SAN DIEGO (Tribune News Service) — An internal investigation by the U.S. Veterans Affairs department has found that the San Diego VA system botched its care of former Camp Pendleton Marine Jeremy Sears, who killed himself at an Oceanside gun range in October 2014.
After Sears’ suicide at age 35, his family, friends and some veterans advocates have questioned how the VA handled his case. The combat veteran waited 16 months to hear that he would receive no disability pay after serving multiple tours in Iraq and Afghanistan and being diagnosed with a brain injury.
Critics said the VA's medical and benefits divisions let Sears fall through the cracks and more could have been done to save his life.
The investigation, by the VA’s own inspector general, provides an official measure of confirmation. It’s another black mark against the VA, a sprawling agency that has been under fire in recent years for a massive national claims backlog followed by whistleblowers exposing that administrators concealed long waits for medical care, mainly to pocket performance bonuses.
Sears’ story has attracted attention at the highest levels. Democratic Sen. Dianne Feinstein of California, along with VA Secretary Bob McDonald, requested a review after her office learned of the suicide from coverage in The San Diego Union-Tribune. Her office plans to highlight the report in a public statement today.
The investigation’s conclusions show the VA is “still too often falling short in its mission,” said Rep. Jeff Miller, R-Fla., chairman of the House Committee on Veterans’ Affairs.
The report reveals that San Diego VA doctors continued to prescribe a narcotic painkiller — hydrocodone, commonly known as Vicodin — for 22 months without any oversight, even though studies warn that chronic pain elevates risk of suicide attempts. And, high suicide risk makes use of hydrocodone less appropriate.
During Sears’ use of hydrocodone for knee pain, he didn’t get a suicide risk assessment. VA guidelines call for one to be completed when starting pain therapy and during regular installments afterward.
Also, Sears told VA screeners about being near two roadside bombs when they detonated — and once losing consciousness — but physicians never gave him a follow-up plan for treatment of traumatic brain injury, or TBI.
Research has drawn a link between TBI and suicide.
“If the patient had regular follow-up with his [primary care physician], the provider may have identified signs and symptoms of [post-traumatic stress disorder] and depression, and the need for follow-up of TBI and post-traumatic headaches,” the investigation said.
Additionally, Sears emailed his VA doctor in the months before his death to say he wanted to “wean off” hydrocodone, an opium-based drug that can be habit-forming. According to the investigation, his physician never followed up with him — even though patients on this medication are told not to stop on their own for fear of withdrawal symptoms.
Overall, the VA inspector general’s analysis said the San Diego VA erred in several ways during the nearly two years Sears was under its care. That office issued five recommendations in response to those mistakes, including two designed to have impact at the national level.
Sears’ widow, Tami Sears, said the report feels like vindication of her sense that the VA fumbled her husband’s care.
“I do feel they are admitting it, and I hope in the future they change some of their policies and procedures like they are saying,” said Tami Sears, who returned to the Chicago area after her husband’s suicide.
“I just hope so many more veterans are going to be affected by this in a positive way,” she said.
Jeff Gering, director of the VA’s San Diego health care system while Sears was a patient there, said he had “significant concerns” about the investigation’s conclusions.
He noted, among other points, that Sears canceled seven medical appointments — during which his primary care doctor could have taken the steps indicated in the report.
Last week, a spokeswoman for the La Jolla VA hospital said the staff is “very saddened” by Sears’ death.
In a statement to the Union-Tribune, Cindy Butler also said: “The data, findings and actions resulting from internal investigations are confidential and protected.”
She declined to specify whether any doctors involved in the case have been disciplined. “However, whenever a significant health care event occurs, we conduct a thorough review of systems and processes and take appropriate actions,” Butler said.
Miller, the committee chairman, said the investigation shows the VA “putting expediency before excellence” despite the lessons of the 2014 national wait time scandal that led to the resignation of VA Secretary Eric Shinseki.
“Sadly, this report documents a host of failures, from medical inattention [to] inconsistent continuity of care,” Miller said in a statement to the Union-Tribune. “The question VA leaders must now answer is: Who will be held accountable for these failures?”
Sears served eight years in the Marine Corps infantry, including five combat tours in Iraq and Afghanistan, before being discharged as a sergeant in October 2012.
He almost immediately filed a disability claim for a dozen physical conditions. The VA was wrestling with a national claims backlog at the time. When it did finally respond, the agency acknowledged that Sears had traumatic brain injury, “post-traumatic headaches” and hearing loss. But it said the conditions weren’t disabling enough to merit compensation.
Friends said Sears went into a tailspin afterward.
Finances were tight as he struggled to find and keep a job. His wife said he was hiding emotional trauma that, in the days before his suicide, he started calling “survivor’s guilt.” She suspected he was using the Vicodin to dull his feelings.
The VA inspector general found fault with the compensation screening for Sears as well.
The San Diego VA benefits worker who processed Sears’ claims didn’t gather all of the veteran’s military records before denying him compensation. But the investigation also said the missing information wouldn’t have changed that determination.
No disciplinary action was taken against the worker because the inspector general found that the claim decision was ultimately correct, according to local VA officials.
The report urged the San Diego VA benefits director to review the worker’s record to see if the error happened in other cases. It’s unclear what the outcome was.
In his response to the inspector general, the regional director, Patrick Prieb, said it was “more appropriate” to give extra training to the entire staff. He also appeared to argue that VA guidelines don’t explicitly direct rating specialists to do what the inspector general’s office cited.
In a statement to the Union-Tribune, Prieb said his office “is dedicated to adjudicating veterans’ claims with high quality and in a timely fashion.”
Other recommendations from the investigation:
National impact: Doctors who examine veterans for disability ratings should document that they counseled patients on the need for follow-up care when making new diagnoses.
National impact: The VA should make sure all relevant communications are documented in a patient’s electronic medical record. Sears emailed his doctor monthly to ask for pain medication refills, but only one of those requests was archived in his record.
Local impact: The San Diego health care director should create a process to ensure that physicians follow the VA guideline on using opium-based drugs for chronic pain. The guideline calls for a doctor’s evaluation at least every six months. Sears got 22 months of hydrocodone refills without a face-to-face visit with his physician.
Last week, Feinstein called Sears’ story “deeply troubling” and a “powerful reminder” of the care doctors must take in prescribing opium-based medications.
In a letter to McDonald, she also said, “I recognize the department has taken important steps to improve its oversight of opioids and coordination of mental health care and that it has responded positively to the recommendations made by the deputy inspector general.”
Feinstein suggested additional steps for California’s VA medical centers. One is to create an automated computer alert when patients request opium-based drug refills without the related, broader check-ups.
The senator acknowledged that providing mental health care to veterans can be tricky. Like Sears, vets commonly dodge scrutiny by canceling appointments or avoid the topic entirely by remaining mum about their symptoms.
“One of the challenges of diagnosing and treating veterans who are at risk of suicide is that illnesses like PTSD and depression can impair the ability of veterans to actively seek medical care,” she wrote. “I realize that clinicians have limits to how much they can do to ensure patients make and keep appointments, but I believe we owe it to our veterans to continually figure out how to do more.”
Bill Rider, co-founder of American Combat Veterans of War in Oceanside, was one of the first people to voice concerns about Sears’ case after his suicide. He called the inspector general’s report a good step.
“I think [VA health care providers] are all overworked,” said Rider, a Vietnam War veteran. “And at some point if a warrior doesn’t show complete obeyance and doesn’t take care of what he’s got to do, they give up on him.”
It’s not uncommon for the VA to scrutinize individual cases, though observers said the inspector general’s office has become more aggressive with investigations since the 2014 wait time scandal. The inspector general looked into 62 health care complaints in the 2015 fiscal year, it said in a report to Congress.
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