Less than two years after disabled Army veteran Barry Coates told a House committee, "I stand before you terminally ill," the South Carolina man is dead from the cancer that went undetected by VA doctors for nearly a year.
Coates, only 46 when he died on Jan. 23, became the face of the Veterans Affairs Department wait-time scandal -- in which patients whose appointments were put off by a system unable to handle the volume of men and women needing its services.
"It is likely too late for me," he told the House Veterans Affairs Committee during an April 9, 2014 hearing. "The gross negligence of my ongoing problems and crippling back log epidemic of the VA medical system has not only handed me a death sentence but ruined the quality of my life I have for the meantime."
Coates was among disabled veterans interviewed as part of a CNN investigative report on delays to veterans care. In his case, a cancer that could easily have been detected with a rectal exam grew and spread over 11 months of delays and inadequate care at VA facilities in South Carolina.
"Through no fault of his own, Barry Coates was dealt a tragic hand in life," Rep. Jeff Miller, a Republican from Florida and chairman of the House Veterans Affairs Committee, said Thursday morning.
"Time and again he was let down by the very agency established to serve him," he said. "Yet after all he endured, he kept a positive attitude and remained focused on ensuring that other veterans would not have to suffer the same mistreatment he did."
Sen. Johnny Isakson, a Republican from Georgia and chairman of the Senate Veterans Affairs Committee, in a statement said he mourns for the loss of any veteran, "but especially for someone like Barry Coates, who suffered from the systemic and cultural failings of the [VA]."
He added, "As a committee, we will continue working to right the wrongs at the VA that Barry Coates helped to uncover and restore the quality care at the VA that all veterans deserve and should receive."
The wait-times scandal broke with reports of delays and secret patient appointment waiting lists at the VA Medical Center in Phoenix, Arizona. CNN reported in April 2014 that up to 40 veterans died awaiting care.
The VA's subsequent investigation found that unofficial wait lists and delays to care were systemic across the department. The Inspector General's office also concluded that up to 35 people seeking care through the Phoenix facility died, but initially stated their deaths were not caused by delays.
The IG later backpedaled and said delays likely contributed to the deaths of some veterans.
Few VA hospital officials have been fired over the wait-times scandal. The former head of the Phoenix facility appealed her termination to the Merit System Protection Board. It was only because the board found she had accepted gifts from a would-be vendor that her firing was upheld.
On Capitol Hill, lawmakers continue to criticize the VA for its failure to hold people accountable for the delays.
But well before the CNN investigation, lawmakers had been told that VA officials were manipulating appointment data to conceal the fact they were not able to meet patient demand.
The Government Accountability Office reported the problem to Congress in 2013. A year before, a former VA hospital official in New Hampshire told lawmakers that medical center executives across the country were swapping best practices for getting around VA wait-time standards. Executives had a financial incentive for meeting wait-times standards, Nicholas Tolentino said: earning bonuses.
It was only after CNN reported in April 2014 that dozens of veterans died waiting for an appointment at the Phoenix hospital that lawmakers in Congress and leaders at the VA started to pay attention to the issue.
A VA Inspector General report concluded that wait-time workarounds was a systemic problem, but stopped short of saying the delays killed patients. The IG instead said the delays contributed to veteran deaths.
The scandal ultimately led to the resignation of VA Secretary Eric Shinseki.
During his testimony, Coates said VA never told him he might have qualified for fee-based treatment in the private sector and never offered him any recourse for his treatment delays, The American Legion reported at the time.
An emotional Rep. Jackie Walorski, a Republican from Indiana, apologized to Coates "on behalf" of the VA and its broken system time, according to the Legion.
"This is an American disaster," she said, crying. "If I could change your circumstance, I would do it in a heartbeat."
Miller said Coates is "proof that bureaucratic incompetence, indifference and corruption can result in tragic consequences."
"His heartbreaking story should be required learning for every Veterans Health Administration employee," he said. "Barry and his family will remain in my thoughts and prayers."