For nearly half a year, the flagship medical center of the U.S. Department of Veterans Affairs experienced delays in sending some results of mammography exams and other breast cancer screenings to patients.
According to a News4 I-Team investigation, the Washington DC VA Medical Center failed to promptly provide letters detailing results of exams to women who underwent breast cancer screenings, allowing weeks or months to elapse.
The errors are a violation of VA policy, which require such "lay summary letters" to be distributed within 30 days.
According to a memo sent by the medical center director to a Virginia congressman, the delays occurred between Feb. 28 and Aug. 31. During roughly the same time period, the hospital completed approximately 1,410 breast cancer screening tests.
According to the memo, the medical center was also "not in compliance" with VA policy requiring abnormal results be reported to women within a week.
The medical center memo said the unsent "lay summary patient letters" were discovered in late August and, at that time, finally sent to veterans.
Though the medical center's letter said all patients whose exams showed suspicious findings were eventually notified about the findings of their tests, the letter does not specify how much time elapsed before those women were notified.
"That's very surprising, and it's also scary, because of the time frame and the issues that could come up," said Gwen Murphy, a U.S. Army veteran who receives breast cancer screenings through the VA.
Though Murphy's most recent mammogram was conducted after the recent error and performed at a private medical facility, she said she's worried other women might have been delayed in seeking treatment and stopping the spread of a possible cancer.
"Time is not your friend when it comes to being diagnosed with cancer," Murphy said.
The Department of Veterans Affairs declined requests for an interview about the incidents.
“While there was a delay in mailing a number of letters due to an administrative error, there was absolutely no delay in notifying any patients of their mammography results, which the patients’ primary care providers or mammographer personally communicated to each patient," a VA spokesperson said in a written statement to the I-Team. "As a result, there was no impact to patient care.”
According to the medical center's letter to Congress, a clerk at the hospital failed to mail the patient letters.
In its statement to the I-Team, the agency said multiple employees have been disciplined. The agency said it has also “made a number of changes to strengthen the program in the future, including moving oversight of the program to the Women’s Health Program manager and assigning registered nurse navigators to work directly with veterans with suspicious or positive findings.”
After learning of the I-Team's findings, Rep. Gerry Connolly (D-Va.) requested a review of the case by the inspector general of the U.S. Department of Veterans Affairs.
"I was horrified," Connolly said. "If you have a loved one who is diagnosed with breast cancer, you want those results right away."
The DC VA Medical Center would not share copies of the letters sent to the impacted patients. Connolly told the I-Team the agency also declined to provide his staff with a list of all patients impacted and dates upon which those women were notified about the delayed results letters.
Connolly said he is concerned some of the impacted women are unaware of the errors and could still be awaiting their results letters.
The I-Team learned the medical center has reduced its mammography program this year, in the months after the errors were discovered in August. Patients told the I-Team recently they have been sent to private providers to obtain mammography exams, with the VA paying the costs of the tests.
“The DC VA Medical Center is currently providing limited mammography and interventional services on-site due to a maternity leave and subsequent resignation of our full-time mammographer,” the agency said.
The VA said a new full-time mammographer will begin work in January.
"Their operation needs to be adjusted," said Natasha Davis, who has previously undergone mammography exams at the medical center. "There needs to be checks and balances on how they follow up with people."
The DC VA Medical Center, the flagship hospital of the nationwide VA medical system, has suffered a series of recent failures. News-4 I-Team investigations in 2018 and 2019 revealed the escape of a psychiatric patient, the spoilage and disposal of thousands of flu shots, air conditioning failures, staffing shortages and a May 2018 flood.
The U.S. House Oversight committee staged a formal hearing into the medical center's failures in June, citing several I-Team investigations as the reason.
Entire statement from US Department of Veterans Affairs:
The Washington DC VA Medical Center’s mammography program maintains accreditation with the American College of Radiology and our health care professionals are committed to providing quality care to Veterans.
While there was a delay in mailing a number of letters due to an administrative error, there was absolutely no delay in notifying any patients of their mammography results, which the patients’ primary care providers or mammographer personally communicated to each patient. As a result, there was no impact to patient care.
We have taken appropriate disciplinary action against the individuals responsible for the delayed letters and made a number of changes to strengthen the program in the future, including moving oversight of the program to the Women’s Health Program Manager and assigning registered nurse navigators to work directly with Veterans with suspicious or positive findings.
Any Veteran with concerns should contact the Women’s Health Clinic at 202-745-8582 and ask to speak with a nurse navigator to discuss their concerns.
Reported by Scott MacFarlane, produced by Rick Yarborough, and shot and edited by Steve Jones.