Communication breakdowns between two medical departments may have compromised the care of patients being treated in the Veterans Affairs Salt Lake City Health Care System, according to a new report by the VA Office of Inspector General.

But the report, released Monday afternoon, did not substantiate an unidentified complainant's allegations linking the failures to four patients' deaths at the VA Medical Center.

John D. Daigh assistant inspector general, wrote that "miscommunication and the lack of a cohesive team approach" between the system's Interventional Radiology Department and vascular surgery residents at the University of Utah caused delays in care for one of the patients, described in the report as a man in his 50s. That patient's death led to an apology to the man's family and a two-week moratorium on vascular surgeries and interventional radiology procedures.

In the case of a second patient, a man in his 70s, Daigh noted a "lack of collaboration" between doctors from the two departments. He asked the VA's regional counsel to decide whether the involved physicians should be referred to the National Practitioner Data Bank, which tracks cases of potential malpractice.

In a statement, VA spokeswoman Jill Atwood noted that the inspector general "was impressed with the way our leadership took action with our own internal reviews and system checks even before and during their entire investigation." She said the VA saw the situation "as an opportunity for improvement."

The inspector general did not substantiate suspicions of poor collaboration in the cases of two other patients who died.

The complainant in the case had also alleged that the system had a higher occurrence of unwarranted amputations -- VA records show a three-fold increase in the number of amputations conducted in 2009 compared with 2008. However, the inspector attributed the increase to an associated upsurge in the number of surgeons and patients in the system.

Daigh also noted "tensions" between the two departments leading to the July 2009 resignation of the interventional radiology chief. A university spokeswoman confirmed that Laura Findeiss had resigned from her position but was unable to provide any further information.

The system also has delineated responsibilities of each department.

"With these changes and numerous process improvements, system managers report that tensions have resolved," Daigh wrote.

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