The VA Office of Inspector General has published a report stating that a Denver-area hospital kept unofficial wait lists that resulted in veterans not receiving mental health appointments in a timely manner. The Associated Press reports:

Investigators with the VA Office of Inspector General confirmed a whistleblower’s claim that staff kept unauthorized lists instead of using the department’s official wait list system. That made it impossible to know if veterans who needed referrals for group therapy and other mental health care were getting timely assistance, according to the report.

The internal investigation also criticized record-keeping in PTSD cases at the VA’s facility in Colorado Springs. Patients there often went longer than the department’s stated goals of getting an initial consult within a week and treatment within 30 days, investigators found.

This investigation was sparked by a whistleblower named Brian Smothers who claimed last year that he had found the lists in the form of spreadsheets on the VA computer system. Smothers resigned from his job last November claiming the VA retaliated against him after he took the information to two Senators. From an AP report dated Nov. 16, 2016:

Brian Smothers told The Associated Press Wednesday the VA had opened two separate inquiries into his actions and tried to get him to sign a statement saying he had broken VA rules. He said he refused.

Smothers also said the VA reassigned him to an office with no computer access, no significant duties and no social contact.

He called the VA’s actions punitive and his working conditions intolerable. He said he resigned as of Tuesday.

The danger of delayed mental health treatment was made clear in a separate report the VA Inspector General released Wednesday. The report concludes that a VA clinic in New Jersey failed to provide mental health care for nearly a year to a veteran who later set himself on fire outside the clinic:

The Veterans Affairs Department’s inspector general found Charles Ingram III went almost a year without seeing a counselor or taking medications for his mental health problems before his death in March 2016.

He requested an appointment to see his psychologist at the Northfield clinic and was given an appointment date more than three months later. He had lost his job and was on the verge of a divorce.

The use of unofficial wait lists by VA clinics became a major story in 2014, when multiple hospitals and treatment centers around the country were discovered to be using them. The wait lists were believed to have contributed to the deaths of dozens of patients who died waiting for treatment. Just this summer, the LA Times reported 100 veterans died while waiting for care from the Los Angeles VA, though the report did not claim the delays were directly responsible for the deaths.