A Senate probe into a Department of Veterans Affairs medical center in Wisconsin has uncovered serious and systemic flaws in a VA inspector general’s office, USA Today reported. The Senate concluded that those problems could have contributed to otherwise preventable tragedies, including the death of one Marine Corps veteran.

The internal agency is tasked with independently investigating complaints regarding the Tomah, Wisconsin, facility, but the way it handled its most recent report showed signs that “the inspector general … had lost the sense of what its true mission was,” said Sen. Ron Johnson, R-Wis., who chairs the Senate Homeland Security and Governmental Affairs Committee that conducted the investigation.

The flaws that the Senate uncovered in the inspector general’s office were “systemic,” Johnson told USA Today, which obtained the 350-page Senate report containing the findings of its investigation.

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