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.
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.
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.
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