Federal investigators have confirmed that a lethal cocktail of prescription drugs killed Marine Corps veteran Jason Simcakoski, a psychiatric patient at the Tomah, Wisconsin, veterans hospital known as “Candy Land” for its rampant use of opiates.
The inspector general’s report comes nearly a year after Simcakoski’s death on Aug. 30, 2014, in the psychiatric ward of the Tomah VA Medical Center, after he was prescribed yet another opiate to go with more than a dozen other drugs he had been issued. He was being treated for anxiety after entering the facility earlier that month, saying he felt suicidal.
“It’s been a rough year,” said Marvin Simcakoski, the father of the 35-year-old Marine, whose death featured prominently in Reveal’s investigation of the Tomah VA, which reinvigorated calls to curb opiate prescriptions at Department of Veterans Affairs facilities.
“We can’t have Jason back, but at least they admitted they screwed up. We knew it was hard for them to do, so we’re happy,” he said after attending a news conference convened today by the hospital’s acting director to discuss the report.
The Simcakoski family, which long had called for an investigation with little result, said the new report helps bring closure.
“We knew what happened,” Marvin Simcakoski said. “We just wanted somebody else to say what we knew all along.”
A medical examiner had blamed “mixed drug toxicity” for the former Marine’s death – a finding confirmed in Thursday’s report signed by Dr. John D. Daigh Jr., the VA’s assistant inspector general for health care inspections.
“We determined that the patient died in the facility and that he was prescribed medications with potential for respiratory depression,” his report stated, adding that the combination of drugs was “the plausible mechanism of action for a fatal outcome.”
The inspector general’s office faulted the hospital for failing to obtain the required written consent before administering dangerous drugs, including buprenorphine, a medication distributed under the name Suboxone that often is used to treat opiate addictions. The report noted that neither of the psychiatrists involved in ordering the drug for Jason Simcakoski adequately informed him of the risks it posed.
One of the doctors involved in the case, Dr. Ronda Davis, “is no longer employed by the Tomah VA,” said Matthew Gowan, the medical center’s public affairs officer. He would not elaborate but said her employment at the hospital ended July 10. He said other “administrative action is still ongoing.” The inspector general’s report notes that “administrative proceedings for Physician 2 are in process.”
The report also noted the confusion that ensued as medical personnel tried to resuscitate Simcakoski in the psychiatric ward, including delays in starting cardiopulmonary resuscitation and administering an antidote.
His death was one of at least five fatal overdoses linked to the Tomah VA hospital while under the charge of chief of staff Dr. David Houlihan, referred to by some as the “Candy Man” for his prolific prescribing practices. A Reveal investigation earlier this year found that opiate prescriptions at the Tomah facility sharply increased under Houlihan’s watch.
A search of Tomah police records by Reveal and the La Crosse Tribune found that employees at the Tomah VA had called 911 more than 2,000 times in the past five years, seeking local law enforcement help with cases of battery and burglary, an attempted kidnapping and 24 unexpected deaths.
U.S. Sen. Tammy Baldwin, D-Wis., called Thursday’s report confirmation of a tragic failure by Tomah physicians. Baldwin had joined Republican Wisconsin Sen. Ron Johnson in asking the VA’s inspector general to investigate Simcakoski’s death.
“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,” Baldwin said in a statement.
Baldwin has introduced legislation in Simcakoski’s name that she said would 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 our veterans.”
In a statement issued following the release of inspector general’s report, John Rohrer, the Tomah medical center’s acting director, vowed to learn from Simcakoski’s death.
“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,” he said.
He said the hospital is addressing the report’s findings and vowed to implement recommendations by January, including further personnel actions, improved staff training and strengthening of the process for obtaining informed consent when prescribing drugs.