Tomah probe finds no wrongdoing in death

WASHINGTON — An investigation by the chief watchdog at the Department of Veterans Affairs found practitioners acted appropriately when treating a 74-year-old veteran who died after treatment at the VA Medical Center in Tomah.

The inspector general concluded a doctor failed to diagnose Thomas Patrick Baer's stroke as he waited to be seen in the urgent care clinic at the medical center, "however, the physician properly considered broad diagnostic possibilities," the IG report says.

His family took Baer, who was from Marshfield, to the clinic Jan. 12 and waited with him for more than two hours to be seen by a doctor. He suffered two strokes and was not given anti-clotting medication or a CT scan because the center's scanner was down.

MORE:Full coverage of the Tomah VA scandal

"We concluded that, overall, the UCC staff acted appropriately in the face of a patient experiencing a sudden and unexpected acute ischemic stroke while waiting for a mental health evaluation in a rural hospital that is not equipped to treat a health problem of this magnitude," said the report, which was released Thursday.

VA providers transferred Baer to a hospital an hour away in La Crosse, where they performed surgery, but he never regained consciousness and family members removed life support a few days later.

Baer's widow and daughter said they were devastated by the findings. Representatives from the inspector general's office visited the Baer home in Marshfield to share the results.

"We basically threw them out," Baer's widow, Suzette, said in an interview afterward. "Watch your husband die for three days and then tell me nobody's at fault."

His daughter, Candace Baer Delis, described the result as "a lie."

"I would call it the VA investigating itself," she said. "Of course they're not going to find anything wrong. That would be just akin to giving yourself an employee review. Of course you're going to say that you're wonderful and there's no problems."

The investigation is one of several into deaths at the Tomah facility. The VA, the Drug Enforcement Administration and state officials have also been looking into operations and care in Tomah since news reports revealed in January that 35-year-old Marine Corps veteran Jason Simcakoski,who was from Stevens Point, died from mixed drug toxicity as an inpatient last August.

Simcakoski's family is still waiting for information from the investigations into his death, which happened just days after doctors agreed to add another opiate to the 14 drugs he was already prescribed. A preliminary probe earlier this year by the VA found prescribers in Tomah were doling out opiates at a significantly higher rate than the national average and in dangerous combinations with other drugs. The VA also found a "culture of fear" at the facility that compromised veteran care.

VA officials reassigned the hospital's administrator and chief of staff but is still investigating care at the facility that could spur further discipline.

The VA inspector general's office said earlier this week it is still looking into Simcakoski's death. The IG had previously conducted an investigation of opiate prescribing practices and mismanagement in Tomah and found the rates of opiate prescriptions "highly concerning" but did not substantiate they were improper and failed to release the report publicly when it was completed last March — five months before Simcakoski died.

Baer's daughter said Thursday interim Inspector General Richard Griffin and Assistant Inspector General for Health Care Inspections Dr. John Daigh, whose staff conducted the probe, should be held accountable.

"They should be fired," she said. "People are dead because of them."

"Not only do I grieve for my family, but I grieve for the Simcakoskis because this is what they're facing, too," she said.

Catherine Gromek, a spokeswoman for Griffin, called Baer's accusations "outrageous" and said the investigation of her father's death was "meticulous." She issued a statement from the IG's office saying investigators reviewed medical charts and physician credentials and conducted on-site interviews.

"All of our findings and conclusions are fully supported by testimonial and documentary evidence generated by these interviews and reviews, and based on the analysis and expert judgment of OIG board certified physicians," the statement said.

The inspector general's office also released a report Thursday defending the earlier probe that found concerning opiate prescription rates but no wrongdoing.

The IG spent 2-1/2 years looking into allegations that Tomah providers prescribed excessive amounts of opiates to veterans, that employees who raised concerns were retaliated against or scared into silence and that veterans were given more opiates even when they tested negative for their use, a sign they may have been selling the pills rather than taking them.

The report Thursday said the inspector general could not substantiate a majority of the allegations based on the evidence and testimony they received at the time.

Sen. Ron Johnson, R-Oshkosh, chairman of the Senate Homeland Security and Governmental Affairs Committee, has been reviewing the inspector general's earlier opiate investigation, and Griffin issued the report defending his findings in response to that probe.

Johnson said Thursday he believes both the opiate investigation and the Baer investigation were inadequate. He said the Baer results were "hauntingly similar" to the earlier opiate probe.

"What are the standards for substantiation? What does it take?" Johnson said. "Or is this just somebody (who) creates his own standards, and if that's the case, that's way too loose a standard, because if you don't want to hold anybody accountable, it's pretty easy to just write, 'couldn't substantiate that charge.' I've got a great deal of concerns with this inspector general."

Gromek, Griffin's spokeswoman, said his office follows the same standards used by other inspectors general and the determinations are made by medical professionals.

"While Senator Johnson is entitled to his personal opinion, he is not a medical expert and has not identified any facts or medical literature to refute our findings and conclusions," she said.

Contact dslack@usatoday.com. Follow @donovanslack.