As the confirmed death toll remains frozen at 64, Puerto Rico has estimated that more than 1,400 people were killed by Hurricane Maria.
In a report to the US Congress detailing a £139bn reconstruction plan, the Puerto Rico government estimated there were 1,427 more deaths between September and December last year than the average for the same time period in previous years.
Most of the deaths resulted not from the storm directly, but the "cascading failures" in infrastructure that followed it, with power and water knocked out, homes and roads damaged, and widespread flooding.
Unable to reach hospitals or get around easily, the injured and elderly found themselves facing life-threatening challenges months after the hurricane wrought its initial devastation.
As what the report called "post disaster failure" stretched onward, people lost their jobs, schools were closed and businesses shut down.
Residents lacked electricity, food and water for a "prolonged period".
An investigation into fatalities was ordered by the administration of Governor Ricardo Rossello several months ago, when it stopped updating its official death toll amid claims it had been dramatically under-counted.
The final investigation, and a scientific review of the new estimate, is expected in the coming weeks.
Hurricane Maria hit Puerto Rico, an unincorporated territory of the US, in September 2017 and closely followed Hurricane Irma passing through the Caribbean.
"The hurricanes' devastating effects on people's health and safety cannot be overstated," the government said in the report.
"Because the resources available for response were inadequate for the scale of the disaster, the failure of the lifeline systems meant that emergency services were severely compromised."
In the US, the estimates were received with upset, but no surprise as opposition politicians turned fire on the US government's response.
"Don't let this get swept under the rug," Democratic senator Kamala Harris said.
"This administration needs to be held accountable for their neglect."
Don't let this be swept under the rug: More than 1,400 people died in Puerto Rico, not 64 like the government claimed. This Administration needs to be held accountable for their neglect. https://t.co/nTbfbKiWXf
— Kamala Harris (@KamalaHarris) August 9, 2018
Nydia Velazquez, a New York congresswoman born in Puerto Rico, called for legislation to establish federal standards for death counts after disasters.
"It has been tragically clear for some time that the devastation from Irma and Maria was many magnitudes worse than the official death toll suggested," she said.
More from Hurricane Irma
This isn't the first time the death toll has been pitched as far larger than previous estimates.
In May, a report in the New England Journal of Medicine concluded that there may have been as many as 4,600 excess deaths in the aftermath of the hurricane.