This post has been updated

Some patients with bladder and prostate cancer died waiting for care, and medical treatment for almost 1,500 others was delayed because of short-staffing and mismanagement of urology care at the Veterans Affairs hospital in Phoenix, a new investigation has found.

Senior officials at the medical center, the center of a national scandal last year over fudged wait times, did little to respond to a severe staffing shortage as recently as April 2015, investigators for the Department of Veterans Affairs inspector general found.

Their solution? They canceled appointments for 3,200 urology patients, some of them for crucial follow-up tests, and never rescheduled them. And many veterans had no idea they couldn’t see a doctor until they showed up for their appointment.

“The Urology Service was not able to manage the volume of patients in need of either diagnostic evaluation, treatment, or routine follow-up related to multiple urological conditions,” the report by John Daigh, Jr., assistant inspector general for health-care inspections, said. The delays placed patients at “unnecessary risk for adverse outcomes.”

Seven patients died after delayed treatment and lapses in the quality of medical care they received in Phoenix, investigators wrote.

Hospital administrators “did not promptly respond to the staffing crisis, which contributed to many patients being “lost to follow-up” and staff frustration due to lack of direction,” Daigh wrote.

When some patients finally were referred to outside doctors for follow-up care, almost a quarter of them may never have received it. In 23 percent of the cases, investigators would find no documents to show the appointments ever took place.

Over two years, this delayed or non-existent care affected almost half of all patients in Phoenix with bladder, prostate and urinary-tract issues, even after patient wait times became a national scandal. The former director of the medical center was fired amid reports that managers falsified waiting lists in order to collect bonuses by covering up months of delays in appointments.

Sen. Johnny Isakson (R-Ga.), chairman of the Senate Committee on Veterans’ Affairs, called the report’s findings “absolutely tragic and appalling.”

“No veteran should ever be denied care after he put his life on the line in our country,” he said in a statement. “I expect every person responsible for this tragedy to be held accountable.”

VA officials said in a statement that the agency “is committed to providing quality, safe, and timely health care to all veterans who have chosen VA as their health care provider. ”

“Over the course of the past two years, VA has taken steps to address appointment and consult delays created by the ever increasing demand among Veterans for VA services,” spokeswoman Victoria Dillon said in a statement. “We take seriously service delays at any one of our 1,588 sites of care.”

The inspector general returned to Phoenix this year to follow up on the most serious problems that came to light during the wait-times scandal.

Starting in 2013, the urology clinic in Phoenix grew woefully understaffed and overbooked with the departure of doctors and nurse practitioners. At one point, almost the entire urology staff had quit or was on leave, with one part-time physician left, the report found.

Schedulers pleaded with hospital administrators for guidance. One employee pleaded to then-director Sharon Helman:

“We as clerks’ (sic) are dealing with the frustrations of the veterans daily and we don’t have any answers for them. We can’t make appointments for them … This has been going on now for months and still no guidance or answers. We are getting our heads handed to us by the patients. How much are we supposed to endure … PLEASE HELP. We are leaving our vets in limbo.”

Patients who were referred to outside doctors had little information from VA to go on, the report says. The private doctors frequently misinterpreted referring vouchers as authorizing only one visit for an initial evaluation, instead of follow-up care as well.

The inspector general recommends that the Phoenix hospital ensure that it has enough urology staff to  guarantee timely care. The report also calls for records of visits to private doctors to be readily accessible electronically.

Dillon said the Phoenix hospital has hired additional doctors and other staff in the urology unit, bringing the full-time staff to 6 1/2 employees from a sixth that number in 2013. Wait times have declined significantly, she said.

Investigators did not estimate the number of deaths that might have been prevented by more timely care. The report says that 1,484 patients experienced significant delays, and listed 10 who were placed at “unnecessary risk for adverse outcomes.” At least half of those died.

For example:

  • A veteran with a history of prostate cancer had a checkup canceled and not rescheduled. When he finally saw a primary care physician 10 months later, he had relapsed with metastatic cancer. He died four months later.
  • A patient who was referred for a urology evaluation with symptoms did not get an appointment for three months. It was canceled and rescheduled a month later. That appointment also was canceled. After more delays, the veteran finally had a biopsy and was diagnosed with metastatic prostate cancer. He did not begin radiation therapy until about 18 months after the initial referral.
  • A elderly patient who had begun treatment for an enlarged prostate discovered blood clots in his urine eight months later. His daughter tried to get him to see a specialist, but was told repeatedly to “be patient, there are still no providers.” Eleven months later, she got her father an appointment with a private physician. He needed a procedure requiring further authorization. The veteran died 10 days later.