The Department of Veterans Affairs’ Office of Inspector General released a final report Tuesday that found 20 veterans died while either waiting for health care services, or as a result of substandard care.

But while the report indicated a link between poor VA practices and the death of these veterans, it could not say definitively that the VA’s actions or inactions were the cause of these deaths.

VA Veterans Affairs health care scandal

U.S. President Barack Obama shakes hands with Secretary of Veterans Affairs Robert McDonald have said the VA is on the way to being fixed. A report out Tuesday said 20 veterans’ deaths are linked to delayed or shoddy care in the Phoenix VA system. AFP PHOTO / Saul LOEB

“While the case reviews in this report document poor quality of care, we are unable to conclusively assert that the absence of timely quality care caused the deaths of these veterans,” the report said.

Still, House Veterans’ Affairs Committee Jeff Miller (R-Fla.) said Tuesday that the report confirms major problems with the VA that may have contributed to the death of veterans.

“The inspector general’s report paints a very disturbing picture,” Miller said. “Delays in care that VA officials tried to hide caused harm to veterans.”

“Even though the IG says it can’t conclusively assert that deaths were caused by VA negligence, the report does link 20 deaths to substandard care,” he added.

Specifically, the report said investigators were able to 28 instances of “clinically significant delays,” and said six of these 28 veterans died while awaiting care.

It also found 17 cases of “care deficiencies,” or substandard care, that was unrelated to access or scheduling. Of these cases, 14 veterans died.

The final report follows up on the OIG’s interim report in May that found a breakdown in the VA’s mission to provide health services to veterans. One of the questions left over from the interim report is whether evidence existed to confirm a whistleblower’s claim that 40 veterans died due to their inability to quickly get the care they need.

The final report largely confirms the broad findings of ethical lapses and leadership failures described in the interim report. It includes a somber conclusion about the disappointment that the Phoenix VA has caused among veterans and their families.

“This report cannot capture the personal disappointment, frustration, and loss of faith of individual veterans and their family members with a health care system that often could not timely respond to their mental and physical health needs,” the report said. “Immediate and substantive changes are needed.”

Among other things, the final report found ethical lapses among VA employees and the wide-spread use of scheduling practices designed to make it look as if veterans were not waiting very long for a health appointment.

For example, the OIG started its final report in the spring with the assumption that 1,400 veterans in the Phoenix area were still waiting for their first health care appointment. But the final report said the OIG found another 3,500 veterans on unofficial waiting lists that are still waiting for a health appointment.

“These veterans were at risk of never obtaining their requested or necessary appointments,” the report said. “PVAHCS senior administrative and clinical leadership were aware of unofficial wait lists and that access delays existed.”

The report said it confirmed that 11 staffers at Phoenix either “fixed” or were told to fix appointment dates to make it look like wait times were not long. It also blamed PVAHCS Director Sharon Helman for setting a wait-time goal that ended up misleading its performance.

“Despite her claimed improvements in access measures during fiscal year 2013, we found her accomplishments related to primary care wait times and the third-next available appointment were inaccurate or unsupported,” it said.

Similar to the interim report, the final report found a “nationwide systemic problem” exists at the VA that led officials to fake their wait-time data. It also noted that in 2013, a top VA official waived a requirement for facility directors to certify rules about wait-time data, “further reducing accountability over wait time data integrity.”

The OIG said it has been coordinating with the Department of Justice and the FBI about possible criminal conduct. “Where we confirmed potential criminal violations, we presented our findings to the appropriate Federal prosecutors,” it said.

The OIG has made two dozen recommendations for fixing the problem, and the VA secretary said he agrees with each of them, according to the report.

“The VA Secretary acknowledged that VA is in the midst of a very serious crisis and will use the OIG’s recommendations to hone the focus of VA’s actions moving forward,” it said. “The VA Secretary also apologized to all veterans and stated VA will continue to listen to veterans, their families, Veterans Service Organizations, and VA employees to improve access to the care and benefits veterans earned and deserve.”