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.