IG: VA Staff Didn't Cause Vet's Death in Wisconsin

Staff at the Veterans Affairs facility in Tomah, Wis., were not responsible for the death of a 74-year-old vet who suffered a stroke in January, according to a new inspector general report.

“We did not substantiate the general allegations of poor care and delayed care,” the IG report stated. “We concluded that, overall, the UCC [Urgent Care Clinic] 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.”

Thomas Patrick Baer’s family brought him to the Tomah facility on Jan. 12, 2015, for symptoms they at first believed were associated with his bipolar disorder. He checked in at 11:09 a.m., according to records, and suffered his first stroke at approximately 1:25 p.m. Within five minutes, he was transported to a bed, a physician evaluated him for approximately 30 minutes, but the doctor did not diagnose a stroke. Baer then suffered a second stroke at 3:05 p.m., according to the report. Despite missing the first stroke and not ordering a CT scan until after the second one, the IG concluded that the doctor followed procedure and “properly considered broad diagnostic possibilities” for the initial incident.

Baer’s family alleged that the vet had waited three hours to be seen, that other patients came and went while he was waiting, and that VA staff were dismissive of Baer’s signs and symptoms. The IG concluded there was no evidence to support those allegations. But the IG did note that the CT machine was unavailable at the Tomah facility at the time of Baer’s emergency; without a scan, the facility does not administer anticoagulant medication. The watchdog did not, however, conclude that those factors contributed to Baer’s death.

Baer eventually was transported to a larger health center later where he received treatment, and died two days later.

The family of the late Army veteran told the postcrescent.com, that they were “devastated” by the IG’s findings. His daughter called the report “a lie,” according to a June 18 news article. The IG took the unusual step of briefing Baer’s family in person about the results of its investigation.

The watchdog recommended, in part, that the VA review its acute stroke policies, ensure patients and their families are educated about the services provided by urgent care clinics, and train employees on assessing and treating stroke patients.

The department also is investigating the death of veteran Jason Simcakoski who overdosed at the Tomah facility because of a toxic drug combination.

An earlier inspector general report looked into allegations of overprescribing and abuses of authority at Tomah. That IG report concluded there was no conclusive evidence of criminal activity or gross clinical incompetence or negligence, but it said the investigation revealed “potentially serious concerns” that should be brought to the attention of upper management. The watchdog on Thursday released a white paper with more information on that investigation because of an April subpoena from Sen. Ron Johnson, R-Wis., to conduct a more extensive probe. The IG reiterated that it could find no evidence of criminal activity, whistleblower retaliation, abuse of power or clinical negligence at the facility.

Sen. Tammy Baldwin, D-Wis., on Tuesday, introduced legislation in honor of Simcakoski that would require stronger guidelines for opioid prescriptions and increased coordination and communications among the VA, providers, patients and their families on treatment.