Office of Inspector General report on Grand Junction VA Hospital

Rodger Holmes, a Vietnam Veteran, died December 20th, 2014 after a problem with his liver was incorrectly treated by the VA in Grand Junction over the course of several months.  Chris Blumenstein was Roger’s social worker at the VA hospital in Grand Junction.  He resigned in protest of Rodger’s care saying it was systemic of larger problems at the VA.

Just before Roger’s death in 2014, Sen. Michael Bennet announced that he had asked the VA Office of Inspector General for a full investigation of Rodger’s care at the Grand Junction VA Medical Center. That report has just been released and Chris Blumenstein says that it reinforces much of what he has said about Roger’s care.

“First and foremost it substantiates the allegation that Roger’s hepatitis C care was unsafe, uncoordinated and chaotic. So that’s extremely gratifying that there were problems both at the systemic level, and also deficiencies with the actual hepatitis C doctor that was providing the care.”

The report however falls short in directly assigning blame on the VA for Roger’s death. Blumenstein says this is part of a pattern of investigation of VA shortcomings. “It’s definitely a glass is half empty, glass is half full investigation.  The empty half of the glass unfortunately is that like a lot of these OIG investigations that have been criticized nationally…it documents all of these problems with care but it distances itself from the result of those problems.  So unfortunately the investigation into Roger’s care erroneously states that he recovered in the Fall of 2014 and that his deficient episode of care was unrelated to his death only a couple of months later.  As our independent expert report documents, that’s just patently untrue.”