Chairman Johnson Releases 359-Page Report Detailing Committee Investigation Into The Tomah VA Tragedies

TOMAH, WIS. —Sen. Ron Johnson, chairman of the Senate Homeland Security and Governmental Affairs Committee released a 359-page report on Tuesday, detailing the tragedies at the Veterans Affairs Medical Center in Tomah, Wis. (Tomah VAMC). Chairman Johnson had this to say following the release of the report:

“Today, my committee is releasing its 359-page report that details the systemic failures of the Department of Veterans Affairs and VA Office of Inspector General to identify and stop the mistreatment of veterans and retaliation against whistleblowers at the Tomah VAMC.  The report presents the findings of the committee’s extensive 16 month long investigation into how the problems that plagued the Tomah VAMC were allowed to fester for so long, thereby resulting in multiple tragedies.

“The lack of transparency and not having an independent watchdog over the facility are the primary culprits.  Now that appropriate oversight and publicity have occurred, those responsible for these tragedies have been held accountable.  They no longer work for the VA, and can do no further harm to veterans. I look forward to working with VA officials and the new VA inspector general that I was proud to help confirm to enact necessary reforms to prevent tragedies like what occurred at the Tomah from ever happening again.  The finest among us – our veterans – deserve no less.”

The committee report states, “The over-prescription, retaliation, veterans’ deaths, and abuse of authority at the Tomah VAMC did not occur in a vacuum.  Veterans, employees, and whistleblowers tried for years to get someone to address the problems.  Along the way, since at least 2004, there were several opportunities when federal agencies could have investigated further or taken direct action.  At each step, however, these opportunities were missed.  The tragedies that occurred at the Tomah VAMC were preventable and were the result of systemic executive branch failures.

“The Tomah VAMC is a microcosm of both the VA’s cultural problems with respect to whistleblower retaliation and the VA OIG’s disregard for whistleblowers.  Former employees of the Tomah VAMC—Dr. Christopher Kirkpatrick and Dr. Noelle Johnson—were fired from the facility after they raised concerns about mismanagement at the facility.  In addition, they faced attacks from the VA OIG when the OIG issued a ‘white paper’ defending its investigation of the Tomah VAMC and disparaging the whistleblowers who took the courageous step to speak out.”

The majority staff highlighted 14 findings in the report. The findings include:

  • From at least 2007 to 2015, serious problems of over-prescription and abuse of authority existed at the Tomah VAMC, resulting in at least two veterans’ deaths and the suicide of a staff psychologist.
    • o Kraig Farrington (p. 6)
    • o Jason Simcakoski (p. 45, 293)
    • o Dr. Chris Kirkpatrick (pp. 124, 297)
  • The allegations of over-prescription at the Tomah VAMC were known to law enforcement and executive branch agencies since at least 2009, as were the monikers “Candy Land”—referring to the facility—and the “Candy Man”—referring to the facility’s chief of staff, Dr. David Houlihan. (pp. 22, 29).
  • Employees at the Tomah VAMC referred to Dr. Houlihan as the “Candy Man” since at least 2004. (p. 24)
  • Despite receiving various complaints over the course of several years, federal law-enforcement agencies and other executive branch entities failed to identify or address the root causes.  For example:
    • VA consultants and peer reviews in connection with the 2007 death of a Tomah VAMC patient showed concerns about prescription practices at the facility. (pp. 10, 17)
    • The VA headquarters identified higher-than-average prescription rates at the Tomah VAMC in 2013. (p. 43)
    • The VA OIG received information about deficient patient care and abuse of authority in 2009 from the Tomah VAMC employees union and apparently ignored the complaints. (p. 22)
    • The VA OIG received anonymous complaints about over-prescription in March 2011, referred the matter to the VA’s regional office, and closed the case. (p. 62)
    • The VA OIG received a similar complaint about over-prescription in August 2011, initiated a health care inspection, and ultimately closed the case in 2014 with a non-public report. (pp. 79, 183)
    • The VA OIG received a complaint in March 2012 during its inspection—”HOUSTON, WE NEED SOME HELP DOWN HERE.” (p. 105)
    • The VA OIG surveilled Dr. Houlihan and subpoenaed a car dealership in 2012 in connection to Tomah VAMC allegations. (p. 137, 140)
    • The Drug Enforcement Administration inquired about potential drug diversion relating to the Tomah VAMC in 2009, 2012, and 2015, but the DEA will not discuss the results of its investigations. (p. 336)
    • Less than a year before he died, Jason Simcakoski reached out to multiple local and federal law-enforcement agencies, including the Federal Bureau of Investigation, about drug diversion at the Tomah VAMC.  In contemporaneous Facebook and text messages, Mr. Simcakoski claimed he was in contact with the FBI.  The FBI denies having a record of its contacts with Mr. Simcakoski. (p. 45)
  • A culture of fear and whistleblower retaliation at the Tomah VAMC allowed over-prescription and other abuses to continue unaddressed.  The belief among Tomah VAMC staff that they could not report wrongdoing compromised patient care. (p. 295)
  • The VA OIG’s Office of Healthcare Inspections lacks clear standards for substantiating allegations it receives.  The lack of clear standards leads to the potentially arbitrary and subjective treatment of health care inspections. (p. 195)
  • The VA OIG inspection team originally intended to publish the findings of its multi-year inspection in a public report before OIG leadership decided to administratively close the inspection without a public report.  The failure to publish the results of the Tomah VAMC inspection compromised veteran care at the facility. (p. 250)
  • The VA OIG narrowly focused its inspection of the Tomah VAMC on just the allegations it received and did not fully probe other related issues it observed during the inspection, including the interaction of opioids with other medication, and the potential impairment of Dr. Houlihan during an interview with OIG staff. (p. 208)
  • The VA OIG ignored findings of independent pharmacy consultants retained to evaluate prescription practices at the Tomah VAMC, including findings that the facility could be in danger of losing its controlled substance license. (p. 244)
  • The VA OIG, under acting leadership of Deputy Inspector General Richard Griffin, lacked independence and transparency.  The VA OIG dismissed concerns about whistleblower retaliation at the Tomah VAMC and its non-public administrative closure prevented the Tomah community from fully knowing the concerns about the facility. (p. 334)
  • There is uncertainty about the date on which the VA OIG completed its Tomah VAMC health care inspection.  The administrative closure notes a handwritten date that appears to be March 2014, but internal OIG case tracking documents show an August 2014 date. (p. 268)
  • The reporting structure of the Tomah VAMC pharmacy department to the facility’s chief of staff led to conflicts of interests that discouraged pharmacists from reporting concerns about Dr. Houlihan’s prescription practices. (pp. 41, 229)
  • In      addition to managing a large patient case load, Dr. Houlihan served for a      time as the facility’s acting director or chief of staff, creating a      potential conflict between his administrative duties and his care of      veterans at the Tomah VAMC.
  • Dr.      Houlihan was the facility’s acting director or chief of staff while still      seeing patients, creating a conflict of interest with respect to the Tomah      VA police’s inquiries into potential drug diversion at the facility. (p.      53)

A copy of the report can be found HERE.

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