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A Florida Veterans Affairs hospital refused treatment for a veteran dying of heart failure because first responders could not prove his military service, a clear violation of federal law, according to a new report released by a department watchdog Tuesday.

The incident, which occurred at the Malcom Randall VA Medical Center in Gainesville in summer 2020, was not the first failure by emergency medical staff there to provide care to individuals facing critical medical crises. Staff from the VA Inspector General’s Office said without policy and staffing changes, it may not be the last.

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