A series of deficiencies in care at the Tomah (Wis.) VA Medical Center contributed to the "avoidable" death of a 35-year-old Marine last summer, according to a Veterans Affairs Department report released Friday.
The report by the agency's Office of Inspector General comes a year after Jason Simcakoski, of Stevens Point, was found unresponsive and died in the hospital's inpatient unit of mixed drug toxicity. Whistle-blowers also have brought to light other deaths at the facility that they alleged stemmed from overprescribing practices.
Investigators determined that two psychiatrists who prescribed Simcakoski medication didn't discuss the risks of the drugs with him or his family, as required. The report also found that staff didn't immediately perform CPR or use an in-room emergency call system when they found him unresponsive.
Drugs to revive him also were not available in his unit where he was staying, so he wasn't given them until more than a half hour later. The report also said that because his cardiac status wasn't taken when he was found unresponsive, "it cannot be determined with any degree of certainty whether resuscitative efforts would have been successful."
"We are deeply saddened by the tragic, avoidable death of this veteran and are committed to learning from this event and making improvements in the care we provide to our veterans," the Tomah medical center said in a statement Friday.
John Rohrer, the acting director at Tomah VA, said the Tomah facility is accepting full responsibility for the treatment of Simcakoski leading up to his death. He also said the facility is taking steps to address the problems identified, including complying with rules on informed consent, improving life-saving emergency procedures and reviewing medications available on emergency crash carts.
He said management has disciplined the two doctors involved: One no longer works at the facility, while "administrative proceedings" against the other are ongoing.
WXOW-TV reported that Simcakoski's father, Marv Simcakoski, said he was "really encouraged by the changes" coming as a result of the investigation.
"People make mistakes. Nobody is perfect. As long as changes come as a result and they take accountability," he said.
Heather Fluty Simcakoski, Jason's widow, told Gannett Wisconsin Media: "I feel some comfort knowing they have admitted they failed Jason. It doesn't bring him back but I know it's a step closer to getting justice for him... It was heartbreaking to relive but at least we now have some answers."
The facility in west-central Wisconsin came under scrutiny in January following reports that physicians were prescribing more painkillers than most VA hospitals, and that employees who spoke out were subjected to intimidation. The hospital became the subject of investigations by the VA, the VA Office of Inspector General and the Drug Enforcement Administration.
