Here is a detailed case history of ethical decay at the US Department of Veterans Affairs. While the failures were those of individual staffers the institution failed to correct any errors for several years. The example cited is USAF C-123 cargo airplanes and their active duty and reserve aircrews.
C-123 veterans flew these former Agent Orange spray aircraft after the Vietnam War. The aircraft remained contaminated but in a long series of ethical shortfalls, VA denied every claim between 2007-2015 while also insisting it had no such "blanket denial policy."
VA staff invented a myth of “overwhelming preponderance of evidence” against the veterans...but that myth failed to persuade the National Academy of Sciences.
VA paid its favored consultant $600,000 in a unique no-bid, sole source contract, not for good science but to to help block veterans’ claims. VA staff heard the contractor’s prevarications during the June 2014 Institute of Medicine hearings but did nothing to correct his errors.
VA staff violated regulation VAM21-1MR and the Veterans Claims Assistance Act, ignored for years exposure confirmations from CDC, US Public Health Service and dozens of other authorities, citing instead the VA web site as the paramount authority. VA misled elected representatives.
In January 2015 the Institute of Medicine confirmed crew exposures. In June 2015 VA finally began honoring disability claims, yet blocked retroactive compensation normally provided once claims finished adjudication. Ethical failures were in advocacy, privacy, scientific accuracy, fairness, excellence and respect.
Had staff adhered to VA values, scandals like Phoenix and this abuse of C-123 exposure claims could have avoided to the benefit of all veterans.
Going forward, hundreds of thousands of VA employees need to adhere to “I Care” values and develop systems for enforcement of VA high ethical standards.