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Report: Tomah VA hospital story is one of ‘systemic failures’

By   /   June 1, 2016  /   News  /   No Comments

Part 28 of 46 in the series Tomah VA Scandal

TOMAH, Wis. – A Senate committee’s exhaustive report into the “culture of fear” that contributed to the deaths of at least two veterans at Tomah’s Veterans Affairs hospital could not have been more aptly named.

“The Systemic Failures and Preventable Tragedies at the Tomah VA Medication Center” lays out a long list of misconduct, abuse, and retaliation charges over several years, and nearly as many red flags that critics say, had they been heeded, could have saved lives.

“Dating back nearly 10 years, the Tomah VA has been plagued by allegations of dangerous prescription practices and administrative abuses. For years, actions that should have served as warning signs were ignored and problems at the Tomah VA festered,” said Sen. Ron Johnson, R-Oshkosh, chairman of the Homeland Security and Governmental Affairs Committee.

The committee held a field hearing Tuesday in Tomah to take testimony from VA officials as it released the 359-page majority staff report.

Photo by Wisconsin Watchdog

TROUBLING FINDINGS: Sens. Ron Kind and Tammy Baldwin at Tuesday’s Senate Homeland Security and Governmental Affairs Committee hearing into scandal-ridden Tomah VA medical center.

Tomah’s scandal-plagued story is more than just missed opportunities, the report’s authors found. It is the result of repeated failures by VA administrators from the very top and what appears to be an incredibly obtuse VA Inspector General’s Office to respond to troubling allegations from medical center employees. And, while the report stayed away from politics, blame may fairly be laid at the feet of congressional members and the law enforcement community, both failing to act even as whistleblowers begged them to do something.

RELATED: Kind flees questions, Senate committee turns up heat on Tomah VA hospital scandal

VA Deputy Secretary Sloan Gibson was forced to admit that lapse in leadership.

“We are deeply concerned and distressed about the allegations that employees who sought to report deficiencies at the Tomah VAMC were ignored, or worse, intimidated into silence,” Sloan said in a prepared opening statement before the committee.

He pointed to a “number of actions” VA administrators have taken to create a “more transparent culture,” but said leadership has to “own” the failures.

The trouble began even before Dr. David Houlihan, the medical center’s former chief of staff arrived in 2002, according to the report. Houlihan was promoted to the chief position in 2004, despite previous charges against the psychiatrist from the Iowa State Board of Medical Examiners that he had “inappropriate professional boundaries” with a patient. The VA did not formally address the Iowa allegations until 2009, but by that time VA regional leadership determined the matter was “resolved.”

Houlihan, known at the hospital as the “Candy Man” for his alleged liberal policies on prescribing painkillers, was at the helm in Nov 2007, when Tomah VA veteran Kraig Ferrington died from “poly medication overdose.” Ferrington had been discharged less than 24 hours before. Investigations determined there were deficiencies in the medical center’s medication management.

“(T)here is a general concern regarding the number of medications (Ferrington) was on, and the potential interactions among them,” one VA consultant wrote, according to the committee report.

In June 2009, a Drug Enforcement Administration investigator interviewed Noelle Johnson, a pharmacist at the facility who was fired after questioning prescriptions. She showed the DEA 10 examples of patients who had prescriptions that were either too high in dosage or too long in duration, according to the report.  The DEA investigation remains open to this day, Johnson said.

Roberto Obong, who served as Tomah VA Medical Center police chief from September 2009 to September 2013, said that he took the post knowing the western Wisconsin law-enforcement community referred to the hospital as a “big pill box.”

“I spoke to the Sheriff. I spoke to the Chief of Police. I spoke to the firefighters, you name it. I researched it,” Obong told Johnson’s staff during an interview in December.  “Their (Tomah VAMC) reputation is really not quite well.”

He told staff that he was aware before his hiring that the medical center had the nickname “Candy Land” and that one of the doctors was known as “Candy Man,” according to the committee report.

Still, Obong said, if the allegations were true, “I’m pretty sure somebody is already investigating it or had investigated it.”

As Wisconsin Watchdog reported Tuesday, Jason Simcakoski contacted multiple law enforcement agencies before the 35-year-old Marine Corps veteran died from a “toxic cocktail” of prescription medication in August 2014, according to phone records contained in the report.

In November 2013, Simcakoski contacted Obong’s successor, Tomah VA Medical Center Police Chief Perry Huffman, four times, and his underlings many more times, according to the report.

The veteran’s cell phones contained a voicemail from someone claiming to be an FBI agent, on Nov. 4, 2013.

Johnson played the voicemail recording at Tuesday’s hearing.

“Jason, this is Andy Chapman from the FBI returning your call. My phone number is 608-782-6030,” the person on the voicemail says.

An official from the FBI satellite office in La Crosse answered at that number Tuesday, but would not state his name and when asked whether an Andy Chapman works there said Wisconsin Watchdog would need to contact the FBI office in Milwaukee.

Phone records show Simcakoski was in contact with the FBI on at least five separate occasions that November, including a call that lasted 12 minutes and 25 seconds, according to the report.

Just a half hour after a call to the FBI on Nov. 4, 2013, Simcakoski sent a text to his wife: “I talked to the FBI today.” In Facebook posts he wrote, “ I’m not working with Tomah PD or va pd I’m a lot higher than them … FBI … “

Johnson said officials from the FBI declined to appear at Tuesday’s hearing, but stated in a letter to the committee that “Our records have not shown that Mr. Simcakoski was in contact with any FBI field office.”

Phone records, included in the report’s sources notes, also show U.S. Rep. Ron Kind’s office received a call from Simcakoski. The call lasted 7 minutes and 39 seconds, according to the phone record, found on page 1,305 of the report. Kind, a La Crosse Democrat, refused to discuss the matter at Tuesday’s hearing. He told VA officials, as he has said in the past, that he was in the dark about what was going on at the medical center.

There were other deaths.

After being fired on July 14, 2009, Dr. Christopher Kirkpatrick died of a self-inflicted gunshot wound. Prior to his death, Kirkpatrick had raised concerns about overprescribing practices at the medical center.

“At least one of Dr. Kirkpatrick ‘s supervisors testified to the VA accountability board that he felt coerced into disciplining Dr. Kirkpatrick. This same supervisor also testified that he disagreed with the decision to fire Dr. Kirkpatrick,” Johnson said in his opening statement.

While Gibson asserts the Tomah facility does “so many things so well” (it boasts a 93 percent satisfaction rate and leads the VA health system in the lowest number of health care-related infections, Johnson pointed out that Tomah also has a “jaw-dropping” level of retaliation against whistleblowers.

Part of 46 in the series Tomah VA Scandal
  1. After damaging silence, Baldwin now calls for probe of troubled VA center
  2. Legal expert says U.S. Sen Tammy Baldwin is in full ‘damage control’
  3. Baldwin aide breaks silence, alleges senator engaged in ‘coverup’
  4. Baldwin’s public relations team kicks into high gear following ethics complaint
  5. Ethics watchdog urges Senate committee to investigate Baldwin
  6. Tammy Baldwin’s political fixer is helping Hillary attack voter ID
  7. Senate committee asking if FBI missed the call in veteran’s death at VA
  8. When lawmakers failed Wisconsin’s veterans
  9. Is political pressure behind Lin Ellinghuysen’s differing accounts on VA memo?
  10. Bernie Sanders failed to act in deadly VA scandal, whistleblower says
  11. Does government union chief’s threat show AFGE’s hand on veterans care?
  12. What would Russ Feingold’s 1992 self say to the 2015 version?
  13. Ad attacking Feingold asserts veterans died because of ‘politicians who looked the other way’
  14. Feingold’s campaign caught up in VA scandal memo war
  15. PolitiFact Wisconsin trusts Russ Feingold to deliver its facts
  16. Sources: Ron Kind received call from Jason Simcakoski not long before Marine’s tragic death
  17. Captain Campaign Finance Reform, Russ Feingold, changes ‘dark money’ tune
  18. Baldwin talks transparency while keeping her secrets in Tomah VA scandal
  19. Ron Kind knew about Tomah VA abuse years before the story broke
  20. Ron Kind now solving Tomah VA scandal one press release at a time
  21. Tammy Baldwin silent on her failures as she blasts Tomah VA medical center
  22. Tomah VA whistleblower says he’s getting pressure from unhappy Dems
  23. Feingold’s facts fail again in face of Tomah scandal
  24. Senate field hearing to shine more light on Tomah VA scandal
  25. Tomah VA supervisor accused of misconduct gets promoted
  26. Senate hearing to look deeper into scandal-plagued Tomah VA hospital
  27. Kind flees questions, Senate committee turns up heat on Tomah VA hospital scandal
  28. Report: Tomah VA hospital story is one of ‘systemic failures’
  29. Tomah VA hospital whistleblower: ‘It will not change’
  30. Ron Kind breaks silence on call from veteran victim at Tomah VA hospital
  31. VA union holds rally to save itself, Tomah whistleblower says
  32. Sound familiar? Illinois Rep. Tammy Duckworth accused of retaliation at VA
  33. Emails say Tomah VA patient reached out to Feingold, Kind, in 2008 about abuse
  34. Johnson: Hold accountable those who put Tomah veterans at risk of HIV, hepatitis
  35. Veteran jumps out of third-floor window at Tomah VA hospital
  36. Tomah VA employee: ‘We have forgotten who we work for’
  37. Congressional committees want answers on Tomah VA hospital
  38. Senators ask Pence, Trump transition team, to hold troubled VA accountable
  39. Veterans advocate: VA hospitals’ ‘improvement’ doesn’t tell whole story
  40. Tomah VA Medical Center’s ‘Candy Man’ stripped of license
  41. Opinions differ on whether it’s ‘meet the new boss, same as the old boss’ at Tomah VA
  42. Latest data show Tomah VA hospital improving in opioid prescriptions, veteran satisfaction
  43. VA secretary nominee faces little resistance, lots of challenges
  44. Insiders: Tomah VA troubles continue with nurse shortage, neglectful care
  45. VA whistleblower has questions for Congressman Ron Kind
  46. Johnson brings back whistleblower protection bill as Sunshine Week opens

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M.D. Kittle is bureau chief of Wisconsin Watchdog and First Amendment Reporter for Watchdog.org. Kittle is a 25-year veteran of print, broadcast and online media. He is the recipient of several awards for journalism excellence from The Associated Press, Inland Press, the Wisconsin Broadcasters Association, and others. He is also a member of Investigative Reporters & Editors. Kittle's extensive series on Wisconsin's unconstitutional John Doe investigations was the basis of a 2014 documentary on Glenn Beck's TheBlaze. His work has been featured in Town Hall, Fox News, NewsMax, and other national publications, and his reporting has been cited by news outlets nationwide. Kittle is a fill-in talk show host on the Jay Weber Show and the Vicki McKenna Show in Milwaukee and Madison.