A combat veteran, who killed himself at a gun range in 2014, had waited for 16 months to hear from the VA that he would receive no disability pay even after serving multiple tours in Iraq and Afghanistan and being diagnosed with a brain injury. How could this happen?
An internal investigation was launched by the Department of Veterans Affairs to find out that very question. And the results of that investigation pointed the finger directly at the VA for botching former Camp Pendleton Marine Jeremy Sears' care.
The investigation came as his family, friends and veterans advocates questioned how the VA handled his case. Now according to their own internal investigation, the Department of Veterans Affairs determined that the VA's medical and benefits divisions let Jeremy Sears fall through the cracks while they could have done more to save his life.
The VA has been under fire almost continually in recent years. The microscope was focused on the Department of Veterans Affairs when it was first revealed that there was a national claims backlog followed by whistleblowers exposing that administrators concealed long waits for medical care, mainly to pocket performance bonuses.
In Sears' case, the VA's own inspector general was asked to investigate after Democratic Sen. Dianne Feinstein of California and her office learned of the suicide from coverage in The San Diego Union-Tribune.
The internal investigation revealed that San Diego VA doctors continued to prescribe a narcotic painkiller -- hydrocodone, commonly known as Vicodin -- to the former Marine for 22 months without any oversight. They did this even though studies warn that chronic pain elevates risk of suicide attempts, and high suicide risk makes use of hydrocodone less appropriate.
The VA also failed Sears by never giving him a suicide assessment. The VA's very own guidelines says a veteran must be given a suicide assessment when starting pain therapy and during regular installments afterward.
On top of those failings, VA physicians never gave the veteran a follow-up plan for the treatment of TBI (traumatic brain injury). This was vital to Jeremy Sears' care as research shows a link between TBI and suicide.
Rep. Jeff Miller, R-Fla., chairman of the House Committee on Veterans' Affairs, said the investigation shows the VA "putting expediency before excellence" despite the lessons of the past.
"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?"
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