The San Diego Department of Veterans Affairs (VA) ruined the care of Marine veteran Jeremy Sears, who ended up killing himself in October 2014, according to an VA internal investigation.
Sears, 35, committed suicide at a gun range. Given his young age, veterans’ advocates started to look into his case, The San Diego Union-Tribune reports.
It turns out Sears received a brain injury diagnosis and then subsequently waited 16 months to discover the VA wouldn’t give him a cent of disability pay. He served multiple tours in Iraq and Afghanistan.
But what the VA did give him, said the inspector general in an internal report, is narcotics.
Doctors prescribed Sears Vicodin for 22 months without providing any oversight whatsoever. There were no face-to-face checkups with a physician.
Sears used Vicodin for knee pain. The presence of crushing, chronic pain heightens suicide risk, but at no point did the VA decide a suicide risk assessment was necessary.
This is in clear violation of standard procedure. The VA is supposed to complete a suicide risk assessment when providing pain therapy and also must regularly follow-up with additional reports.
Drugging up patients to pacify them is a recurring problem at the department, with the epicenter of the scandal erupting in Tomah. Marine veteran Jason Simcakoski died from a toxic drug cocktail, a death which was preventable, reflecting a trend of opioid overprescription at the facility. This lead to the firing of the facility’s chief of staff, Dr. David Houlihan, for his role in prescribing an astounding amount of narcotics.
VA staff had another opportunity to move forward with risk assessment, as Sears suffered from a traumatic brain injury (TBI) due to roadside explosives. There is a causal connection between TBI and suicide. Veterans already have a suicide rate that is 50 percent higher than civilians. Among women, the rate is almost six times higher.
“If the patient had regular follow-up with his [primary care physician], the provider may have identified signs and symptoms of [post-traumatic stress disorder] and depression, and the need for follow-up of TBI and post-traumatic headaches,” the report says, according to The San Diego Union-Tribune.
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