In 2015, John Kilby was thriving as an experienced nurse specializing in caring for mentally ill patients at the Roseburg Veterans Affairs Medical Center.

Two years later he had been fired from his job after developing a depressive form of bipolar disorder and post-traumatic stress disorder.

The VA attributed his firing to what it said were unexcused absences. In the lingo of the VA, he was accused of being absent without leave, or AWOL. But Kilby said he took leave guaranteed to him under federal law and approved by a VA psychiatrist. He said it’s retaliation for whistle-blowing that led both to his mental illness and his firing.

Kilby said after he brought up safety concerns about a new building where mentally ill patients were housed, the mental health nurse manager who was his supervisor bullied him. At first, he said, he didn’t know why. He thought maybe it was a gender thing. Later he came to the conclusion that he was targeted for retaliation because he was a whistle-blower.

When the VA Office of Accountability and Whistleblower Protection and the Office of Medical Inspector investigated the Roseburg VA last year, both agencies found significant problems with the mental health nurse manager and the mental health chief at the time. Both were removed from their posts following the investigation.

But the OAWP found that Kilby’s firing was due to absenteeism, and not to retaliation.

That didn’t sit well with Kilby, who recently received a copy of the OAWP investigator’s executive summary of findings from the investigation. It’s been more than a year, a year in which Kilby said he has remained unemployed and has been working on his own healing. But he said finally receiving the executive summary, in response to a Freedom of Information Act request, brought it all back.

Shortly after patients and staff moved into the bright and shiny new Acute Psychiatry Unit building in April 2016, Kilby noticed some issues he said compromised patient safety. It started on day one, when all the lights suddenly turned off in the evening, as though it were a daytime-only facility. This was a 24-7 unit with inpatient care for people suffering from severe mental illnesses, and Kilby was on the graveyard shift.

They’d soon learn that the lights in patient rooms could only be turned back on at the building’s central nurse’s station, not in the rooms, and that the bathroom lights didn’t work at all. Worse, they discovered that in any room where a patient used medical equipment such as a CPAP machine for sleep apnea, if the lights went off, so did the machine. In those cases, they were having to turn the lights on at the nurse’s station and then leave them on all night. The patients were sleeping with towels over their heads to block out the light while they used the machines that ensured they kept breathing at night. Sleep disruptions can make mental illness worse.

Kilby became increasingly concerned about the impact on the patients as the problems dragged on for weeks, then months. On May 31, 2016, he sent out an email to fellow staff members about the lights, which had still not been fixed. It had been two months. He called it lunacy, and neglect.

“Seriously, WHAT ARE THEY DOING? There is absolutely NO EXCUSE WHATSOEVER for having a patient WHOSE SLEEP IS ALREADY MEDICALLY COMPROMISED BEING FORCED TO SLEEP IN A FULLY LIT ROOM,” he wrote. He framed it as a patient safety issue, but management seems to have begun framing the issue very differently.

A response the same day from the mental health nurse manager seemed to take Kilby to task rather than acknowledge his efforts to improve patient safety. It began, “I’m sorry to hear you are so unhappy right now.”

She went on to say the VA was working on it, but then pushed Kilby to route complaints through her first — something the OAWP report states is not a requirement for whistle-blowing on safety issues.

“Sometimes these things take time, and it requires patience on our part to stand behind and support those who lead,” she wrote.

They did take time. According to the Inspector General’s report, the lighting problem was not fixed until August 2016.

Six days after he had sent the email, on June 6, Kilby had a verbal altercation with the mental health nurse manager. During that argument, Kilby said the nurse manager yelled so much that one of the staff members asked her to stop because she was upsetting the psychiatric patients.

“It was like I was a dirty dog on her white carpet, that’s how I felt,” Kilby said.

Following the altercation, the nurse manager reported Kilby to the VA police.

Kilby subsequently filed a complaint with the Equal Employment Opportunity Commission. The EEOC questioned about a dozen of Kilby’s coworkers, most of whom backed Kilby’s version of events. Many said they thought he was targeted for bringing up safety complaints.

One of them also testified that she had received an email that was sent from the nurse manager to multiple employees asking them to make complaints about Kilby.

Things went from bad to worse. Near the end of the year, Kilby was accused of patient abuse, for allegedly yelling at a patient and putting him in a seclusion room. Kilby said he never yelled, but spoke firmly to a patient who was delusional and convinced him to go into an unlocked quiet room so he could calm down and avoid upsetting other patients.

Following that incident, Kilby was removed from his nursing duties and assigned to move furniture. He hasn’t worked as a nurse since.

After he was pulled off nursing, Kilby had a breakdown. He said he had never been mentally ill before, but at that time he was diagnosed with post-traumatic stress disorder and bipolar disorder, and began having a lot of absences. He showed The News-Review a copy of a note from his psychiatrist explaining that he would need time off. He also said his absences were covered under the Family and Medical Leave Act. Apparently the VA disagreed. He was reprimanded, then suspended, then fired for his absences.

The nurse manager he fought with, the mental health chief who reassigned him to move furniture, even the VA director who ultimately fired him are all gone, removed following the investigations performed by the OAWP and the OMI. The OAWP report noted staff members described the mental health nurse manager as yelling, having outbursts, being a bully. But it found Kilby was dismissed for absenteeism, not retaliation.

Kilby disagreed.

“I guess the reason I’m not working for the VA is I refuse to be complicit with harm. I cannot,” he said.

On Friday, Roseburg VA spokeswoman Traci Palmer issued a statement that didn’t directly address Kilby’s situation, but did say that the VA has made clear it will hold employees accountable if they don’t live up to the high standards taxpayers expect from the VA.

“We make no apology for doing just that,” the statement said.

Reporter Carisa Cegavske can be reached at or 541-957-4213.

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Senior Reporter

Carisa Cegavske is the senior reporter for The News-Review. She can be reached at or 541-957-4213. Follow her on Twitter @carisa_cegavske

(4) comments


"The OAWP investigator did find, as did the OMI investigators, significant problems with management in the Acute Psychiatry Unit. It discussed reports that the former mental health nurse manager yelled at staff and told staff they would be reassigned to undesirable shifts or duties if they did not put up with her outbursts. Two staff members quit because of her behavior, the report said. It also said that Beiring, the mental health chief at the time, was told about the nurse manager’s misconduct but did not investigate it adequately.

In a particularly striking example, the report detailed an incident in which the mental health nurse manager, also referred to as the APU nurse manager, demanded that blood be drawn from a psychiatric patient who was refusing it, over the objection of the nurses.

“Essentially a group of nurses were opposed to drawing blood from a patient that was actively refusing consent. On the other side was the previously mentioned APU nurse manager ordering the nurses to draw the blood despite their professional objections,” the report said. Ultimately, it said, the nurses stood their ground and the nurse manager performed the blood draw herself. Afterward, the patient’s condition worsened.

Both the APU nurse manager and the mental health chief were removed from their posts following the investigations." -


OAWP wouldnt know retaliation if it slapped them upside the head.


Please remember to keep the time frame in context -

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