HAMPTON, Va. — Several failures at the Hampton VA Medical Center over nearly two years led to a delayed cancer diagnosis for a veteran, a report from the Department of Veterans Affairs' internal watchdog found.
The report, released by the VA's Office of Inspector General (OIS) on Tuesday, details several healthcare providers’ failures with communicating, acting on, and documenting abnormal test results between July 2019 and April 2021, when the patient was diagnosed with metastatic prostate cancer. The report didn't identify the person involved but said he was a man in his 60s.
The first failure happened in July 2019 when a vascular surgeon didn't communicate and act on an abnormal CT scan, which found possible cancer in the prostate gland (a malignant lesion, to be specific), according to the report.
In September 2020, a nurse practitioner didn't adequately address the patient’s complaints regarding urinary issues, which were discussed during an assessment over the phone.
In the fall of 2020, a primary care provider didn't communicate test results to the patient and didn't act on an abnormal result of a prostate-specific antigen test (used to screen for prostate cancer) by not performing follow-up tests or talking with a urologist.
In March 2021, the primary care provider didn't correctly enter bone scan orders in an electronic health record, causing a delay in results that found possible metastatic bone disease. A technology expert tried to fix the problem, but a registered nurse with no knowledge of the patient was entered as the ordering provider, which resulted in those results not being sent to a primary care provider.
In April 2021, the patient’s new primary care provider became aware of the bone scan findings and shared the results with the patient.
The OIS concluded the report with seven recommendations to assure something like this doesn't happen again, including better communication of test results and a possible review of other patients' prostate-specific antigen test results.
'We are appalled and disheartened': 4 of Virginia's federal leaders respond
U.S. Sens. Mark Warner and Tim Kaine (both D-VA) released a joint statement with U.S. Reps. Elaine Luria (D-VA-02) and Bobby Scott (D-VA-03), condemning the report's findings.
“We are appalled and disheartened to learn that a series of failures at the Hampton VA Medical Center led to a veteran’s delayed cancer diagnosis. Veterans and their families must be able to trust that they are receiving high-quality, comprehensive, and timely health care whenever they turn to the VA — and it is the VA’s responsibility to provide that level of care to its patients. The findings outlined in the Inspector General report suggest a dangerous series of care coordination and communication failings, both at the individual and systemic level. We commit to engaging directly with the senior leadership at Hampton and pursuing appropriate accountability. We are also committed to conducting close oversight as the Hampton VAMC works to implement the Inspector General’s recommendations, and put in place processes to guard against future failings as happened here.”