An investigation held by the Department of Veterans Affairs has revealed that the death of a former Marine was caused by staff failing to properly prescribe medications and providing the improper medical response when the patient was found unresponsive.

The veteran, Jason Simcakoski, passed away on August 30th, 2014 in the VA hospital mental health unit from “mixed drug toxicity.” Jason took 13 prescription medications, several of which cause respiratory depression, within a 24-hour period. Drugs such as Quetiapine and Tramadol are known to be sedatives. One of the newer medications, Suboxone, could also have contributed to the issue.

As stated in the report, the prescribing doctors informed investigators that Simcakoski was able to leave the hospital for short intervals and accused that he, “obtained additional quantities of his prescription medications on his own and ingested them,” but investigators proved otherwise.

Nearly all of the drugs found in the veteran’s system are able to cause sedation and the patient’s medical records confirmed that the medications were indeed prescribed by the VA providers.

According the report, Simcakoski and his family were not advised of the risks of the new medications.

It was also discovered that the Tomah VA hospital staff was incompetent in addressing the unresponsive veteran. They first failed to establish if he still had a heartbeat, failed to initiate immediate resuscitation, did not use a portable defibrillator, and did not have medication ready for an accidental overdose.

“Furthermore, we learned unit staff stopped CPR when facility firefighters arrived [expecting they] would take over CPR efforts … however, firefighters at the facility are not designated as first-line staff to provide hands on emergency care,” said the investigators.

The Tomah VA, nicknamed “Candy Land”, has been under investigation and scrutiny following a report released in January that showed a 14-fold increase in the number of oxycodone pills prescribed from 2004 to 2012. The numbers surged from 50,000 to 712,000 within that time.

In response to the VA report, Sen. Tammy Baldwin, D-Wis., introduced legislation requiring VA and Defense Department to change the clinical guidance on the prescription of opioids, mandate training for all Veterans Affairs doctors who prescribe opioid painkillers, and establish pain management boards to oversee compliance.

This same VA report confirms that the VA physicians at the Tomah VA hospital failed to keep their promise to care for Simcakoski, stated Baldwin on August 7th.

“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 veterans.”

Officials from the Tomah VA hospital claim they are determined to learning from the case and upgrading care. According to public affairs officer, Matthew Gowan, the IG’s recommendations are being followed.

One physician involved in the case is no longer employed at Tomah, and another is facing administrative action.

Facing this tragedy has been difficult for the Simcakoski family, including Jason’s parents, his wife, and his daughter. The family has testified before Congress on the issue of the pain medication practices at the VA and supported Baldwin and her bill. His father, Marvin, stated that the inspector general’s report has helped “ease the pain […] since the VA admitted to wrongdoing.”

Marvin also included that he has noticed changes at the Tomah VA, but would like Baldwin’s bill to become law to provide protection to veterans.

“It wouldn’t bring him back, but sometimes it takes something bad to happen for something good to come out of it […] He’d be proud to know that his death helped other veterans.”

The Archuleta Law Firm handles injury, death, and veterans medical malpractice claims under the Federal Tort Claims Act. We handle claims in all 50 States and Worldwide. Our focus is helping Veterans, and the families of Veterans and Military Service Members in their claims involving Veterans (VA) Hospitals, Doctors and Clinics and Military Hospitals, Doctors and Clinics. We handle claims involving the Department of Veterans Affairs, the U.S. Army, the U.S. Navy, and the U.S. Air Force.

Source: Military Times