A new report by the Department of Veterans Affairs Office of the Inspector General finds that staff at the Phoenix VA continue to inappropriately cancel medical appointments and that in one case failure to make an appointment may have contributed to a patient’s death.

The Inspector General was asked to look into claims of poor management at the Phoenix VA in July 2015, about a year after the initial wait time scandal. The IG found plenty of cause for concern. Specifically, 24% of the sample of appointments the IG reviewed had been inappropriately canceled by staff:

We substantiated that in 2015, PVAHCS staff inappropriately discontinued consults. We determined that staff inappropriately discontinued 74 of the 309 specialty care consults (24 percent) we reviewed. This occurred because staff were generally unclear about specific consult management procedures, and services varied in their procedures and consult management responsibilities. As a result, patients did not receive the requested care or they encountered delays in care. Of the 74 inappropriately discontinued consults, 53 patients had not received the requested care at PVAHCS.

The IG also reviewed the cases of 215 patients who died with appointments (or requests) on the books and found “untimely care from PVAHCS may have contributed to the death of 1 patient.” Here’s the case summary from the main report:

At the time of his death, this patient was a 58-year-old male with a past medical history of previous moderate tobacco use. He presented as a new patient to the facility in May 2015, complaining of dull chest pain that was exacerbated by strenuous activity. The provider ordered an exercise treadmill test to further evaluate the patient’s chest pain. A consult was submitted to Cardiology Outpatient Treadmill Consult. Within the consult, the ordering provider requested that the test be completed within 1 week. Minutes later, a staff physician approved the consult.

In June 2015, the patient was found deceased in his home by a family member. According to the death certificate, an autopsy was performed confirming the cause of death as atherosclerotic cardiovascular disease. At the time of his death, the treadmill test was not scheduled. The consult was closed when the facility was informed of the patient’s death. A Primary Care provider evaluated this patient and appropriately referred the patient for further cardiac testing based on his symptoms. In addition, the Primary Care provider appropriately requested the test be completed within a week, as his symptoms were concerning and suggestive of heart disease. Timely testing may have indicated that the patient had significant disease and could have prompted further definitive testing and interventions that could have forestalled his death.

Overall, the VA had thousands of appointments with wait times that exceeded 30 days:

We determined that, as of August 12, 2015, more than 22,000 individual patients had 34,769 open consults at PVAHCS. The total open consults included all categories, statuses, and ages of consults. Of all the open consults at that time, about 4,800 patients had nearly 5,500 consults for appointments within PVAHCS that exceeded 30 days from their clinically indicated appointment date…

The report concludes that, despite efforts to improve, problems persist at the Phoenix VA:

During the past two years, the OIG has reviewed a myriad of allegations at PVAHCS and issued six reports involving policy, access to care, scheduling and canceling of appointments, staffing, and consult management. Although VHA has made efforts to improve the care provided at PVAHCS, these issues remain.

CNN’s Jake Tapper reported on the story Tuesday: