VA hospital at fault in Marine veteran's death

WASHINGTON — An investigation into the death of a former Marine at a Tomah, Wis., VA Medical Center found that staff improperly prescribed medications and blundered its response when the veteran was found unresponsive in his bed.

Jason Simcakoski, 35, of Stevens Point, Wis., died Aug. 30 in the hospital’s short-stay mental-health unit from “mixed drug toxicity.”

He took 13 prescribed medicines, including several that cause respiratory depression, in a 24-hour period. Staff psychiatrists had added new medications to Simcakoski's lengthy list of prescriptions in the days preceding his death, according to a Veterans Affairs Department Inspector General report released Aug. 6.

Several of the drugs, including quetiapine and tramadol, are known sedatives, and one of Simcakoski's new medications, Suboxone, also can cause severe drowsiness.

Prescribing doctors told investigators that Simcakoski had privileges to leave the hospital for a few hours at a time and he probably "obtained additional quantities of his prescription medications on his own and ingested them," and thus may have been responsible for his own death, according to the report.

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But investigators found that nearly all the drugs found in the veteran's system were sedatives and the patient's record "confirmed that all these drugs were prescribed by providers at the facility."

Doctors also failed to advise Simcakoski or his family members of the risks of taking the new prescriptions and their off-label use to treat symptoms such as anxiety, pain and migraine headache, according to the report.

Hospital staff were woefully inept in treating the former corporal when he was found unresponsive, the report found. Staffers failed to determine whether he had a heartbeat, immediately initiate lifesaving measures, employ a portable defibrillator or administer medications that could have countered an accidental overdose.

"Furthermore, we learned unit staff stopped CPR when facility firefighters arrived (expecting they) would take over the CPR efforts," investigators wrote. "However, firefighters at the facility are not designated as first-line staff to provide hands on emergency care."

The Tomah VA Medical Center has been under scrutiny since the January release from the Center for Investigative Reporting that found the hospital had a 14-fold increase in the number of prescribed oxycodone pills from 2004 to 2012, from 50,000 to 712,000.

Veterans told a reporter that distribution was so rampant, they nicknamed the place "Candyland" and said Simcakoski’s death served as an example of overzealous prescribing practices.

In response to the report, Sen. Tammy Baldwin, D-Wis., introduced legislation that would require the VA and Defense Department to update clinical guidance on prescribing opioids, mandate training for all VA doctors who prescribe narcotic painkillers and create pain-management boards that would oversee compliance.

“This report highlights the need for the reforms we have proposed to give veterans and their families a stronger voice in their care and put in place stronger oversight and accountability for the quality of care we are providing our veterans,” Baldwin said.

Tomah VA officials said they are committed to learning from the case and improving care, according to a statement provided to The Associated Press.

The tragedy has been difficult for the Simcakoski family, including Jason's parents, Marvin and Linda Simcakoski; his wife, Heather; and daughter, Anaya. They have testified before Congress on the issue of VA pain-medication practices and stood with Baldwin to support her bill.

Marvin Simcakoski said Wednesday that the inspector general report has helped “ease the pain ... since the VA admitted to wrongdoing.” He added that he has seen changes at the Tomah VA but would like Baldwin’s bill to become law to protect more veterans.

“It wouldn't bring him back, but sometimes it takes something bad to happen for something good to come out of it," Marvin Simcakoski said. "He'd be proud to know that his death helped other veterans."

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