The navy reported that no misuse or harmful intent was found, and no punishments were levied against anyone. Patients were not informed their scans were not read, with the navy saying it intended to reach out if areas of concern were found but that none were uncovered to follow up. The scans were read and the backlog was deleted.

Following this incident, another 500 cases were discovered in 2018. The navy admitted that one patient’s pathology that went missing for seven months did delay needed treatment, but found no indications that any cases became worse. It disagrees with the notion that patients were harmed.


A colleague of Ike’s, whose name was also redacted, called the investigation “a farce,” saying the unread reports led to “hundreds of cases” involving potentially dangerous oral lesions going untreated.

Though Ike was told that patients would be made aware of the situation, no record of notification was provided, she said. In addition, the list of names for the original 1,300 patients was deleted due to “privacy concerns” by an employee whose name was redacted from the investigation. The list is impossible to reconstruct, according to investigators.

The scans " were properly reviewed later and the backlog cleared with the conclusion that there was no harm to patients," said Gulick.

Gulick says the Navy is implementing recommendations made by investigators to prevent similar incidents in the future.

A request for comment to Walter Reed National Military Medical Center was directed to the Department of the Navy's Bureau of Medicine and Surgery, BUMED. No response has been offered at this time.

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