(InvestigateTV) — When a recurring shoulder injury flared up for Jordan Way, the 23-year-old’s parents encouraged him to wait until he came home to have surgery and had a doctor they knew and trusted. Way originally hurt himself years earlier, playing high school football in Maryland. Going under the knife across the country in California, so far from family, made his parents uneasy.

“He kept saying to me, ‘Mom, I’m going to be okay. I trust them’,” his mother Suzi Way said.

It made sense. Way, a Navy Corpsman stationed at Bush Naval Hospital in Twentynine Palms, California would have medical care provided by his colleagues at the facility where he worked as a pharmacy tech. He was one of them. Why worry, he told his family.

So, on December 12, 2017, Jordan underwent routine shoulder surgery to repair a minor tear. Four days later, he was dead.

“I live with that guilt,” Mrs. Way said. “Why didn’t I get on a plane and do something about this?”

The hollow of heartbreak for Suzi Way is amplified only by the aggravation of trying to figure out what killed her son in the first place. The family’s years-long fight to find answers is emblematic of a military system that InvestigateTV discovered operates behind a curtain of secrecy, often shutting out families and shielding problematic providers from public view.

‘It’s a chasm of untruths. Zero transparency’

Service members and their families typically receive medical care within the military healthcare system overseen by the Defense Health Agency – care that’s provided by 140,000 medical personnel at an expansive network of about 600 military treatment facilities across the country.

But when mistakes are made by those personnel or when providers engage in misconduct at military facilities, those individuals are protected. Information about their discipline, malpractice settlements, and payouts are kept confidential under a federal law that leaves patients in the dark.

InvestigateTV has spent the last two years investigating the system, battling the Defense Health Agency for records and interviewing nearly 20 experts, patients, advocates, attorneys, and Congressional lawmakers about the lack of transparency in a system responsible for treating thousands of military personnel and their dependents across the nation.

Now, for the first time, InvestigateTV is getting a look behind that curtain of secrecy, courtesy of a military whistleblower who supplied documents that shed light on some of the initial evaluations done after medical cases result in serious injuries and deaths.

The documents supplied are internal hospital records typically kept confidential under federal law. They lay out the play-by-play that happens after a mishap in a military treatment facility, as doctors lay bare problematic and tragic cases in the days and weeks that follow.

The paperwork reveals the first piece of internal framework that’s used internally at military medical facilities to evaluate the potential for discipline or liability. It details whether doctors or other healthcare personnel made errors in technique or judgment, delayed diagnosis, or communicated ineffectively - even whether equipment was missing or failed to work.

Those forms include two critical questions:

• Was the incident preventable?
• Did military providers meet the standard of care?

But even when mistakes are made and acknowledged in black and white, what’s said in the documents is withheld from military families, even if they sue or file a malpractice claim with the government.

It’s the kind of paperwork people like Ways wish they could see as they try to piece together how an otherwise healthy young man could wind up dead within days of a simple surgery.

“Your mind just starts writing a story that you don’t have any content - true content - to fill in the gaps so to speak. And then to try and get that information and be told continually, we don’t have to tell you anything,” she said.

Instead, the family had to fight the military for information about the events leading up to Jordan’s death – filing multiple Freedom of Information Act requests and enlisting the help of Congressional representatives to obtain the investigative file from the Navy and other materials related to his death.

That work helped them build a tragic timeline, detailing the final hours and days of a life that should have had years left to flourish.

Records obtained by the family show Jordan’s surgery went off without complication on December 12, 2017. But just hours after he was discharged with a prescription for oxycodone for pain, he returned to the emergency room at Twentynine Palms. Medical staff described him as “disheveled”, “sobbing” and “in obvious distress”. He reported the pain medication was not working.

A call was made to Jordan’s surgeon, who increased the dosage, added a muscle relaxer and sent the young man home. His friends, fellow Navy corpsmen, drew up a schedule to monitor the distribution of his medication, carefully dosing out the pills as directed on a rotation - communicating to ensure there was no overlap between their shifts.

The next day, records show, Jordan called his surgeon again - still feeling no relief, and his oxycodone was increased to the maximum dose without further physical evaluation. Despite continued severe pain and suffering, and more calls to the hospital, Jordan still wasn’t seen in person.

One of his caretakers heard him snoring on the morning of Dec. 16, so they left Jordan to sleep. Just two hours later, upon noticing the snoring had stopped, they checked again – finding Jordan unresponsive. They dialed 911. CPR was started. But it was too late. Jordan was gone.

Way and her husband, Dana, got the news first through a frantic FaceTime call. Then within hours, they got the knock on the door no military family ever wanted to hear.

Jordan’s official cause of death was listed as opioid intoxication. His NCIS file indicates that in the three days following his surgery, he took more than 80 oxycodone as directed.

“Jordan’s command staff from the top all the way down, the doctors, the procedures that were and are in place, failed him. They failed him,” Mrs. Way said. “He was opioid naive and the dosing that the doctors were giving him - the other dosage, they weren’t clearing his system. So, he was having a buildup of toxins in a very short period of time.”

Military has reported hundreds of problematic providers, kept identities confidential

Suzi Way and her family didn’t have a complete picture of the circumstances of Jordan’s death until months later. And they never got the kind of confidential form supplied to InvestigateTV by a whistleblower. What they were able to obtain left them many questions, with Jordan’s file filled with redactions.

The names of all the medical providers involved in Jordan’s care have been redacted, blacked out, and covered with federal code, keeping the curtain of transparency about who treated him firmly closed.

His case is not the first time InvestigateTV has seen military officials playing doctors of defense.

After filing numerous information requests over the last two years and threatening legal action, InvestigateTV obtained data showing:

• Between 2018 and 2022, nearly 500 reports of military medical providers were made to a confidential government data bank that tracks discipline, lawsuit settlements and malpractice payouts
• Hundreds of suspensions and disciplinary actions were taken in that timeframe against military providers following misconduct and mistakes that have resulted in injuries and deaths
• Nearly $1 billion dollars in taxpayer money has been spent on malpractice claims filed against military providers in the last 15 years

The names of all the providers involved in those cases are kept confidential by the military.

In March InvestigateTV took its findings to Sen. Chuck Grassley, R-Iowa. “It shocked me,” he said. “On the civilian side, we know who those people are. Their names are public, and the public ought to be protected from people that don’t deliver medical care the way that the profession dictates.”

Grassley, a longtime advocate for transparency and auditing, especially when it comes to the Department of Defense, wouldn’t commit to an investigation. But when asked about the agency’s ability to keep information about problematic providers secret, he told InvestigateTV, “Transparency brings accountability.”

Audit shows failures in notifications about discipline, investigations into military medical providers

The Government Accountability Office, a federal watchdog agency, has long taken an interest in the military’s handling of the providers responsible for treating service members and their families.

“It’s important for us to ensure that they are getting care that is from providers that are competent and qualified and that we are reducing any chance that there is any patient safety risk,” said Sharon Silas, a director in the GAO’s healthcare unit.

Silas oversaw a recent audit of the Defense Health Agency, which was released in April. It focused on what the military refers to as “adverse actions” involving military medical providers, looking at 55 discipline cases at just four military treatment facilities. GAO auditors found:

• Military doctors in some cases weren’t being suspended as required while investigations into their conduct were done
• Notifications about suspensions to state medical boards and that confidential federal data bank were sometimes delayed for weeks or months beyond the required deadline
• Some of the military facilities weren’t notifying other hospitals or clinics about discipline at all, both in and outside the government system

Silas said, “It’s important for those healthcare systems to understand and know what types of concerns have been raised.”

Military families have almost no way of hearing about concerns raised about military providers. Some eventually end up on the internet when legal filings are made public by various entities including attorneys celebrating victories against the system.

But generally, those problem providers are unknown. Unlike the civilian system, which results in disciplinary documents being publicly posted by almost every state medical board in the country, actions taken against military doctors and nurses are kept under wraps.

It’s frustrating for families like the Ways, who believe people willing to die for their country should know the names of military healthcare providers involved in the harm of service members that’s resulted in disciplinary action or malpractice payouts.

The family filed a malpractice claim against the military, including expert testimony from two physicians who reviewed Jordan’s file. Those two experts concluded the doctors who treated Jordan were negligent in overprescribing and failing to evaluate him as he took more and more of the pills they ordered while his pain continued. They called his death “avoidable.”

Yet Way family’s claim and subsequent appeal were denied, with the Defense Health Agency telling them the standard of care had been met in Jordan’s case.

They’re not alone. According to the DHA, nearly 600 malpractice claims involving military providers have been filed since January 2020. More than 250 have been denied. Only 20 have been paid. The rest sit in limbo.

“They hold all the cards. They hold all the cards, and the DOD (Department of Defense) is not being held responsible,” Mrs. Way said. “It is a cancer. Military medical negligence and the DOD, what they’re doing in hiding these doctors and not being transparent with the families, is a cancer.”

Have you experienced military medical malpractice? InvestigateTV would like to hear from you.

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