A Veterans Affairs Department investigation into the death of a former Marine at the Tomah, Wisconsin, VA Medical Center found the staff failed to properly prescribe medications and blundered the medical response when the veteran was found unresponsive in his bed.

Jason Simcakoski died Aug. 30, 2014, in the hospital's short-stay mental health unit from "mixed drug toxicity," having taken 13 prescribed medications, including several that cause respiratory depression, in a 24-hour period.

According to a VA Inspector General report released Aug. 6, staff psychiatrists had added new medications to Simcakoski's lengthy list of prescriptions in the days preceding his death.

Several of the drugs, including quetiapine, tramadol and others, are known to cause sedation, and one of Simcakoski's new medications, Suboxone, also can contribute to the problem.

According to the report, the prescribing doctors told investigators that Simcakoski had privileges to leave the hospital for a few hours at a time and he probably "obtained additional quantities of his prescription medications on his own and ingested them," and thus may have been responsible for his own death.

But investigators found that nearly all the drugs found in the veteran's system could cause sedation and the patient's record "confirmed that all these drugs were prescribed by providers at the facility."

The doctors also failed to advise Simcakoski or his family members of the risks of taking the new prescriptions or the recommendation they be used off-label to treat symptoms such as anxiety, pain and migraine headache, according to the report.

The report also found that hospital staff were woefully inept in treating the former corporal when he was found unresponsive. First, they failed to determine whether he had a heartbeat, failed to immediately initiate lifesaving measures, did not employ a portable defibrillator and did not have medications on hand that may have countered an accidental overdose.

"Furthermore, we learned unit staff stopped CPR when facility firefighters arrived [expecting they] would take over the CPR efforts … however, firefighters at the facility are not designated as first-line staff to provide hands on emergency care," the investigators wrote.

The Tomah VA has been under scrutiny since the release in January of a report by the Center for Investigative Reporting that found the medical center had a 14-fold increase in the number of prescribed oxycodone pills from 2004 to 2012, from 50,000 to 712,000.

Veterans at the hospital told a reporter that distribution was so rampant, they nicknamed the place "Candy Land," and said Simcakoski's death served as an example of overzealous prescribing practices.

As part of the response to the report, Sen. Tammy Baldwin, D-Wis., introduced legislation that would require VA and the Defense Department to update clinical guidance on prescribing opioids, mandate training for all VA for doctors who prescribe opioid painkillers and create pain management boards that would oversee prescribing compliance.

The VA report confirms that VA physicians failed to keep their promise to care for Simcakoski, Baldwin said Aug. 7.

"This report highlights the need for the reforms we have proposed to 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," she said.

Tomah VA officials said they are committed to learning from the case and improving care. According to public affairs officer Matthew Gowan, the facility is following the IG's recommendations.

One physician in the case is no longer working at Tomah, while another referenced in the report is facing administrative procedures. Leadership also is working to fulfill the remaining recommendations, he said.

The tragedy has been difficult for the Simcakoski family, including Jason's parents, Marvin and Linda Simcakoski, his wife, Heather, and daughter Anaya.

They have testified before Congress on the issue of pain medication practices at VA and stood with Baldwin to support her bill.

Marvin Simcakoski said Wednesday that the inspector general report has helped "ease the pain ... since the VA admitted to wrongdoing."

He added that he has seen changes at the Tomah VA but would like Baldwin's bill to become law to protect more veterans.

"It wouldn't bring him back, but sometimes it takes something bad to happen for something good to come out of it," Marvin Simcakoski said. "He'd be proud to know that his death helped other veterans."