Local brief
VA inspector general reviews a delayed breast biopsy at VA Eastern Colorado and urges flagging suspected cancer for closer care coordination
In an Oct. 6 report, the VA Office of Inspector General reviewed how the VA Eastern Colorado Health Care System in Aurora coordinated care for a patient whose breast biopsy, ordered after an abnormal late-2023 mammogram, was not completed until late spring 2024. It made one recommendation: consider adding high-risk conditions such as suspected cancer to the consult tool's list of complex conditions. Notice Nearby brief, not Legal Publication.
The VA Office of Inspector General (OIG) released a report on Tuesday, Oct. 6, 2026, on care coordination for one patient with breast disease at the VA Eastern Colorado Health Care System in Aurora. The OIG opened the inspection on Dec. 4, 2025, after concerns came up during a hotline review, and held a virtual site visit from Dec. 17, 2025, through Feb. 23, 2026.
What happened: after an abnormal mammogram in late 2023, the patient's primary care provider ordered a breast biopsy consult that was not completed until late spring 2024. The OIG found that community care staff gave the consult a basic designation, which was consistent with Veterans Health Administration guidance at the time. Despite several outreach attempts, the patient did not schedule the appointment, and the consult was canceled. When the patient was later seen at a community emergency department, imaging suggested the disease had spread.
The OIG also found that in mid-winter 2024 the primary care provider saw the patient for an unrelated pre-operation visit but did not document or arrange follow-up for the unfinished biopsy, and that the facility's breast imaging tracking spreadsheet did not include the patient's late-2023 results.
What has changed: the facility hired a breast cancer screening coordinator in June 2025 and started using a new tracking tool. Because of those fixes, and a similar recommendation in an earlier OIG report, the OIG did not make a separate tracking recommendation.
The one recommendation: the OIG suggested that adding high-risk conditions such as suspected cancer to the consult tool's list of complex or chronic conditions would help make sure those patients get a clinical review for care coordination. The VA Under Secretary for Health said the department will review the list and look at expanding it.
Veterans who have had an abnormal screening result and have not heard back about follow-up can call their VA primary care team. Any veteran in crisis can dial 988 and press 1, or text 838255. The full report is on the VA OIG website.
Source: the public notice on this register NN-PUBDESK-20261006-ADAMSCO-VAOIG-03 · VA Office of Inspector General · Review of Care Coordination for a Patient with Breast Disease, VA Eastern Colorado Health Care System (Oct. 6, 2026).
This is a Notice Nearby local brief — an in-house explainer written from a government-posted notice on this register. It is not official minutes, not a newspaper story, and not Legal Publication.