BEDFORD, Mass. (AP) — Confusion over proper procedures at a Veterans Affairs hospital allowed a dead veteran to go unnoticed in a stairwell for more than a month after he was reported missing, according to a federal report released Thursday.

The report by the VA’s inspector general detailed a series of missteps by VA staffers and police who searched for the missing veteran at the Edith Nourse Rogers Memorial Veterans Hospital campus in Bedford, Massachusetts.

The body of 62-year-old Tim White, a U.S. Army veteran, was wearing the same clothes as when he was last seen in May 2020. White was found about 20 yards from his room in an emergency exit stairwell of his residential building, which is on the grounds of the VA hospital but is operated by Caritas Communities, an organization that provides services to homeless people.

A preliminary report on White’s death found no evidence of injury or foul play.

VA investigators determined the stairwell was never searched, in part because VA police wrongly believed that since White’s residence building was privately operated, it wasn’t their responsibility to search the stairwell. For the same reason, VA staff didn’t monitor or clean the area.

The report identified other lapses. VA rules require staffers to follow a specific protocol when searching for missing patients that includes searching stairwells. But White was considered a resident, and not a patient, so so those rules weren’t followed.

Poor communication also hampered the search. Shortly after White disappeared, Bedford police asked the VA police to use dogs to search the property. The VA police didn’t respond to the request for two weeks.

“Mr. White’s disappearance did not receive the attention it deserved from (the) VA, an agency that is required by federal law to provide for the protection of all persons on its property,” the investigators concluded in their report, which offered several suggested changes in procedure.

In a formal response to the investigative report, the VA said it would adopt many of the suggestions laid out in the report. The chief of the VA police department resigned earlier this year.

“We extend our condolences to the family and friends of this patient and are deeply saddened by this loss,” the VA wrote.

Messages left with Caritas were not immediately returned Thursday. In an earlier statement, Caritas had said that while it provides services and housing on site, the stairwell is controlled by the VA.

U.S. Rep. Seth Moulton, who had sought an investigation into White’s death, said Thursday that the report shows the need for big improvements.

“Tim White deserved better from the country than dying alone in a stairwell,” Moulton said in a statement. “His life might have been saved if the Bedford VA Police Department did its job.”

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