment sooner.”

The consequences, from his prepared statement: a permanent colostomy; daily catheterization after bladder nerves were severed in tumor removal; total and permanent impotence and incontinence; permanent chemotherapy neuropathy in his hands and feet. He was never told he could have been authorized the procedure through a private provider, and he never received the institutional disclosure — the VA’s own notice to a patient of an adverse event — for any of it. Chairman Jeff Miller, opening the hearing at which Coates testified, summarized the wait for the record: “Mr. Coates waited for almost a year and would have waited even longer had he not personally persistently insisted on receiving the colonoscopy that he and his doctors knew that they needed.”

In January 2014 a CNN investigation into delays in VA care — the first national story on the delays that year — made him the face of what was coming. He was asked to testify. On April 2, 2014, a follow-up found new lesions on his liver, multiple new lesions on both lungs, and a feared spread to his brain; a new round of chemotherapy “would have been started immediately but was postponed so I would be able to come and speak to all of you.”

What the institution did afterward

On April 9, 2014, Barry Coates, forty-four years old, testified first on the panel at the House Committee on Veterans’ Affairs hearing titled “A Continued Assessment of Delays in VA Medical Care and Preventable Veterans Deaths” (Serial No. 113-64). His opening words are in the official record: “My name is Barry Lynne Coates. And due to the inadequate and lack of follow-up care I received through the VA system, I stand here before you terminally ill today.” His prepared statement carried the passage the scandal would be remembered by: “It is likely too late for me, the gross negligence of my ongoing problems and crippling backlog epidemic of the VA medical system has not only handed me a death sentence but ruined the quality of my life I have for the meantime. I am not here today for me, I am here to speak for those to come so that they might be spared the pain I have already endured and know that I have yet to face.” And on accountability: “In the civilian world, these doctors would face malpractice suits and medical review boards. As the saying goes ‘heads would roll.’ In the VA system oversight is not as clear cut and complaints are often either lost or covered up by bureaucracy. So I ask you today, how many more vets will be allowed to suffer and die before someone is held accountable?” To his knowledge, he told them, none of the doctors involved in his delays had been disciplined. Two days before the hearing, the VA had finally given the committee the accounting it had sought for months: 23 veterans dead from delays in care, most likely between 2010 and 2012, “primarily from delays in gastrointestinal care” — nine of them at Columbia and Augusta alone.

His hearing sat at the edge of the larger detonation. Within weeks, the Phoenix VA’s secret wait lists became national news, and the Inspector General’s interim report of May 28, 2014 found some 1,700 Phoenix veterans waiting for appointments who were not on the official Electronic Wait List at all — “at risk of being forgotten or lost” — and, in a sample of 226 appointments, real waits averaging 115 days against the 24 days the VA’s data reported. Secretary Eric Shinseki resigned on May 30, 2014. The final Phoenix report of August 26, 2014 reviewed more than 3,400 veterans’ records and documented 28 patients with clinically significant delays (six of whom died) and 17 more with care deficiencies unrelated to scheduling (fourteen of whom died) — while stating, with a care this page preserves, that “we are unable to conclusively assert that the absence of timely quality care caused the deaths of these veterans,” and declining to substantiate the whistleblower’s allegation of forty deaths. The scheduling practices were found to be systemic throughout the VA. On August 7, 2014, the Veterans Access, Choice, and Accountability Act (Public Law 113-146) was signed — $16.3 billion, a Choice Program for veterans facing long waits, money to hire clinicians. The reforms arrived eleven months after Coates’s cancer did, and in his case they changed nothing that could still be changed.

Barry Coates died on Saturday, January 23, 2016, at the age of forty-six — twenty-one months after his testimony — and was buried in Timrod, South Carolina, after a service at Timrod Baptist Church. (His death is misreported in some later summaries as 2015, at 44; forty-four was his age at the hearing. The Congressional Record controls: Senator Tim Scott’s “Remembering Barry Lynn Coates,” March 17, 2016, records that he “passed away at the age of 46 on January 23, 2016.”) His family sued the VA, and the claim was settled — the fact of the settlement is documented; its terms appear nowhere in the public record.

His widow carried the question one level higher. On September 28, 2016, at a CNN presidential town hall at Fort Lee, Virginia, Donna Coates — clutching her husband’s folded flag, as the Army’s own report of the event records — questioned President Barack Obama directly: “So when are we going to actually start holding these contracted doctors and the VA employees accountable? For it’s a difference between life and death.” And: “We’ve heard a lot about reform. And the only true change that’s come since we began talking was that I am now a widow. And my family — we will never be the same.” The President answered: “My heart goes out to you… we can’t bring your husband back. I don’t in any way want to sugarcoat the fact of significant problems in the VA.”

Where it stands now

The system Coates indicted now publishes its own waiting times. The VA’s Access to Care site posts average wait times by facility and specialty, updated daily. The Choice Program he never got to use was succeeded by the VA MISSION Act’s community-care framework, under which a veteran the VA cannot schedule within 20 days for primary or mental-health care, or 28 days for specialty care, may go outside — standards that exist, in direct institutional descent, because men like Barry Coates were made to wait a year for a test their charts already requested. No law, program, or facility bears his name; the searches this page rests on found none. His name survives where he put it himself — in a hearing record — and in the Senate tribute entered after his death.

What has never been published is any accounting addressed to his case: no institutional disclosure was given him in life, no discipline of the physicians involved was known to him when he testified, and the settlement of his family’s claim was made without public terms. The Dorn backlog’s other names — the six dead the Inspector General counted, the fifty-two patients whose malignancies the delays attended — are not on this wall, because their names are not in the public record this section requires. They stand behind his, the way his stood, that April morning, for all of them: “I am here to speak for those to come.”

The ledger

The accounting, in three lines — what the record shows has been done, what it shows has not, and what was sought.

What has been done

What has not been done

What is being sought

The record, on video

Barry Coates’s testimony was filmed, and CNN’s investigation was broadcast nationally — this case is not unrecorded. But the video wall in this section carries only uploads verified to the section’s standard: embeddable, from the publisher of record — the committee, the network, the institution. As of this page’s publication, no upload of Coates’s April 9, 2014 testimony, of CNN’s January 2014 investigation, or of Donna Coates’s September 28, 2016 town-hall question could be verified to that standard, and the wall stands empty rather than borrow a stranger’s re-upload of a dying man’s testimony. The footage exists; the official hearing record is in the Sources below, and this wall will be completed when a verifiable publisher’s upload is available.

Sources

Part of Betrayed, Not Forgotten — this site's accounting for the service members and veterans their own institutions failed. Videos are embedded from their publishers; nothing here is re-hosted.