HAMPTON, Va. - A recent report from the Office of the Inspector General details "multiple failures" in a patient's cancer treatment at the Hampton Veteran Affairs Medical Center.
The report, which was issued last week, details a series of missteps that delayed the patient from getting properly diagnosed with prostate cancer.
It says communication issues and documentation problems led to the delays, but it does note the delays may not have impacted the patient's outcome.
The patient is not named in the report, but it says the Inspector General began reviewing the case in August 2021.
Virginia's representatives, including Sen. Tim Kaine (D-Virginia), said they were "appalled."
"It was a very horrible situation," Kaine told News 3. "We have to dig into why did this happen and then, can we put systems in place in Hampton sure, but in other VA's to reduce [errors]."
It all started in July 2019, when the report says a surgeon did not properly respond to and communicate the patient's abnormal CT scare.
Following that "failure," the report says other medical providers didn't communicate or act on other red flags, including one where the patient was not told about test results for about five months.
The report lists off seven recommendations the Hampton VA can take to stop this from happening again, including improving communication on test results.
Within the report, the Director of the Hampton VA responded, saying she agrees with the recommendations and will work to implement them over the next few months.
Another report also reviewed the overall care the Hampton VA Medical Center is providing. The report found there were six areas for improvement, including on documentation concerns. The report says the number of recommendations isn't meant to look into the overall quality of care, but a road map to make improvements.
Kaine says he's going to keep a close eye on what's happening at the VA.
"There's always projects on the drawing board with respect to the VA, but we have to get to the bottom of exactly why this happened," he said.