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VA watchdog under fire for failings over mental health unit scandal

An inspector general’s office continues to withhold valuable information requested by a U.S Senate committee investigating a drug and whistleblower scandal at a veterans’ mental health unit in Wisconsin, a report published Tuesday claims.

The report, by the Homeland Security and Governmental Affairs Committee, was published just ahead of a Senate hearing that focused on the alleged failings of the Veteran Affairs’ Inspector General’s office in connection with the Tomah VA Medical Center.

It follows revelations of rampant over-prescription  of drugs at the center, and how whistleblowers faced retaliation amid a “culture of fear.”

The report is highly critical of the office of inspector general (OIG), accusing it of being more interested in protecting the VA than investigating “systematic failures” at the center.

Further, the investigation, led by committee chair Sen. Ron Johnson, “has been hampered by the VA OIG’s obstruction.”

“The VA OIG continues to withhold valuable information and has heavily redacted some material produced to the chairman,” the report concludes.

Sen. Johnson said the report is the result of a 16-month investigation into how the problems that plagued the Tomah center “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,” Sen. Johnson, a Wisconsin Republican, said in a statement.

Tom Devine, of the Government Accountability Project, a whistleblower watchdog, said problems still persist with the VA, which he said accounts for 35-40 percent of all retaliation complaints across the entire federal government.

“Suppression of challenges to patient care is a deeply ingrained tradition within the VA,” said Devine.

But he said the scandal at Tomah, and others, means there is a greater chance for change than at any time in the past. Bills aimed at protecting whistleblowers specifically within the VA have been introduced in the Senate and the House.

The investigation into Tomah, a short-stay mental health facility in western Wisconsin, began in January 2015, following a news report that centered on the death of patient, Jason Simcakoski.

That report, by the Center for Investigative Reporting, first revealed publicly that Tomah was known as ‘Candyland’ by veterans.

Chief of staff, Dr. David Houlihan, was dubbed "Dr. Candy". He was known by that name since at least 2004, according to the Senate committee report. Dr. Houlihan was fired in November, 2015.

From at least 2007 to 2015, serious problems of over-prescription and abuse of authority existed at the Tomah facility resulting in at least two veterans’ deaths and the suicide of a staff psychologist, the Senate report concludes.

It continues: “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”...and the “Candy Man” — referring to the facility’s chief of staff, Dr. David Houlihan.”

Simcakoski, a Marine veteran, died in August 2014, from “mixed drug toxicity,” having taken 13 prescribed medications in a 24-hour period.

Two individuals, a psychologist and a nurse, were earlier fired after raising concerns about the over-prescription of drugs, including opioids. Psychologist Dr. Chris Kirkpatrick fatally shot himself shortly after his firing. He complained that some of his patients were too drugged to treat properly.

The report concludes that 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,” the report states.

In his opening statement at the Senate committee hearing Tuesday, Johnson said: “Dating back nearly 10 years, the Tomah VA  has been plagued by allegations of dangerous prescription practices and administrative abuses. For years, actions that should have served as warning signs were ignored and problems at the Tomah VA festered."

In his testimony to the committee, the newly appointed VA Inspector General Michael Missal said: “We need to maintain our independence in all of our work, including avoiding even the mere appearance of any undue outside influence.”

Former acting Inspector General Richard Griffin retired last year, under pressure and criticism for the failings of his office.

The inspector general’s office spent two and a half years investigating allegations of narcotic abuse within the center. The DEA, and the Milwaukee municipal police were also involved.

“We did not find any conclusive evidence affirming criminal activity, gross clinical incompetence or negligence, or administrative practices that were illegal or violated personnel policies,” Missal told the committee Tuesday.

Yet, the Senate report, published by the Republican majority on the committee, found that, “for years, veterans, employees, and others were shouting for help at the Tomah VAMC.

“They were pleading with whoever would listen. The VA OIG inspected, the DEA investigated, the FBI engaged, the VA inquired. Nothing was fixed. Instead, whistleblowers faced retaliation and a 'culture of fear' descended upon the facility.”

The scandal at Tomah has become a political issue in Wisconsin, where Johnson is in a tight race against former Sen. Russ Feingold.

A television advertisement, funded by a Johnson-supporting outside group Freedom Works, claimed Feingold was hand delivered a memo that detailed serious problems within the facility in 2009, when he was still a senator. The advertisement included a direct claim that Feingold was responsible for the deaths of veterans. Three television stations refused to air the advertisement.

A union official, Lin Ellinghuysen, later said the memo she wrote was not hand delivered to Feingold.