A recently released report from the VA Office of Inspector General says that Tomah VA Medical Center is to blame for the death of an infantry Marine nearly one year ago.
35-year-old Jason Simcakoski died of “mixed drug toxicity” on August 30, 2014, according to the medical examiner. After launching an investigation into his death, OIG determined that Simcakoski 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.”
There’s one drug in particular that stands out in the report and that’s Suboxone. The psychiatrists who reportedly ordered this hazardous drug apparently never discussed the risks with Jason before administering it, according to WKBT.
The report said Suboxone should only be taken once a day, but Simcakoski received it three times in 24 hours. Jason’s family argued with doctors to reduce his number of medications, but that didn’t seem to work.
Tomah VA admits Jason’s death was avoidable. “We accept responsibility for any action or inaction that contributed to this young man’s death,” said Acting Tomah VA Medical Director John Rohrer.
When staff found Jason unresponsive, there were delays in administering CPR and calling for help, the report said. The investigation also found that medications used to reverse the effects of a possible drug overdose were not available on the unit.
The OIG made four recommendations as a result of the investigation. They include making sure the VA staff is fully trained in responding to medical emergencies, ensuring that physicians are talking to patients about their medications as required, and looking into disciplinary action. One of the psychiatrists involved in the case has already been fired.