At the request of Congressman Jo Bonner, OIG conducted an inspection to assess allegations concerning a patient’s quality of care and problems with Services at the VA Gulf Coast Veterans Health Care System, in Biloxi, MS. We substantiated that the patient’s overall medical evaluation during one of four Emergency Room visits did not meet VHA standards. We substantiated that the telephone service at the Mobile CBOC is problematic, and that payment for a non-VA hospital stay was originally denied. We did not substantiate allegations that the patient’s chronic back pain was not addressed at the CBOC or that the patient did not receive timely delivery of durable medical equipment. We could neither confirm nor refute that the CBOC provider received any telephone calls from the patient’s family during the months of January, February, or March 2012. We recommended that leadership ensure that a quality of care review is conducted with specific attention to the deficiencies identified in this report, and strengthen processes to address patient complaints regarding the problematic telephone system at the CBOC. The VISN and Facility Directors concurred with our recommendations and provided an acceptable action plan.