More than 200 veterans died while waiting for treatment at just ONE VA hospital, damning report reveals
- Inspectors investigated the VA Health Care system in Phoenix, Arizona
- A damning 47-page report found 215 people died while awaiting treatment
- One died one month after attending the clinic complaining of chest pains
- Special tests that should have been booked within a week never happened
More than 200 veterans died while awaiting treatment at a VA hospital in Phoenix, Arizona, a shocking new report has revealed.
The Phoenix VA Health Care System was the center of a national scandal in 2014 when an audit by Veterans Affairs discovered 35 people had died while awaiting care.
The internal investigation found veterans were being kept on 'secret waiting lists' and were reportedly facing delays of up to a year.
Phoenix VA Care System, pictured, failed to treat veterans in a timely fashion according to a damning 47-page report by the Inspector General's office which has just been published
In a damning 47-page report, the VA Office of the Inspector General found that 215 veterans had died while awaiting treatment.
Among them was a 58-year-old man who was described as a 'moderate smoker'. He arrived at the hospital in May 2015 complaining of chest pain which got worse with strenuous activity.
The first doctor ordered an 'exercise treadmill test' from the Cardiology Outpatient Department and said the examination should take place within a week.
However, one month later, in June 2015, a family member discovered the man dead in his home.
The report said: 'According to the death certificate, an autopsy was performed confirming the cause of death as atherosclerotic cardiovascular disease.
'At the time of his death, the treadmill test was not scheduled.'
The report claimed the primary care provider had evaluated the patient properly and sent him forward for further tests 'as his symptoms were concerning and suggestive of heart disease'.
Arizona senator John McCain said a 'cultural change' was needed inside the Phoenix VA
The report concluded: 'Timely testing may have indicated that the patient had significant disease and could have prompted further definitive testing and interventions that could have forestalled his death.'
The review found that some 35,000 patients were waiting for consultations, with some facing delays of more than 300 days for vascular care.
One patient underwent surgery for vascular care in October 2015 after being recommended for treatment in June 2013.
A scheduler who attempted to warn of poor appointment practices in the surgical department was removed from their position after reporting the problems.
Michael J Missal, Inspector General at the US Department of Veterans Affairs said: 'Because consults were inappropriately discontinued, some patients did not receive the care requested or experienced delays in receiving care.
'OIG's 14 recommendations will help improve consult procedures at PVAHCS and ensure veterans receive the follow-up medical care with specialty doctors that they earned through their service in our military.'
The Inspector General's report said the VA Office reviewed more recent allegations that the Phoenix system's staff 'inappropriately discontinued and canceled consults, management provided staff inappropriate direction, patients died waiting for consultative appointments, more than 35,000 patients were waiting for consults' as of August 2015.
Consults include appointments, lab tests, teleconferencing and other planned patient contacts.
As of July 2016, there reportedly were 38,000 open consults at the Phoenix VA.
Jeff Miller, US House Veterans Affairs Committee Chairman said: 'More than two years after the Phoenix VA Health Care System became ground zero for VA's wait-time scandal, many of its original problems remain, and this report is proof of that sad fact.
'It's clear veterans are still dying while waiting for care, that delays may have contributed to the recent death of at least one veteran and the work environment in Phoenix is marred by confusion and dysfunction.'
The Phoenix system enrolls about 85,000 veterans and announced last week the hiring of yet another new director since the 2014 firing of Sharon Helman.
Miller added: 'VA's performance in Phoenix and across the nation will never improve until there are consequences up and down the chain of command for these and other persistent failures.
'Unfortunately, given that this report is largely devoid of clear lines of accountability to those responsible for Phoenix VAHCS's current problems, it is unlikely these issues will be solved anytime soon.'
Arizona senator John McCain said: 'Despite nationwide outrage following the scandal, today's report confirms that cultural change at the Phoenix VA is still desperately needed'.
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