A patient seen at a U.S. Department of Veterans Affairs (VA) hospital committed suicide after a delayed cancer diagnosis, according to an investigation conducted by the VA Office of Inspector General (OIG). The report comes a day after a hearing in the U.S. Congress on delays in patient care in the VA system.
The patient's initial CT scan was performed in summer 2016 at a medical facility in the VA's Veterans Integrated Service Network 15, which covers Illinois, Kansas, and Missouri. But a complete evaluation was not delivered until spring 2018, when the patient was diagnosed with cancer. The patient committed suicide prior to treatment, the OIG said.
The OIG identified a variety of problems in the coordination of the patient's care among several primary and specialty care providers that contributed to the delayed diagnosis, including the following:
- Changes in providers or assignments of surrogate providers
- Untimely receipt of automated electronic notifications for imaging study abnormalities
- Untimely communication of abnormal test results to the patient
The OIG has made 11 recommendations to the facility, including planning and implementation of the electronic health record, review of the patient's clinical care, designation of provider surrogates, view alerts, secure messaging communication, and patient notification of test results, it said.
Delayed patient care in the VA has become a major issue in recent years. In 2018, an article in USA Today accused VA hospitals of canceling valid orders for radiology scans in an effort to clear a backlog of outdated requests for imaging studies.
And in 2014, a federal investigation of delays at a Phoenix VA hospital found a backlog of imaging studies was so bad that some veterans may have died waiting for their exams. An OIG investigation found that shortcomings in radiology scheduling were the reason for the problem.
Indeed, the ongoing issues in the VA healthcare system were the subject of hearings on June 25 in the House Committee on Veterans' Affairs subpanel on oversight and investigations. Congressional members heard from a number of VA physicians who had raised concerns about delays in patient care in the system and whether the agency has retaliated against doctors who have reported problems.
One of the physicians who testified was one of the whistleblowers in the Phoenix VA case, Dr. Katherine Mitchell, who told representatives that the VA retaliated against her for testifying on the delays in congressional hearings in 2014, according to an article by ABC News. Mitchell told the House panel that while there has been an improvement in patient care at the VA, the agency has a "malignant leadership culture" that makes it difficult for employees to come forward and express their concerns, the article stated.