CONCORD, N.H. — Stroke patients at a Department of Veterans Affairs medical center have received substandard care, including a failure to transfer them to another facility that could provide the necessary tests and treatment, according to a report released Thursday.

The report, by the VA’s inspector general, is the latest criticism of the New Hampshire facility. The criticisms first emerged after the Boston Globe reported on a whistleblower complaint filed by physicians alleging substandard care at the state’s only medical center for veterans. The physicians described a fly-infested operating room, surgical instruments that weren’t always sterilized and patients whose conditions were ignored.

The inspector general’s report, inspired by a 2010 complaint from a patient who later filed a tort claim, reviewed nearly two dozen patients who arrived with stroke symptoms in 2014 and 2015 and found they received inconsistent care. Among the problems was that patients weren’t always transferred promptly to a facility with expertise in treating stroke victims nor were they transferred to the closest acute-care facility.

Democratic U.S. Rep. Annie Kuster, who requested the report in 2015, said it “emphasizes the need to improve services for our veterans” at the Manchester center and at centers around the country.

“While I’m hopeful that the lessons learned from this report will prevent any veteran that suffers a stroke from receiving substandard care, this report still underscores the need to reform the VA’s community care programs,” she said in a statement. “We need to ensure the Department of Veterans Affairs has the necessary funding to bolster the quality of care for our veterans. Our veterans deserve better.”

The acting director of the Manchester VA, Al Montoya, said he appreciated the review and said the center has moved to address many of the concerns in the report.

Montoya said the center has made changes to address its transfer policy and a complaint that it didn’t complete peer reviews of its stroke treatment. He said it expects by the end of the month to have addressed another recommendation, calling for it to review the records of 13 stroke patients identified in the report as not being transferred to the nearest facility to determine if they were harmed by that action.

The center “has improved its stroke care services by enhancing its documentation practices and establishing an urgent care transfer process to address Veterans who present with stroke-like symptoms,” Montoya said in a statement.


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