Critical staffing shortages in the Phoenix VA Health Care System's urology department contributed to the deaths of at least four patients and placed other veterans at risk for advanced cancer, a new government report has found.

Eighteen months after the Phoenix hospital became the bellwether for a nationwide scandal on treatment delays and scheduling malfeasance at VA, the department's Office of Inspector General found that the health of at least a dozen patients with prostate or bladder cancer was endangered when their medical appointments were canceled or postponed.

In a report released on Thursday, Dr. John Daigh, VA's assistant inspector general for health care inspections, determined that unexpected staffing shortages at the Phoenix hospital starting in April 2013 caused 3,321 urology patients to be "lost to follow-up" or suffer delays in care, either from the Phoenix clinic or with a referral to a civilian provider.

Nearly a dozen either died or needed advanced treatment to address illnesses that had progressed as a result of delays in care.

Clinic staff was supposed to notify patients by mail of the cancellations and schedule follow-up appointments with civilian providers. But according to the IG report, many veterans showed up at the clinic unaware of the cancellations and staff failed to make the needed referrals.

"Patients who experienced delays also experienced frustration, confusion and often fear related to not getting appointments they were told they needed," Daigh wrote.

For some patients, according to the report, the consequences were fatal, including:

  • A veteran in his early 70s who called repeatedly for an appointment after noticing blood urine in his urine blood and finally was referred to a non-VA provider after first noticing his symptoms. He died 10 days after that appointment;
  • A patient in his 60s with a history of prostate cancer who had a spike in his PSA readings but was never informed of those test results by his VA provider. When he was seen four months after the test was run, his cancer was found to have metastasized, and he died less than year later;
  • A man in his early 60s who received an injected medication every three months at the clinic to manage his prostate cancer missed an appointment due to clinic cancellation. He did not receive his needed medication nor did the staff follow up on the results of a bone scan he had received. When he finally was seen, his cancer had spread to his spine. According to the IG, he died as a result of failure to follow up or for VA to aggressively treat his cancer.

In the report, interim Phoenix VA Medical Center Director Glen Grippen said the facility has "initiated action" to address staffing shortages and has hired enough staff to handle all urology appointments, with the exception of erectile dysfunction appointments, in house.

Grippen added that the center is working with the contracting company overseeing non-VA care, TriWest, to ensure timely exchange of medical records between civilian doctors and the VA, and is reaching out to the families of the veterans identified in the report to discuss their cases.

The report comes more than a year after a nationwide scandal broke over patient wait times and doctored appointment schedules at the Phoenix facility and other VA hospitals and clinics.

The new report drew fierce response from lawmakers who have aggressively pushed VA to solve staffing problems, improve patient care and hold accountable those responsible.

Sen. Johnny Isakson, R-Ga., chairman of the Senate Veterans' Affairs Committee, called the report "tragic and appalling."

"From a lack of coordination of non-VA care to a slow response to provider shortages, the Phoenix VA Health Care System has repeatedly failed our veterans," Isakson said.

"It's well past time for VA to clean up the mess in Phoenix," added Rep. Jeff Miller, R-Fla., House Veterans Affairs Committee chairman. "That means providing veterans with the care they have earned in a timely fashion and swiftly firing any employee standing in the way of this important task."

This week, the VA named Skye McDougall the new health care director for the region that oversees the Phoenix VA medical center as well as other hospitals in the Southwest. McDougall has been serving as acting director of the VA Desert Pacific Healthcare Network in southern California.

But according to a CNN report based on VA data and interviews with whistleblowers, McDougall's sworn testimony in March before the House Veterans' Affairs Committee on patient wait times at the Greater Los Angeles VA Medical Center was untrue.

McDougall testified that veterans at the facility waited an average of four days for doctor appointments, but the CNN review found that more than 12,700 patients waited for specialty care for at least three months and the average wait for a first-time primary care appointment was 48 days.

After that report was released, acting VA Undersecretary for Health Dr. Carolyn Clancy said McDougall did not falsify testimony and said the department uses two measures to calculate wait times that show different results.

On Thursday, Sen. John McCain, R-Ariz., urged VA to reconsider McDougall's appointment.

"I believe this selection does does nothing to regain veterans' confidence that the VA has been reformed in the aftermath of the tragic scandal during which veterans died waiting for care while senior VA executives collected monetary bonuses," McCain said.