December 10, 2020

GAO Releases Udall-Requested Report Evaluating IHS Response Management in Child Patient Abuse Case


For Immediate Release

December 10, 2020

Contact: Ned Adriance

202.228.6870 | | @SenatorTomUdall 


GAO Releases Udall-Requested Report Evaluating IHS Response Management in Child Patient Abuse Case


Calls on IHS to open transparent implementation process on GAO recommendations


WASHINGTON—Today, U.S. Senator Tom Udall (D-N.M.), vice chairman of the Senate Committee on Indian Affairs, responded to the results of an investigation he requested from the Government Accountability Office (GAO) to review management issues at federally-operated Indian Health Service (IHS) facilities that resulted in the cover up of misconduct that endangers patients, other employees, and Tribal communities. U.S. Senators John Hoeven (R-N.D.), Jon Tester (D-Mont.), Lisa Murkowski (R-Alaska), Catherine Cortez Masto (D-Nev.), John Barrasso (R-Wyo.), Tina Smith (D-Minn.), James Lankford (R-Okla.), and Steve Daines (R-Mont.) joined Udall on the request. The senators requested the investigation after the case of former IHS pediatrician Dr. Stanley Patrick Weber, who abused Native children on multiple reservations he was assigned to by IHS, came to light.


The GAO investigation found that IHS lacks a standardized oversight policy directed by national headquarters to prevent and evaluate provider misconduct and misconduct allegations, instead delegating primary oversight responsibility for provider misconduct at federally-operated IHS facilities to the nine IHS area offices. While each of the nine area offices require new supervisors to attend supervisory training, not all require or provide additional training to identify and prevent provider misconduct and the content of the trainings vary widely between area offices. Additionally, the GAO found evidence that patient complaints and reports of provider misconduct were not consistently reviewed and investigated by the governing boards of federally-operated IHS facilities. The GAO issued three recommendations in light of the findings to review and standardize misconduct policies.


“The United States government has fundamental trust and treaty responsibilities to provide medical care to American Indians and Alaska Natives, and every patient receiving care from the Indian Health Service should have full confidence that their care will be safe, professional and high-quality,” Udall said. “Across the country, the vast majority of IHS medical professionals work hard to provide quality and culturally-competent health care to the Native communities they serve, and are currently demonstrating immense dedication and sacrifice during the COVID-19 pandemic. However, it is unacceptable that IHS officials failed to address and prevent the abhorrent abuse perpetrated by Dr. Weber on multiple occasions. It is essential that IHS management takes the steps needed to prevent misconduct from happening in the future, and I am encouraged by IHS’s commitment to implementing the report’s recommendations. I am calling on IHS management to open a transparent implementation process in light of the GAO report to encourage and restore public trust. And I continue to call for full transparency and for the Department of Health and Human Services to release its internal audit report, with appropriate redactions to protect patient privacy, on IHS management of this case compiled by Integritas.”


The GAO recommends that the IHS Director:

1. Establish a process to ensure that IHS area office policies related to misconduct and substandard performance are consistent with the policies of IHS headquarters.

2. Establish a review process at headquarters to standardize IHS area office trainings related to misconduct and substandard performance to ensure that staff receive consistent information about how to address misconduct or substandard performance.

3. Establish a standard approach or tool to ensure that the governing boards of federally-operated IHS facilities consistently document their review of information related to provider misconduct and substandard performance.


The full GAO report can be read here.