A well-known veteran in Grand Junction received inadequate treatment at the local Department of Veterans Affairs hospital before he died, the agency's inspector general found.
Vietnam War veteran Rodger Holmes had survived homelessness, recovered from alcohol addiction and volunteered as a Salvation Army van driver.
But he suffered from liver disease, and his health deteriorated rapidly despite numerous visits to the Grand Junction VA medical center in 2014. He died that December.
Three Colorado members of Congress, Sens. Michael Bennet and Cory Gardner and Rep. Scott Tipton, requested an investigation of the hospital's treatment of Holmes.
"We substantiated the allegation that followup care was inadequate and led to further hospitalization," says the inspector general's report released this week. "The hepatitis C care provider often did not provide the care or assess the patient thoroughly when seen. The circumstances of discontinuity of care and the lack of a thorough analysis of the patient's condition may have contributed to his progressive decline and slower recovery."
The report stopped short of concluding that VA treatment killed Holmes, however, by finding that his final hospital admission was timely.
One contributing factor to Holmes' treatment was a decision by the hospital's hepatitis specialist to reduce his hours. The inspector general report recommended that the hospital ensure "contingency plans for specialities" when too few specialists are available.