Delayed Cancer Diagnosis and Deficiencies in Care Coordination for a Patient at the Overton Brooks VA Medical Center in Shreveport, Louisiana

The VA Office of Inspector General (OIG) evaluated allegations that a primary care provider did not timely identify a liver abnormality nor inform a patient about a terminal cancer diagnosis at Overton Brooks VA Medical Center (facility) in Shreveport, Louisiana. The OIG identified additional concerns related to care coordination, resident supervision, communication of abnormal results, surrogate provider coverage, and patient safety event reporting. In early 2019, a primary care provider referred the patient to the facility’s Emergency Department for evaluation of leg pain. The patient was admitted and had imaging tests that showed a liver lesion with further testing recommended. The inpatient medicine provider (resident) included the imaging results in the patient’s progress note; however, the resident did not document findings or follow-up needs in the patient’s discharge summary. During four subsequent visits, the primary care provider’s notes lacked documentation of the lesion and recommended follow-up. In summer 2019, the patient reported having imaging at a community hospital that identified a liver tumor, and the primary care provider ordered a liver scan. The scan showed a liver mass and lesion. The primary care provider was on leave during the time the scan was conducted and an Emergency Department physician assistant was assigned as a surrogate for coverage. The OIG found no documentation that the primary care provider or the surrogate informed the patient of the abnormal findings. The patient died in fall 2019, after a confirmed liver cancer diagnosis. Facility leaders and staff did not take timely administrative action in response to the patient’s adverse event. Staff did not initiate a patient safety report and review the episode of care and the issues related to coordination of care. The OIG made four recommendations related to communication of abnormal test results, resident supervision, provider surrogate assignments, and patient safety reporting.