The death of Marine Corps veteran Jason Simcakoski last year resulted from systematic and avoidable failures at the Tomah VA facility in Wisconsin, according to an investigative report from the office of the inspector general published Thursday.
The report discovered that physicians at the facility prescribed Simcakoski a mixture of depressants without warning him or his family about any of the side effects. He died on August 30, 2014, while an inpatient in the psychiatric unit. When nurses discovered him, they didn’t bother to use the emergency call system or perform resuscitation. They failed to administer drugs to revive him until 30 minutes after he was first found.
“Our inspection’s results were consistent with the medical examiner’s conclusion that the patient’s cause of death was mixed drug toxicity,” the report noted. “Additionally, we found deficiencies in the informed consent process and cardiopulmonary resuscitation efforts.”
Democratic Sen. Tammy Baldwin of Wisconsin has already introduced legislation titled the Jason Simcakoski Memorial Opioid Safety Act, announcing in late July that the bill is continuing to gain support from members of Congress and veterans’ organizations. The legislation requires stronger prescription guidelines for physicians when combining opioids with potentially dangerous interaction effects.
It also mandates more accountability through internal audits and regular Government Accountability Office reports. Medical practitioners must further inform patients of alternative treatment options, instead of relying solely on addictive and often dangerous opioids.
“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,” Democratic Sen. Tammy Baldwin of Wisconsin said in a statement.
“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.”
Acting facility director John Rohrer stated that he agrees with the findings of the investigation and intends to make sure that the nursing staff who acted improperly will be retrained.
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