Mike Coffman actually said...

Make no mistake, the VA will be closely scrutinized for its actions towards those who have testified here today.

There was a tragic failure in leadership at the local level, the VISN level, and at the VA central office level.

Furthermore, there has been a serious breakdown in how the VA assessed its responsibility in diagnosing and reporting Legionella.

This hearing is necessary in order to accomplish a number of items.