Government and Regulations

VA Hospital Deficiencies Contributed to Marine’s Death

Following an OIG report, changes are under way at the Tomah VAMC, which has taken responsibility for the 2014 death of a mental health patient.



On August 30, 2014, a 35-year-old marine died during inpatient treatment for mental health at the Tomah VAMC in Wisconsin. A year later, the VA Office of Inspector General (OIG) Office of Healthcare Inspections determined a number of deficiencies in hospital operations as a result of the investigation of this patient’s death.

Among these deficiencies were a lack of documenting patient consent for treatment and insufficient response to the patient’s cardiopulmonary emergency.

“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,” the Tomah VAMC said in a statement.

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Neither of the 2 psychiatrists treating the patient, Jason Simcakoski, obtained informed consent, verbal or written, for the buprenorphine/naloxone, according to both the patient’s electronic health record and the treating psychiatrists’ accounts. The prescription was administered to the patient with an off-label indication beginning the day prior to his death.

In addition, when the patient was found unresponsive in his room, “unit staff did not immediately assess the patient and determine the need for cardiopulmonary resuscitation,” nor did they use the in-room emergency call system or determine cardiac activity with the automatic external defibrillator, as noted in the OIG report.

Mr. Simcakoski served with the U.S. Marine Corp from 1998 until his honorable discharge in 2002. Mr. Simcakoski established VA medical care in 2003, according to the OIG report. Two years later, he sought help for his addiction to oxycodone, a medication he said he obtained from a friend; no VA provider ever prescribed Mr. Simcakoski oxycodone or other Schedule II opioid analgesic. The patient was treated for addiction at a non-VA clinic through 2007 and again in 2010.

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The patient’s psychiatric diagnoses included posttraumatic stress disorder, bipolar I disorder, generalized anxiety disorder, attention deficit/hyperactivity disorder, panic disorder, opioid dependence, and alcohol and benzodiazepine abuse.

As a result of OIG recommendations, one of the psychiatrists involved in this case was terminated and the second awaits administrative proceedings. Under the direction of the Tomah VAMC acting chief of staff, all appropriate providers will be required to take relevant VHA training on informed consent, and all patients currently on buprenorphine will be reviewed to ensure consent has been obtained, both of which have an October 2015 target date of completion.

“I feel some comfort knowing they have admitted they failed Jason,” Heather Fluty Simcakoski, the victim’s widow, told Gannett Wisconsin Media. “It doesn't bring him back, but I know it's a step closer to getting justice for him.”

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