Report into lack of care at Grand Junction VA

Rodger Holmes was a Vietnam veteran who until 2013 was in relatively good health and enjoying life. A problem with his liver was incorrectly treated by the VA in Grand Junction over the course of several months and Rodger died December 20th 2014.

Chris Blumenstein, was a social worker at the VA who was assigned to Rodgers case. He resigned in protest of Rodger’s care saying it was indicative of systemic problems at the VA.

Late last year, Sen. Michael Bennet announced that he is asking the VA Office of Inspector General for a full investigation of Rodger’s care at the Grand Junction VA Medical Center. Today, the Remembering Veteran Rodger Holmes campaign releases a 14-page report analyzing Rodger’s uncoordinated and chaotic care at the Grand Junction VA Medical Center.

The report was written by Dr. Joanne C. Imperial, a nationally prominent liver-disease expert and Fellow of the American Association for the Study of Liver Diseases who not only holds teaching positions at Stanford University Medical School and the Lucille Packard Children’s Hospital, but also previously headed a statewide program to improve hepatitis and liver-disease treatment in California’s prison system.

She spent several months rigorously analyzing Rodger Holmes’s Grand Junction VA liver care.

The report criticized several aspects of the care:

No Specialty Care: “…there was no specialty liver care given to this patient, no direction in his care, and poor continuity of care…. The analysis of this case demonstrates that no one individual involved in Mr. Holmes’ treatment possessed an in-depth knowledge of chronic liver disease.”

Poor Decisions & Missed Opportunities: “This substandard care is described by a succession of potentially harmful treatment decisions or omissions…. Multiple opportunities existed within each phase of Mr. Holmes’ healthcare to alter his clinical course. Unfortunately, those opportunities were missed, and these missed opportunities more likely than not resulted in the unfortunate outcome in the case.”

Unsupported Front-line Providers: “…numerous providers at Grand Junction VA made strong efforts during the last months of Mr. Holmes’ life to provide him with adequate care. However, there was no specialty care given to this patient….”

Dr. Imperial makes several recommendations for how the VA could improve specialty care, including using electronic medical record systems and adopting of a Project ECHO model to more effectively leverage specialist expertise.