Report: Marine died from failures at Tomah VA Medical Center

OIG report says, veteran Jason Simcakoski, 35, died from mixed drug toxicity

A Marine veteran died because of a series of failures at the Tomah VA Medical Center, according to a report from the VA Office of Inspector General (OIG) released Friday.

Jason Simcakoski, 35, died at the Tomah VA Medical Center Aug. 30, 2014. The medical examiner determined the cause of death was mixed drug toxicity.

The OIG launched an investigation into the death of Simcakoski at the request of Wisconsin Sen. Tammy Baldwin and Sen. Ron Johnson.

The OIG enlisted the services of a non-VA forensic toxicologist, who agreed with the medical examiner’s cause of death.

The investigation determined that Simcakoski died in the facility, and he was prescribed a mix of medications with the potential to cause respiratory depression. The report from the OIG shows that in the 72 hours before Simcakoski passed, he was given 54 doses of 13 different drugs.

Tomah VA staff said the facility is learning from this tragedy.

The Simcakoski family is just glad they finally have some closure.

“We accept responsibility for any action or in action that contributed to this young man’s death,” said Acting Tomah VA Medical Director John Rohrer.

Rohrer said Simcakoski’s death was avoidable but said the Tomah VA will learn from it and provide better care to veterans from here on out in his memory.

Simcakoski’s parents said that’s all they want.

“It takes something bad usually to make something good happen. Unfortunately, it was our son for this, but hopefully, we’ll be able to save a lot of other veterans out there in the future from this,” Jason Simcakoski’s father, Marv, said.

The OIG report found that Tomah VA staff prescribed drugs, which, when combined, most likely led to his death. One of the drugs is called Suboxone. The report found that the Veteran’s Health Administration requires written informed consent for administering “hazardous” drugs. The OIG investigation did not find any evidence of written informed consent. Both psychiatrists involved in the ordering of the “hazardous” drug given to Jason Simcakoski acknowledged they did not discuss the risks with him.

“You have to talk to that patient, say, ‘You know, this is the risks with this,’ and get them to sign the consent so they know what they’re going into,” Marv Simcakoski said.

The report said Suboxone should only be taken once a day, but Jason Simcakoski received it three times in 24 hours.

The medications were prescribed by the treating psychiatrists at the facility. The forensic toxicologist said it can’t be ruled out that Jason Simcakoski received an additional drug that was not noted in the report.

The Simcakoski family said they argued with doctors about reducing the number of medicines their son was on, but that didn’t seem to work.

“He didn’t seem to get better, he seemed to get worse at time passed,” Marv Simcakoski said.

However, the Simcakoski family had more good things to say about the Tomah VA than bad, and they are pleased with the changes coming out of their son’s death.

“There are a lot of good staff here, like we mentioned, and they do, like we mentioned, work for the veterans, and they enjoy it, and we want that to keep going, and we want to help not just other veterans but also the staff,” Jason Simcakoski’s, mother, Linda said.

“It’s too late for Jason, but it’s not too late for, there’s veterans every day that come to this facility,” Marv Simcakoski said.

The OIG report also found failures with resuscitation efforts. It says there was confusion between unit staff and facility firefighters who responded to the medical emergency. It also found delays in initiating CPR, calling for medical emergency assistance both within the unit and from facility emergency response staff and applying defibrillator pads to determine cardiac rhythm for possible intervention.

Further, certain medications used in emergency situations to reverse effects of possible drug overdose were not available on the unit.

The OIG made four recommendations to the Tomah VA as a result of the investigation. They include making sure staff is fully trained in responding to a medical emergency, making sure physicians are talking to their patients about their medications as they are required to and looking into disciplinary action.

One of the psychiatrists involved in Simcakoski’s care was fired from the Tomah VA in July, and the other is still employed at the facility and still under investigation.

The Tomah VA released a statement saying, in part, “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 office of the inspector general also included several recommendations in its new report.

Representatives from the Tomah VA say steps have been taken to address those recommendations.

Baldwin released a statement in response:

“This report confirms that the Tomah VA physicians entrusted with Jason’s care failed to keep their promise to a Wisconsin Marine and his family.  I have all the evidence I need to conclude that the VA prescribed Jason a deadly mix of drugs that led to his death and that those responsible for this tragic failure should never again serve our veterans and their families.  The sacred trust we have with those who faithfully serve our country has been broken and it needs to be fixed.”

Johnson released this statement:

“My thoughts and prayers go out to the family of Jason Simcakoski. It is past time for VA officials to be held accountable for the tragedies at the Tomah VAMC. I will continue my investigation to get to the truth so all Wisconsin veterans receive the care they deserve.”

Congressman Ron Kind issued this statement:

“My prayers continue to be with the Simcakoski Family. This was a tragedy, and it is one that could have been prevented. It is clear very serious mistakes were made in the course of Mr. Simcakoski’s treatment.  As we move forward the Tomah VA needs to immediately take steps to implement the changes recommended in the OIG report as well as other commonsense solutions to fix the problems we have seen at Tomah and at other VA medical facilities.”