Ethical lapses and scheduling tricks were widespread at the Department of Veterans Affairs hospital in Phoenix, but there is no hard evidence that the failures led directly to patient deaths, the agency’s inspector general said in a report released Tuesday.

“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,” Acting Inspector General Richard Griffin said in the long-awaited report on the manipulation of patient waiting lists in Phoenix.

The IG’s report did confirm a variety of scheduling tricks were used to make it appear patients received appointments for primary care within the agency-imposed 14-day deadline, when in reality veterans faced delays of weeks or months.

The report also identified numerous cases in which patients died after experiencing unacceptable delays in getting a doctor’s appointment, or after receiving poor quality care.

But there is not sufficient evidence to conclude any of the deaths were a direct result of delays or inadequate treatment, Griffin said.

Despite that bottom-line conclusion, Griffin made it clear veterans were harmed by the failures in Phoenix.

“This report cannot capture the personal disappointment, frustration and loss of faith of individual veterans and their family members with a health care system that often could not respond to their mental and physical needs in a timely manner,” Griffin stated.

The scandal over falsified appointment lists to hide backlogs erupted in April after whistleblowers from the Phoenix office reported the practice to the House Committee on Veterans’ Affairs. Committee Chairman Rep. Jeff Miller, R-Fla., directed the IG to investigate the allegations.

That investigation has since spread to 93 VA medical facilities nationwide.

The report issued Tuesday echoed similar findings released by the IG in May that found “systemic” falsification of wait times nationwide to meet agency goals for patient wait times.

Performance reviews and bonuses for top hospital administrators were tied to meeting those goals.

IG investigators reviewed more than 3,400 cases and identified 28 in which there were significant delays in care associated with appointment scheduling. Six of those patients died.

In another 17 cases, deficiencies in care not tied to scheduling were identified, and 14 of those patients died.

The cases discussed in the report “reflect unacceptable and troubling lapses in follow-up, coordination, quality and continuity of care,” the IG found.

However, in the cases it discussed in detail, the IG repeatedly concluded scheduling primary care visits within agency deadlines probably would not have changed the outcome.

In several cases, the patients were treated in the VA emergency room, sometimes repeatedly, but had difficulty getting primary care appointments for follow-up visits.

Top administrators in Phoenix were aware of the inappropriate scheduling practices, but allowed them to continue so the Phoenix hospital could meet its goals on wait times, the IG found.

Appointments for primary care doctors were supposed to be set within 14 days of the date specified by the veteran.

Instead, schedulers would find out when an appointment was available, then log that into the electronic scheduling system as the date selected by the patient, making it appear there was no delay.

Other veterans seeking medical appointments had their information printed out and kept by schedulers until an appointment was available. Only then were they added to the electronic list, again making it appear there was no wait.

There were more than 3,500 veterans waiting for an appointment who were not logged in the electronic waiting list, which is used to measure performance on wait times, according to the IG.

Sharon Helman, who until May was the director of the Phoenix VA health system, bragged in her self-evaluation for her 2013 performance review that she had achieved “dramatic improvement” in patient wait times. For new patients, the average delay in getting an appointment dropped from 338 days to 22 days, Helman said.

Helman claimed that 50 percent of new patients received a primary care appointment within 14 days in the 2013 fiscal year. The IG’s review found it was really about 13 percent.

As a result of her self-assessment and performance rating, Helman received a 1.5 percent pay hike and a bonus of $8,495. Both were later rescinded after the manipulation of patient wait times was revealed last April.

When Helman touted the statistical improvements to her staff in July 2013, one analyst responded in an email challenging the numbers and identifying the tricks used to manipulate the data.

“I think it’s unfair to call any of this a success when veterans are waiting six weeks on an electronic waiting list before they’re called to schedule their first PCP (primary-care provider) appointment,” the unidentified analyst said in the email. “This is unethical and a disservice to our Veterans.”

Miller, chairman of the House veterans’ panel, said the IG report “paints a very disturbing picture” of the practices and ethical lapses at VA.

He also blasted agency officials for leaking a response from VA Secretary Robert McDonald to the media even before the IG report was publicly issued.

“The VA scandal was caused by bureaucrats who chose to whitewash or conceal the department’s problems,” Miller said. “The fact that some department officials are still engaging in similar practices underscores the dire need for real accountability throughout the organization.

“So far, despite repeated requests from our committee, we have seen no evidence that the corrupt bureaucrats who created the VA scandal will be purged from the department’s payroll anytime soon,” Miller said. “Until that happens, VA will never be fixed.”

Also Tuesday, President Obama pledged he would do whatever is necessary to fix the broken culture at VA, including firing those responsible for falsifying patient wait times.

“If you engage in unethical practices or cover up a serious problem, you should be and will be fired,” Obama told the American Legion’s national convention in Charlotte, N.C., before the IG report became public.

“What we’ve come to learn is that the misconduct we’ve seen at too many facilities with long wait times and veterans denied care, folks cooking the books, is outrageous and inexcusable,” Obama told the nation’s largest veterans’ group in a noontime speech.

“We are focused on this at the highest levels. We are going to get to the bottom of these problems. We are going to fix what is wrong. We are going to do right by you and we are going to do right by your families and that is a solemn pledge and commitment that I am making to you here.”

Reform legislation signed by Obama earlier this month gives the VA secretary more power to fire or demote unscrupulous or ineffective managers.

But so far there is little evidence that agency administrators responsible for creating phony waiting lists have been held accountable. VA officials rarely reveal the specifics of personnel actions, citing federal privacy laws.

Helman has been on paid administrative leave since May and agency administrators say they have initiated proceedings to fire her. However, she is still on the payroll.

Two other firings have been proposed as a result of an IG’s investigation into falsified waiting lists kept in Cheyenne, Wyo., and Ft. Collins, Colo.

Several other top officials have retired or resigned, including former Secretary Eric Shinseki, in the wake of disclosures about widespread falsification of patient appointment lists. However, VA has not publicly characterized those as disciplinary moves.

Aside from Helman, the names of the administrators the agency is seeking to fire have not been disclosed.

McDonald said in a speech to the American Legion Tuesday afternoon that more than two dozen health care personnel at VA have been “removed from their position,” but did not provide details.