Delay in Diagnosis and Subsequent Suicide at a Veterans Integrated Service Network 15 Medical Facility

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess an allegation of delays in diagnosis of a patient’s cancer at a Veterans Integrated Service Network 15 medical facility. The OIG substantiated a delay in the patient’s diagnosis. The patient’s initial complaint and abnormal computed tomography scan were in summer 2016, but a complete evaluation did not occur until spring 2018 when the patient was diagnosed with cancer. The patient completed suicide prior to treatment. The OIG identified multiple deficiencies in the coordination of the patient’s care between and among several primary and specialty care providers, changes in providers or assignments of surrogate providers, receipt of automated electronic notifications (view alerts) for imaging study abnormalities, and communication of abnormal test results to the patient that contributed to the delayed diagnosis. Facility leaders did not perform an institutional disclosure and conducted a prospective internal review rather than a retrospective analysis for adverse clinical events as required by the Veterans Health Administration. The OIG made eleven recommendations related to the planning and implementation of the new electronic health record, review of the patient’s clinical care, Patient Centered Management Module and provider assignments, designation of surrogates, view alerts, secure messaging communication, patient notification of test results, disclosures, and quality management activities related to internal reviews.