There were inadequate threat assessments, the report concluded, and “insufficient written operational procedures that resulted in security vulnerabilities.” In one example, agents habitually stored the keys for Shulkin’s motorcade vehicle behind the fuel door, rather than returning them to a secure location. Agents also weren’t wearing proper protective gear, and one agent shared details of the secretary’s whereabouts with unauthorized people.

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The complaints also claimed that Shulkin — who was fired by President Trump in March — had misused the protective services available to him. The inspector general’s office determined that Shulkin ethics rules when he permitted his driver, a VA employee, to use a personal vehicle to drive around Shulkin’s wife.

Generally, the Executive Protection Division provides security and transportation for the VA secretary and deputy secretary. Family may benefit from those protective services only if they are traveling with the secretary or deputy.

Though security staff advised Shulkin of these rules, the secretary’s wife was still transported alone by agents, the report said.

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Shulkin did not respond to a request for comment. He told inspector general investigators, however, that he never asked his security detail to provide his wife such privileges, but that at least on one occasion his assigned driver transported his wife. In the report Shulkin was “adamant” that it was a personal favor on the driver’s personal time and in a personal vehicle. The secretary’s driver confirmed there were instances in which he drove Shulkin’s wife in his personal car on his own time.

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But even those instances are a violation of ethical obligations, according to the inspector general, because federal regulations don’t allow for someone in Shulkin’s position to accept gifts from subordinates.

“Personal favors and transportation services are included in the definition of a gift,” the report said.

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A senior staff person told the inspector general’s office that on two occasions, Shulkin’s primary driver left an official event to take the secretary’s wife somewhere. Both times, Shulkin had to leave the official event in a different car with a different driver. There were other instances in which the secretary’s wife traveled in a government car without her husband, the secretary’s driver said in the report. The driver recalled taking her to the train station.

Investigators also found that drivers often worked excessive hours to collect overtime, putting them and VA officials at risk. One driver worked more than 14 hours straight on 92 occasions and a stint of 19 consecutive days on duty, the report says.

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VA spent about $2.6 million in protective services in 2017, the report says, most of that in personnel base salaries and overtime costs.

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Investigators found that during a trip Shulkin led to Europe in July 2017 — one that mixed business and leisure, and contributed to his firing — three agents on the security detail claimed to be doing advance work for Shulkin and his entourage when they were in fact sightseeing, the report says. They received overtime pay for the work. The report said this was possible because the security division was so poorly managed at the time.

In response to the report, VA officials agreed with the failings and said they had addressed many of them, although the inspector general wrote that the agency has not documented these changes. VA also promised administrative action against employees who submit false time cards or violate other department rules. Officials blamed the problem on Shulkin and his leadership of VA.

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The inspector general’s office also investigated complaints that during his time as VA secretary, Shulkin used his security detail to take him to nonofficial events — despite a risk assessment that determined he required only “portal-to-portal” protection, or protection that ends once the subject goes home at the end of the business day.

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Instead, the report lists instances in which Shulkin requested protection for weekend visits to a furniture store and a Home Depot in Alexandria.

“We’re coming in on a Saturday to take him house hunting?” one agent wrote in an email to Shulkin’s executive assistant after receiving a weekend assignment.

Agents who flagged the issue were not critical of the secretary so much as the lack of training he received on the appropriate use of his security detail, according to the report.

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In October 2017, about eight months after Shulkin’s Senate confirmation hearing, the secretary received a memo with more clear guidelines for his protective staff. Ultimately, the inspector general found that Shulkin had not been given clear guidance and was doing what he thought was within his power. Investigators determined that staff did not flag the behavior as inappropriate or address it with him until the October memo.

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Shulkin, the only holdover from the Obama administration, left the administration 10 months ago amid political infighting between him and top Trump aides grew unsustainable.

In the early months of Trump’s administration, he was one of the president’s favorite Cabinet members, largely because he was seen as advancing a key campaign promise to improve veterans’ care.

But political appointees at VA, installed by the White House, complained that Shulkin was not doing enough to advance private health care for veterans outside the government system. Shulkin complained that the aides were undermining his authority. After months of bad headlines he was ousted.