WASHINGTON, May 31 (UPI) -- A Senate committee report into opiate overprescription at a Veterans Affairs hospital in Wisconsin found systemic failures in a VA inspector general's internal investigation.
Wisconsin's Tomah VA Medical Center was the subject of the Senate Homeland Security and Governmental Affairs Committee report.
In the report scheduled for release on Tuesday, the committee said the VA inspector general's office began investigating claims opiates were being overprescribed to patients with post-tramautic stress disorder in 2011 at the Wisconsin hospital, USA Today reported.
The inspector general's internal investigation into the claims of overprescription was "perhaps the greatest failure to identify and prevent the tragedies at the Tomah VAMC," the report says. The committee slams the inspector general's office for abandoning key evidence, for contracting its investigation and for failing to make its findings public.
The inspector general's investigation lasted until 2014. The agency failed to determine whether the allegedly overprescribed opiates were being prescribed in a dangerous combination with other drugs, the report said, adding the agency also failed to determine whether employees felt threatened with retaliation if they raised concerns related to the overprescription claims.
The Wisconsin VA hospital's chief of staff, Dr. David Houlihan, and nurse practitioner, Deborah Frasher, were both found to have committed no wrongdoing in the agency's report, despite "potentially serious concerns" being raised about opiate overprescription.
The Senate report also condemned the decision to keep the report secret made by Assistant Inspector General for Healthcare Inspections John Daigh, who told Senate investigators he could not "publish reports that repeat salacious allegations that I can't support."
The agency's report was released to intense scrutiny in 2015. It found that the hospital was one of the highest prescribers of opiates in a multistate region.
At least one person, 35-year-old Marine Corps veteran Jason Simcakoski, died from "mixed drug toxicity" at Tomah in a case related to the overprescription. Simcakoski died five months after the inspector general's case was closed and days after Houlihan approved the use of an additional opiate to treat Simcakoski on top of the 14 drugs Simcakoski was already prescribed.