HELENA, Mont. — Montana military veterans who were referred to health specialists in 2015 faced delays in getting appointments or receiving needed medical services nearly half the time, and those delays may have harmed four patients, according to a report released Friday.

The Department of Veterans Affairs Inspector General's Office inspected the VA Montana Healthcare System at Fort Harrison in Helena at the request of U.S. Sens. Jon Tester and Steve Daines. The inspectors were asked to look at how often patients experienced delays in obtaining referrals — called "consults" in the VA system — and how those delays affected the patients.

The inspectors found almost 26,000 delays out of 51,941 referrals ordered in 2015, according to the report. They included delays for appointments within the VA system, referrals to specialists outside of the VA and those conducted through the Veterans Choice Program.

The backlog of referrals began increasing in June 2014 when VA health care providers began regularly referring patients to community providers because appointments within the VA system were not available within 30 days, according to the report.

VA Montana leaders tried to re-focus their efforts once they figured out they weren't managing the backlog, but the delays persisted through August of last year, according to the report.

The inspectors recommended that VA Montana leaders ensure that a non-VA source reviews the care of patients potentially harmed by the delays and that they address the factors that contribute to the delays. They also recommended that Montana VA leaders confer with agency lawyers about making disclosures to patients potentially harmed by delays, which would include giving those patients information about their rights and recourse.

VA Montana spokesman Mike Garcia said the backlog of referrals has been reduced since 2015, but 500 to 700 referrals are still generated every day in the VA Montana system. They include everything from eye exams to appointments with cardiopulmonary specialists, he said.

"We're constantly looking for efficiencies and ways to improve," Garcia said. But, he added, "A delay does not mean harm."

Tester's office released a statement that said the Montana Democrat spoke with VA Secretary David Shulkin about the report, and the secretary assured him that addressing the issues in the report will be a priority.

The four patients who may have been harmed by the delays were a patient who needed psychiatric care because of suicidal thoughts, two patients diagnosed with cancer and one who suffered a heart attack.

The first patient was given an appointment to see a psychiatrist in about seven weeks after contacting a Veterans Center therapist to report suicidal thoughts. The man was hospitalized for suicidal thoughts while awaiting the appointment. The Inspector General's report said that with more timely care, the man may have avoided the mental health decline.

In another case, 45 days elapsed before a further evaluation was ordered after a radiologist noticed a suspicious lesion in the esophagus of a patient in his 70s with a history of smoking. Another 30 days passed from when the referral should have been completed and the time a routine procedure was recommended and done.

By the time the patient was diagnosed — with a tumor in his esophagus — it was too late for surgery and the patient instead received palliative care.

In a second cancer case, a patient in his 60s was referred to a pulmonologist after a scan of his chest raised suspicions of cancer. The referral was not reviewed and approved for nearly three months. The patient ended up having a portion of his lung removed. Inspectors said the delayed visit to the pulmonologist potentially limited his treatment options and long-term prognosis.

In the last case, a man living in rural Montana who was scheduled to have a medical procedure done on his heart had a heart attack while the work was pending. He survived. The delay was in part because the patient did not want to travel more than 600 miles to another VA medical center, as his primary care physician had ordered.