Federal officials again criticize diagnosis and treatment delays at Hampton VA hospital
For the second time in two years, a watchdog for the federal Department of Veterans Affairs has documented delays in diagnosis and treatment at the Hampton Veterans Affairs Medical Center.
The Sept. 29 report from the department’s Office of the Inspector General recounts the experiences of a patient in their 60s who came to the Hampton facility’s emergency department in late September 2021 complaining of chest pain. A CT scan that day found a mass in the patient’s chest that was considered “worrisome for malignancy.”
However, the report found the patient wasn’t seen by a respiratory specialist until 77 days after they came to the emergency department and 58 days after their primary care provider requested that consultation — a delay the Hampton VA hospital’s chief of staff characterized as “highly unacceptable.” A diagnosis wasn’t determined until 151 days after the patient first came to the hospital for their complaint.
The patient died just over a month later.
The inspector general found that “multiple care coordination deficiencies, including scheduling delays, ineffective communication, and insufficient pain management, led to a delay in diagnosis and treatment.”
Virginia’s two Democratic U.S. senators, Mark Warner and Tim Kaine, released a joint statement Monday about what they called “alarming logistical and communication failures.”
“The promise of quality and timely health care is one of the most important commitments we make to the brave men and women who serve our nation, and this Inspector General report makes it clear that the Hampton VA failed to live up to that promise,” they wrote.
Besides diagnosis and treatment delays, the report noted “insufficient pain management,” a failure to follow up on the patient after discharge from the emergency department and a lack of daily “huddles,” when health care providers convene to flag any patient issues.
“In the absence of daily huddles, patient safety and care may be negatively impacted due to possible delays in addressing patient care needs,” the inspector general’s office wrote.
Additionally, the report found the Hampton medical facility did not have a required cancer committee or tumor board to review cancer patient needs and treatment, although both have been created since the inspector general’s review. The hospital also may have been underreporting the number of cancer patients it treated in a national registry, with only 52 patients registered from 2020 to February 2022. In March 2022, the director of the VA’s National Program Office for Oncology emailed the Hampton facility director to flag the low number of registrations, noting, “Hampton likely has 250-300 patients to report annually.”
According to the report, as of April 2020, cancer was the second leading cause of death among veterans.
“Without an active facility cancer committee and tumor board, the facility was unable to conduct the additional review necessary to assist with the assessment and identification of cancer patients’ needs,” the report said. “As a result, there may have been negative impacts on patients’ quality of oncological care.”
In a memo included with the report, Hampton VA Medical Center Director Taquisa Simmons called the inspector general’s findings “a thorough evaluation” and agreed with seven recommendations to address the problems.
“We are deeply saddened by the loss of this patient at the Hampton VA Health Care System, and we empathize regarding the impact this has had on the veteran’s family and the staff within the health care system who are very passionate about the care they provide veterans,” Simmons wrote.
The September report is the second time in less than two years that the Office of the Inspector General has documented problems at the Hampton VA hospital. In June 2022, the office released a document outlining “facility providers’ failures to communicate, act on, and document abnormal test results that led to a delay in a patient’s diagnosis of prostate cancer.”