UPDATE, June 1, 2016: This story updates with a new U.S. Senate report.
Our investigation disclosing skyrocketing opiate prescriptions and retaliatory management practices at the Department of Veterans Affairs medical center in Tomah, Wisconsin, quickly touched off a variety of federal and state government investigations.
Those underway are mentioned below and will be updated with their outcomes over time.
The story first published Jan. 8, 2015 on our website, followed by local Wisconsin media and the Chicago Tribune. It reported that doctors at the hospital handed out so many narcotic painkillers that some veterans had taken to calling the place “Candy Land.” They called the hospital’s chief of staff, psychiatrist Dr. David Houlihan, the “Candy Man.”
Problems had become so acute that one veteran, 35-year-old Marine Corps veteran Jason Simcakoski, died of an overdose in the Tomah VA psychiatric ward.
A subsequent story investigated the damage opiates caused during Houlihan’s 10-year tenure to veterans, hospital staff and the surrounding community. It also ran on our investigative radio program, “Reveal.”
Here are the unfolding results.
Internal probe launched and the ‘Candy Man’ is fired
On Jan. 16, VA Secretary Robert McDonald announced an internal investigation. In a statement, the agency said “a clinical review team consisting of specialists” would travel to Tomah to “review medication prescription practices there.” In the meantime, representatives from the VA’s Office of Accountability Review would look into whether Houlihan had abused his authority as chief of staff.
Results: On March 10, the VA announced that Houlihan and nurse practitioner Deborah Frasher had been placed on administrative leave after a preliminary review found that Tomah patients were 2.5 times more likely than the national average to receive high doses of opiates.
The preliminary report’s author, VA interim Undersecretary for Health Carolyn Clancy, told journalists that “a very large percentage of those patients” also receive benzodiazepine tranquilizers, such as Valium and Xanax, a combination that she said increases the risk for what she called “patient safety events.” The internal review also found that veterans’ medications were not changed even “in the face of aberrant behavior.”
Houlihan and Mario DeSanctis have both been fired. DeSanctis, the hospital director, was let go in September. Houlihan was dismissed a month later. Frasher has left the hospital as well, and while the VA would not comment officially on the circumstances of her departure, sources told the La Crosse Tribune in early February that she had been allowed to resign.
Medical licenses under scrutiny
On Jan. 20, the Wisconsin Department of Safety and Professional Services launched investigations of Houlihan, Frasher and pharmacist Margaret Hyde, which could cause them to lose their medical licenses. Houlihan and Frasher were two of the hospital’s top prescribers before they were placed on administrative leave.
On March 9, the state broadened its investigation to include psychiatrist Dr. Ronda Davis, who prescribed the cocktail of medications that killed Simcakoski.
Results: Although no information about the medical license inquiry has emerged yet, Davis no longer worked at the hospital as of July 10, according to a spokesman.
Secret reports revealed
Many of the facts in our Jan. 8 story – including the startling numbers of opiates prescribed by Houlihan, the dismissal or resignation of pharmacy staff who complained of unethical behavior, and early refills of controlled substances – were first documented in a report by the VA inspector general. But the inspector general’s report, completed in March 2014, was not shared with members of Congress or published on the agency’s website. After the story ran, members of Congress accused the inspector general of a cover-up and demanded change.
Results: On Feb. 6, the VA inspector general officially published its report on Tomah, which was then nearly a year old. USA Today later would report that the independent watchdog had withheld the findings of 140 investigations it had completed since 2006. On March 17, acting VA Inspector General Robert Griffin announced that he would begin releasing those reports. Among the first to be published were investigations into complaints about the care of veterans in Palo Alto, California, and West Palm Beach, Florida.
Inspector general returns
In early February, the VA Office of Inspector General launched a new investigation into Tomah. Cathy Gromek, a spokeswoman for the agency watchdog, said inspectors were looking into “the quality of medical care provided by the Tomah facility.” Jason Simcakoski’s father, Marv, told The Center for Investigative Reporting that representatives of the inspector general’s office had met with him to discuss his son’s death.
Results: On Aug. 6, the inspector general released a report confirming that a lethal cocktail of prescription drugs killed Simcakoski, who was suicidal and being treated for anxiety at the time of his death in the psychiatric ward. The hospital failed to obtain the required written consent before administering dangerous drugs, including buprenorphine, a medication distributed under the name Suboxone that often is used to treat opiate addictions. The report also cited delays in starting cardiopulmonary resuscitation and administering an antidote. Simcakoski’s father said the report gave him a sense of closure: “We just wanted somebody else to say what we knew all along.”
Drug diversion and patient deaths
Drug Enforcement Administration agents visited the Tomah VA on Feb. 11 as part of their probe into whether powerful narcotic painkillers were being diverted to the street. On Feb. 12, Sen. Tammy Baldwin, D-Wis., wrote to Attorney General Eric Holder, asking for a more sweeping investigation from the Department of Justice that would include the deaths of three veterans, whistleblower retaliation and failure to maintain medical equipment.
Results: None yet.
Congressional inquiry begins
The Senate Committee on Homeland Security and Governmental Affairs has deployed a team of congressional investigators to Tomah to independently assess the issues raised in CIR’s reporting. The committee, led by Sen. Ron Johnson, R-Wis., held a joint hearing in Tomah with the House Committee on Veterans’ Affairs on March 30.
Results: The committee’s investigation revealed four additional deaths at the Tomah VA while Houlihan was in charge. They include Kraig Ferrington, a 45-year-old Army veteran and union plasterer who died of an overdose of seven medications prescribed by Houlihan in 2007, and three veterans who died in the VA parking lot in 2008 and 2009, a VA pharmacist told lawmakers. The deaths bring to 33 the number of unexpected deaths CIR has found occurred during Houlihan’s decade at the helm.
On May 30, the Senate released a 365-page report that confirmed the dangerous overuse of opioid prescriptions at a Veterans Administration hospital in Wisconsin, and it did not waste words in casting blame. The report begins: “The tragedies of the Veterans Affairs Medical Center in Tomah, Wisconsin (Tomah VAMC) – the veteran deaths, abuse of authority, and whistleblower retaliation – were preventable.”
Politicians held accountable
After the Jan. 8 story ran, politicians from both parties demanded that the VA investigate rampant overmedication, retaliatory management practices and preventable overdose deaths at the Tomah hospital. But as we reported Jan. 14, many these same politicians had known about the problems for months.
Results: Baldwin, whose office had obtained a copy of the secret inspector general’s report in August, hired a law firm to investigate her staff. After two months of intense media scrutiny, she fired one aide and disciplined three others.
On March 25, U.S. Rep. Ron Kind, a Wisconsin Democrat whose district includes the hospital, introduced the Veterans Pain Management Improvement Act, which would require the VA to establish a pain management board in each of its 23 administrative regions. The boards would file regular reports with the secretary of veterans affairs and Congress on strategies employed and serve as a resource for veterans and their families.
Also on March 25, Sens. Baldwin and Johnson introduced legislation designed to increase openness in the VA inspector general’s office. On April 22, Kind introduced a bill that would ban secret inspector general’s reports. It was co-sponsored by every other House member from Wisconsin.
On April 28, Rep. Sean Duffy, R-Wis., introduced two bills in response to the Tomah situation. One would make it easier for the VA to fire employees who endanger patient safety. The other requires the VA to participate in state-run prescription drug monitoring programs, which are designed to prevent addicted patients from doctor-shopping for narcotics.
The same day, Johnson introduced legislation making it easier for the VA to discipline and dismiss doctors for poor performance and wrongdoing.
“We owe our veterans, the finest among us, the very best medical care,” Johnson said in a statement. “That is why the revelations of terrible failures at the VA Medical Center in Tomah – and at other VA facilities around the country – were so shocking. Our first priority must be to ensure that tragedies such as those in Tomah do not happen again.”
On June 22, Baldwin joined other legislators to introduce bipartisan legislation in Jason Simcakoski’s name to improve safety of opiate prescriptions and pain management care. She said in a news release that this would give “veterans and their families a stronger voice in their care and put in place stronger oversight and accountability for the quality of care we are providing our veterans.”
Results: On April 28, the Senate Committee on Veterans’ Affairs issued a report providing guidance to the VA on how to implement the Clay Hunt Suicide Prevention for American Veterans Act, which President Barack Obama signed in February. The law requires the VA to provide independent third-party evaluations of VA mental health and suicide prevention programs and provide those evaluations to Congress. The committee report specifies that the reports must include a review of opioid prescription trends by doctors in the VA system, an analysis of whether the VA is following its own regulations on opiate prescriptions and “an assessment of VA patterns for prescribing opioid treatment for patients suffering from mental health disorders.”
In December, many of the provisions of the Jason Simcakoski Memorial Opioid Safety Act became law when Obama signed the omnibus spending bill. The legislation overhauls VA and Department of Defense prescription practices and sets up national and regional opiate prescription watchdogs and requires follow-up oversight investigations from the Government Accountability Office.
Also in December, a new VA whistleblower protection law received unanimous support from the Senate Committee on Homeland Security and Governmental Affairs. The bill is named for Dr. Chris Kirkpatrick, a whistleblower from the Tomah VA who took his own life after being fired for questioning prescription practices. That legislation seeks to strengthen penalties for retaliating against whistleblowers and ensure that federal employees have a greater knowledge of whistleblower protections.
“We are doing everything we can to make sure these tragedies don’t happen to others,” Sen. Ron Johnson, chairman of the homeland security and governmental affairs committee, said at the congressional field hearing in Tomah. “Without a free press, few, if any, of these problems would ever have seen the light of day.”