WASHINGTON — A Senate investigation of poor health care at a Veterans Affairs Medical Center
in Tomah, Wis., found systemic failures in a VA inspector general’s
review of the facility that raise questions about the internal
watchdog’s ability to ensure adequate health care for veterans
nationwide.
The probe by the Senate Homeland Security and
Governmental Affairs Committee found the inspector general’s office,
which is charged with independently investigating VA complaints,
discounted key evidence and witness testimony, needlessly narrowed its
inquiry and has no standard for determining wrongdoing.
One of the
biggest failures identified by Senate investigators was the inspector
general’s decision not to release its investigation report, which
concluded two providers at the facility had been prescribing alarming
levels of narcotics. The facility's chief of staff at the time was David
Houlihan, a physician veterans had nick-named “candy man” because he
doled out so many pills.
Releasing the report would have forced VA officials to publicly
address the issue and ensured follow up by the inspector general to make
sure the VA took action. Instead, the inspector general’s office
briefed local VA officials and closed the case.
A 35-year-old
Marine Corps veteran, Jason Simcakoski, died five months later from
“mixed drug toxicity” at Tomah days after Houlihan signed off on adding
another opiate to the 14 drugs he was already prescribed.
The
350-page Senate committee report obtained by USA TODAY also chronicles
instances where other agencies could have done more to fix problems at
the Tomah VA Medical Center, including the local police, the FBI, DEA,
and the VA itself, but it singles out the inspector general.
“Perhaps
the greatest failure to identify and prevent the tragedies at the Tomah
VAMC was the VA Office of Inspector General’s two-year health care
inspection of the facility,” the report concludes, adding that despite
the dangerous drug prescriptions, the IG did not
identify any wrongdoing.
After news reports chronicled
Simcakoski’s death last year, VA officials conducted another
investigation with very different results and ousted Houlihan, a nurse
practitioner, and the medical center’s director.
“In just three
months, the VA investigated and substantiated a majority of the
allegations that the VA OIG could not substantiate after several years,”
the committee report notes.
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