This is the final report addressing allegations of gross mismanagement of VA resources, criminal misconduct by senior leadership, systemic patient safety issues, and possible wrongful deaths at the Phoenix VA Health Care System. The OIG found patients at the Phoenix VA Health Care System experienced access barriers that adversely affected the quality of primary and specialty care provided for them. Patients frequently encountered obstacles when patients or their providers attempted to establish care, when they needed outpatient appointments after hospitalizations or emergency department visits, and when seeking care while traveling or temporarily living in Phoenix. In February 2014, a whistleblower alleged that 40 veterans died waiting for an appointment but the whistleblower did not provide us with a list of 40 patient names. However, we conducted a broader review of 3,409 veteran patients identified from multiple sources, including the electronic wait list, various paper wait lists, the OIG Hotline, the U.S. House Veterans Affairs Committee and other congressional sources, and media reports. We were unable to assert that the absence of timely quality care caused the deaths of these veterans. This report includes case reviews of 45 patients who experienced unacceptable and troubling lapses in follow-up, coordination, quality, and continuity of care. The patients discussed reflect both patients who were negatively impacted by care delays (28 patients including 6 deaths), as well as patients whose care deviated from the expected standard independent of delays (17 patients including 14 deaths). In addition to 1,400 veterans waiting to receive a scheduled primary care appointment who were appropriately included on the Phoenix VA Health Care System Electronic Wait List, we identified over 3,500 additional veterans. Many of the 3,500 veterans were on what we determined to be unofficial wait lists and were at risk of never obtaining their requested or necessary appointments. Since the Phoenix VA Health Care System story first appeared in the national media, the OIG received approximately 225 allegations regarding health care at Phoenix and approximately 445 allegations regarding manipulated wait times at other VA medical facilities. The VA OIG Office of Investigations opened investigations at 93 sites of care in response to allegations of wait time manipulations. We are coordinating our investigations with the Department of Justice and the Federal Bureau of Investigation. These investigations, while most are still ongoing, have confirmed that wait time manipulations are prevalent throughout VHA. VHA did not hold senior headquarters and facility leadership responsible and accountable for implementing action plans that addressed compliance with scheduling procedures. In May 2013, the then Deputy Under Secretary for Health for Operations Management waived the FY 2013 annual requirement for facility directors to certify compliance with the VHA scheduling directive, further reducing accountability over wait time data integrity and compliance with appropriate scheduling practices. The use of inappropriate scheduling practices caused reported wait times to be unreliable. The systemic underreporting of wait times resulted from many causes, to include the lack of available staff and appointments, increased patient demand for services, and an antiquated scheduling system. The ethical lapses within VHA’s senior leaders and mid-managers also contributed to the unreliability of reported access and wait time issues, which went unaddressed by those responsible. Where we confirmed potential criminal violations, we presented our findings to the appropriate Federal prosecutors. If prosecution was declined, we provided documented results of our investigation to VA’s senior management for appropriate administrative action. We will do the same when our investigations substantiate manipulation of wait times but do not find evidence of any possible criminal intent. Finally, we kept the U.S. Office of Special Counsel apprised of our active criminal investigations as they relate to referrals of whistleblower disclosures of allegations relating to wait times and scheduling issues. This report cannot capture the personal disappointment, frustration, and loss of faith of individual veterans and their family members with a health care system that often could not timely respond to their mental and physical health needs. Immediate and substantive changes are needed. If headquarters and facility leadership are held accountable for fully implementing VA’s action plans for this report’s 24 recommendations, VA can begin to regain the trust of veterans and the American public. Employee commitment and morale can be rebuilt, and most importantly, VA can move forward to provide accelerated, timely access to the high quality health care veterans have earned—when and where they need it. The VA Secretary concurred with all 24 recommendations and submitted acceptable corrective action plans. We will establish a rigorous follow up to ensure full implementation of all corrective actions. The VA Secretary acknowledged that VA is in the midst of a very serious crisis and will use the OIG’s recommendations to hone the focus of VA’s actions moving forward. The VA Secretary also apologized to all veterans and stated the VA will continue to listen to veterans, their families, Veterans Service Organizations, and VA employees to improve access to the care and benefits veterans earned and deserve.