Officials at the Indianapolis Veterans Affairs hospital insist they wanted to fire the administrator whose mistakes led to the amputation of a veteran’s foot due to missed home care appointments, but couldn’t because the staffer retired before they could act.

“Had (the investigation) been completed before the employee retired, the Roudebush Veterans Affairs Medical Center would have proposed the employee for termination,” Craig Larson, spokesman for the VA’s Chicago District, said in a statement. “The employee chose to retire while the investigation was ongoing, and there was nothing the center could do to stop that.”

Last week, officials from the U.S. Office of Special Counsel said that an administrative decision in 2017 to stop recording home health care consults into a VA’s patient record system jeopardized the health of numerous patients at the Indiana VA hospital, and forced at least one of them to lose his foot to a medical amputation.

That man, who had been discharged from care after a diabetes treatment, was left to change the dressings on his foot wound by himself for several days, even though VA staffers were supposed to do that.

“[His] worsening infection … and subsequent amputation appears to have been related to the delay of the dressing changes by the home care agency,” the report states.

Pete Scovill, public and congressional affairs officer for Veteran Health Indiana, said hospital officials “remain in close contact with the veteran” today and have offered an apology and “options moving forward.”

He also said that all affected staff have been re-trained to ensure that home health care consults are being properly conducted and recorded.

But the Special Counsel report noted that despite the grave nature of the mistakes, no staffers were fired. A social work assistant chief was reassigned to a different position, and the senior chief retired.

Larson defended the moves, saying center leaders took immediate action in response to the whistleblower allegations. But officials could not prevent the senior chief from retiring, and could not take any adverse job actions after that.

President Donald Trump made accountability at VA a key promise during his election campaign. After less than six months in office, he signed a new department accountability measure into law, speeding up the time in which staffers can be fired and allowing the department to recoup bonuses from individuals later convicted of criminal wrongdoing.

But VA officials said none of those measures would apply in this case.

Overall firings at the department have increased each of the last three calendar years, as the number of VA staff has also continued to climb.

In 2016, VA fired 2,001 individuals through regular removals and probationary terminations. In 2017, that number rose to 2,537. Last year, from January to the end of November, it was 2,889.

But critics have insisted that more firings does not necessarily mean better outcomes for veterans, especially if administrators making sweeping decisions can avoid punishment.

In a statement in response to the Special Counsel report, American Legion National Commander Brett Reistad said that “increased accountability will improve an already strong VA system” and called for the department to institute a broader plan to prevent future communication mistakes.

“Tragedies such as what happened in Indianapolis should never occur,” he said. “We expect VA to learn from this and act accordingly.”