Posted on Aug 10, 2015
"Report: Marine died from failures at Tomah VA Medical Center"
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From: News 8
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."
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."
http://www.news8000.com/news/marine-died-from-failures-at-tomah-va-medical-center/34597650?item=1
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."
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."
http://www.news8000.com/news/marine-died-from-failures-at-tomah-va-medical-center/34597650?item=1
Posted in these groups: 
Marine Corps
Department of Veterans Affairs (VA)
Marine Corps Department of Veterans Affairs (VA)
Posted >1 y ago
Responses: 10
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Someone will have to explain that one. How the hell do you not know what meds the patient is taking and not know how they react to each other. I see a law suite coming on this one.
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SGT (Join to see)
I was stuck at " Suboxone should only be taken once a day, but Jason Simcakoski received it three times in 24 hours"
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Sgt Spencer Sikder
If the veteran gets all his meds at the VA, the pharmacy's computer system will flag when meds are not good with each other. However, if the pharmacist who releases the meds to the veteran at the window just asks the same question they all ask, "Do you have any questions?" and not inject their perspective, we will always see this failure. Why the pharmacist doesn't say, I see you are on XXX and YYYY and did you know that these two are dangerous if you...... ? Each veteran's clinic assignment has a PharmD assigned. Where was the PharmD's review of this patient's meds? On the other hand, if we as patients don't follow the schedule precisely, we stand to harm ourselves.
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PVT Andrew Burd
What I find FASCINATING is how all these troops are given OPIATES for pain medication and then treated like drug addicts later...
Suboxone is for HEROIN ADDICTS
STOP DISHING OUT OXYCONTIN ...I mean... I know you have to do SOMETHING with all that Afghan Opium you have, but damn. ..really?
Suboxone is for HEROIN ADDICTS
STOP DISHING OUT OXYCONTIN ...I mean... I know you have to do SOMETHING with all that Afghan Opium you have, but damn. ..really?
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As an emergency room nurse, I hate to see something that is so preventable happen. The headline is sensationalizing the amount of medications that he is taking. Depending on the condition for which he was being treated (sounds like narcotic withdrawal?), that amount and variety of medications may be indicated. The real problem appears to be that he was talking Suboxone, an opioid medication for the treatment of withdrawal, in greater frequency than approved. Narcotics of this type are well-known to cause respiratory depression. Putting this patient on a simple oxygen saturation monitor would have alerted staff early that this was happening. Anywhere that narcotic medications are being given, reversal agents such as Narcan should be available. A code team should be available within the facility or staff should be trained in ACLS protocols. Had the respiratory depression and subsequent respiratory failure been found earlier, the patient could have been bagged until he received endotracheal intubation. Narcan could have been administered; it provides rapid reversal of the opioid medications causing the respiratory issues. This was entirely preventable, and the blame falls on management for not providing proper training.
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CPT Sarah Persinger
As a nurse, at the very least he should have been on telemetry monitoring and oxygen sat monitoring for opioid withdrawal treatment. This is very sad and very preventable!
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"Learning from this tragedy..."
Hasn't the VA been in the spotlight recently for over-prescribing pain medication? You would think that they would be keeping a closer eye on these things!
Hasn't the VA been in the spotlight recently for over-prescribing pain medication? You would think that they would be keeping a closer eye on these things!
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One of the biggest problems with accountability and the VA is the limitations on what kind of damages you are eligible to recover if you sue for malpractice as a VA Patient. It is hard enough to find a medical malpractice attorney to take your case on a "Contingency basis" in may states like California, because of state caps (Currently $250,000 in California) on malpractice awards. When the Federal Tort Claims Act protects the VA from negligence lawsuits, it is next to impossible to find a lawyer that will take on your case on a contingency basis (no money to the lawyer unless he wins) against the VA. Long story short you can only recover damages to make you whole, not other sort of damages, like Punitive damages or damages for pain and suffering. This is one of the reasons that despite having PPO health Insurance from my spouse, which the VA would gladly take and bill my insurance company as a health care provider, I would be SOL if I was severely injured by medical malpractice at the VA and I wanted to sue to recover for pain and suffering or punitive damages. So I choose to see private physicians or private hospitals for health care that are not protected like the VA under the FTCA.
The Feres Doctrine is modified to some degree by the Federal Tort Claim Act (FTCA)
"And sovereign immunity is still the law of the land – except the United States has waived its immunity in certain limited ways, via a federal law called the Federal Tort Claims Act.
The FTCA provides a legal window for veterans who believe they may be victims of medical malpractice on the part of VA personnel to file suit and recover compensatory damages. The law forbids punitive damages, however, and also does not apply to willful torts committed by government employees. However, you may have recourse under other areas of law to sue these individuals, personally.
The FTCA basically carves out a limited exception to the doctrine of sovereign immunity. As it applies in the context of claims against the Veterans Administration, the law only allows veterans to sue to recover damages incurred due to negligence of an employee or agent acting “within the scope of their employment.” Furthermore, the law only allows for damages if the plaintiff would ordinarily be entitled to damages even if the negligence or omission was due to the actions of an employee of a private company, under the laws in effect where the incident happened.
This last condition, in turn, means that state laws must be taken into account when formulating a lawsuit against the VA, and not just federal laws." http://www.militaryauthority.com/benefits/veterans-benefits/can-you-sue-the-va-for-malpractice.html
The Feres Doctrine is modified to some degree by the Federal Tort Claim Act (FTCA)
"And sovereign immunity is still the law of the land – except the United States has waived its immunity in certain limited ways, via a federal law called the Federal Tort Claims Act.
The FTCA provides a legal window for veterans who believe they may be victims of medical malpractice on the part of VA personnel to file suit and recover compensatory damages. The law forbids punitive damages, however, and also does not apply to willful torts committed by government employees. However, you may have recourse under other areas of law to sue these individuals, personally.
The FTCA basically carves out a limited exception to the doctrine of sovereign immunity. As it applies in the context of claims against the Veterans Administration, the law only allows veterans to sue to recover damages incurred due to negligence of an employee or agent acting “within the scope of their employment.” Furthermore, the law only allows for damages if the plaintiff would ordinarily be entitled to damages even if the negligence or omission was due to the actions of an employee of a private company, under the laws in effect where the incident happened.
This last condition, in turn, means that state laws must be taken into account when formulating a lawsuit against the VA, and not just federal laws." http://www.militaryauthority.com/benefits/veterans-benefits/can-you-sue-the-va-for-malpractice.html
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The only thing salvageable from this tragedy is that there is even more focus on our VA system and instead of covering it up they put everyone on blast. Can criminal charges be sustained by charging someone in the hospital with criminally negligent homicide? The parents are EXTREMELY forgiving and perhaps that is why the VA is putting this out for the masses to see.
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Very sad story. My taught sand prayers to Jason Simcaskoski family. I can't even start to think or imagine what they're feeling.
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Seems we are still experiments always get treated as such. For while there I was on diffrent meds. Just sad how VA treats us not saying everyone in the system. Just seems a select few.
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A truly sad story but a really poor choice in picture.
I am pretty sure that's not Simcakoski on that bed and the two care givers in the picture weren't the ones that killed him!
When you post a picture with the story there is an assumption that the people in the picture actually have something to do with the story or you should expect to see a disclaimer somewhere.
I am pretty sure that's not Simcakoski on that bed and the two care givers in the picture weren't the ones that killed him!
When you post a picture with the story there is an assumption that the people in the picture actually have something to do with the story or you should expect to see a disclaimer somewhere.
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"The OIG enlisted the services of a non-VA forensic toxicologist...." WOW! Finally, trying to present complete reports?
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