But the Department of Veterans Affairs inspector general found no definitive proof that anyone died while on a "secret wait list."
The report was critical, finding "unacceptable and troubling lapses in follow-up, coordination, quality and continuity of care." The hospital's appointment system meant long delays for many patients.
"Our analysis found that the majority of the veteran patients we reviewed were on official or unofficial wait lists and experienced delays accessing primary care -- in some cases, pressing clinical issues required specialty care, which some patients were already receiving through VA or non-VA providers," the report said. "For example, a patient may have been seeing a VA cardiologist, but he was on the wait list to see a PCP (primary-care doctor) at the time of his death. While the case reviews in this report document poor quality of care, we are unable to conclusively assert that the absence of timely quality care caused the deaths of these veterans."
The inspector general examined the treatment given 45 patients, including 20 who died. In 28 of the cases, there were delays long enough to impact care, while in 18 there were other problems.
In one case, a man in his 50s with a history of strokes, pancreatitis and hypertension died at another hospital 12 days after a doctor at the VA said he should get an appointment within two days to follow up on his clinical care plan. He never got the appointment.
Another veteran, who suffered from bipolar disorder, killed himself after a series of delays.
The delays in Phoenix were linked to a former director's plan to reduce the posted waiting times even though the system had lost staff. Sharon Helman was suspended after whistleblowers came forward to report problems.
Glenn Costie, the interim director, said the Phoenix system is working to change.
"We have begun our cultural transformation," he said at a news conference.
The problems in Phoenix set off an examination of the entire VA hospital system.
President Obama promised Tuesday that employees in the future will be held accountable for failures in care. He told an American Legion convention in Charlotte, N.C., that "VA employees who engaged in misconduct should be, and will be, fired."
"What happened in Phoenix ... must never happen again in any VA facility," said U.S. Sen. Bernie Sanders, I-Vt., who heads the Veterans' Affairs Committee. "The people who lied or manipulated data at Phoenix and elsewhere must be held accountable."