Letter to Attorney General Holder - Calling For Criminal Investigation into Tomah VA

Letter

Dear Attorney General Holder:

I am writing to request that the U.S. Department of Justice (DOJ) launch an immediate investigation into allegations of criminal wrongdoing at the Tomah Veterans Affairs Medical Center in Tomah, Wisconsin. I am extremely troubled about reports linking the tragic deaths of three Wisconsin veterans to improper medical care at the facility. Additionally, I have heard concerns regarding the conduct of the Tomah VA and the Tomah VA Police Department in response to the deaths that occurred at the facility. Finally, concerns regarding the illegal distribution and use of prescription drugs that originated at the Tomah VA facility have been raised. The U.S. Department of Veterans Affairs (VA) and its Office of Inspector General (OIG) are currently investigating a number of issues related to the Tomah VA, but I believe the seriousness of the allegations warrant an additional external and objective review by a law enforcement agency totally independent from the Department of Veterans Affairs. Accordingly, I request that you investigate both the circumstances surrounding patient deaths and allegations of the illicit distribution of opioids that originated at the Tomah VA facility.

At least three veterans--Jason Simcakoski, Thomas Patrick Baer and Jacob Ward--who were treated at the Tomah VA have tragically lost their lives. Regarding these three veterans, below is information surrounding their tragic deaths.

Thomas P. Baer, 74, of Marshfield, Wisconsin, passed away in January at Gundersen Hospital in LaCrosse, Wisconsin. Prior to his arrival at Gundersen, Mr. Baer experienced very troubling treatment at the Tomah VA, including excessive wait times, broken medical equipment that was required for his treatment, and inadequate adherence to standard medical protocols.
Jason L. Simcakoski, 35, of Stevens Point, Wisconsin, passed away on August 30, 2014, at the Tomah VA. According to reports, Mr. Simcakoski, a former Marine, checked himself into the Tomah facility citing an addiction to opioid painkillers and severe anxiety. At the time of his death from "mixed drug toxicity," he reportedly was on 15 different prescription drugs, including anti-psychotics, tranquilizers, muscle relaxants, and opioid painkillers.
Jacob M. Ward, 27, of Milwaukee and formerly of Coon Valley, Wisconsin, passed away on September 4, 2013, at his home in Milwaukee. The Army veteran reportedly became addicted to opioid painkillers and other drugs after treatment for PTSD at the Tomah VA.
I would request that you conduct a full investigation of these three tragedies. In addition, I'm concerned about the treatment of other patients who may have died after receiving care at this facility. Therefore, I would encourage your review to not only include the three cases mentioned above, but also include any Tomah VA patient who died after receiving treatment at the facility. The investigation should include a review of both the administration of care and subsequent internal investigations.

Regarding the administration of care, please investigate, at a minimum, the following:

The circumstances surrounding the deaths
The medical treatment these patients received at the Tomah VA
The Tomah VA's protocol for treating patients
Inappropriate opioid prescribing practices
Whistleblower retaliation
Illegal access of confidential medical records
Failure to maintain medical equipment
Failure to comply with appropriate triage and medical treatment protocols
Regarding the internal investigations and conduct following the deaths, I would ask that you investigate, at a minimum, the following:

The investigations conducted by any entity and specifically:
The Tomah VA's leadership
The Tomah VA Police Department
The handling of internal facility and law enforcement records
The accuracy and completeness of death investigation records and the preservation of evidence
In addition, concerns have been raised regarding drug diversion from the facility and the role this has played in illegal drug distribution and use in the area. Therefore, I would ask that you investigate the illegal distribution and use of drugs associated with the Tomah VA facility and the local Tomah area.

A broad and detailed investigation of the Tomah VA will provide much needed accountability and information that will help us improve the delivery of timely and highest-quality care to veterans in Wisconsin and throughout the country. To achieve that goal, and in light of the severity of the allegations, I believe the law enforcement authorities, investigative expertise, and independence of the U.S. Department of Justice are required.

Sincerely,

Tammy Baldwin

United States Senator

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