Did watchdog turn blind eye as Wisconsin VA hospital dissolved into 'Candy Land'?

The US Department of Veterans Affairs has been dogged by scandal in recent years, but this incident suggests that the VA's troubles may be more deeply rooted than bureaucratic red tape and funding woes.

First Look

Accusations of poor care and frequent over-prescription of opioid painkillers once earned the Veteran Affairs Medical Center in Tomah, Wis., the nickname “Candy Land.”

Now, a US Senate investigation has revealed that a VA inspector general’s review of the facility discounted evidence and witness testimony, while the agency’s internal watchdog also declined to make its investigation report public. 

The report is the latest blow to the embattled Department of Veterans Affairs that has been dogged by a myriad of scandals in recent years, including veterans dying while waiting for care. The Tomah scandal suggests that the VA's problems are not merely administrative, but may actually involve a level of willful neglect.

In 2014, investigators at the VA found doctors were frequently over-prescribing painkillers, with some veterans nicknaming former chief of staff David Houlihan “candy man” as a result. The deaths of three people under care at the facility also remain under investigation.

But the investigation by the Senate Committee on Homeland Security and Governmental Affairs, due for release Tuesday ahead of a hearing, found that the inspector general, which is tasked with keeping an eye on VA facilities, did nothing to identify wrongdoing at the facility.

“Perhaps the greatest failure to identify and prevent the tragedies at the Tomah VAMC was the VA Office of Inspector General’s two-year health care inspection of the facility,” the report notes, according to an advance copy obtained by USA Today.

Following news reports of the death of Jason Simcakoski, who died of “mixed drug toxicity” after having taken 13 medications prescribed by the hospital in a 24-hour period, the VA launched another investigation, finding doctors at the facility had failed to properly advise Mr. Simcakoski of the risks of taking the drugs. They also bungled the immediate emergency response after discovering him unresponsive in his bed in August 2014, the VA’s report found last year.

The controversy over conditions at Tomah and the inspector general’s inaction has also become a political battle between a current and a former Wisconsin senator locked in an election contest.

Tuesday’s hearing, scheduled for 10 a.m., Central time, at the Cranberry County Lodge in Tomah, is expected to feature testimony from VA Deputy Secretary Sloan Gibson and new Inspector General Michael Missal.

The replacement of the watchdog came amid other critiques of the office’s investigations in other states, including Illinois, Louisiana, and Texas, USA Today reports.

While Mr. Missal has promised greater transparency, the investigator who led the Tomah inquiry and decided to keep it secret, Dr. John Daigh, is remaining in his current role, the paper reports.

Johnson said the IG’s delay in making its findings public were part of a larger pattern. “The reasons the problems were allowed to fester for so many years is because in the inspector general's office, for whatever reason, for years, the inspector general lacked the independence and had lost the sense of what its true mission was, which is being the transparent watchdog of VA system,” he told USA Today.

This report contains material from the Associated Press.