Substandard care at the Department of Veteran Affairs medical center in Grand Junction contributed to the death of a 64-year-old veteran, according to a liver disease specialist who investigated the case.

Rodger Holmes, a well-known Vietnam veteran in the city, had survived homelessness, recovered from an alcohol addiction and restarted his life. He played drums. He golfed. He volunteered, driving a Salvation Army van.

All that ended in the months after he walked into the Grand Junction VA in April 2014 for treatment of a chronic hepatitis condition. After repeated visits, a two-month stay in the center’s nursing home and a scheduled seven-month wait for his next liver appointment, he died in December, according to a report released Monday.

Dr. Joanne Imperial, a liver disease specialist, concluded that Holmes’ hospital treatment “falls below the standard of care for a patient with cirrhosis who develops complications resulting in end stage liver disease.”

Multiple opportunities to help Holmes were missed, “and these missed opportunities more likely than not resulted in the unfortunate outcome in the case,” she wrote.

Imperial was hired by Remembering Veteran Rodger Holmes, a group campaigning for accountability concerning his treatment and better VA care.

At the request of U.S. Sen Michael Bennet, a Colorado Democrat, the VA’s Office of Inspector General is also examining Holmes’ case.

Paul Sweeney, a spokesman for the Grand Junction hospital, declined to comment, citing the ongoing investigation. “Until OIG releases their report, I’m not allowed to discuss it,” he said.

Imperial reported that the liver-clinic doctor Holmes saw in April was an internist, not a liver disease specialist.

Holmes was prescribed a triple drug regimen that increased his risk of infection. After taking the drugs for two weeks, he complained of weakness, nausea, light-headedness, fatigue and a near fall.

“An opportunity to intervene early in this case was definitely missed here,” Imperial wrote. “The patient should have been seen by a provider at this time.”

From July to September, Holmes was put in the on-site nursing home instead of being transferred to a center specializing in liver diseases. The sole follow-up appointment to address his liver disease occurred with his primary care provider Oct. 3, and the next appointment was scheduled for April 2015, according to the report.

Holmes returned to the hospital by ambulance Dec. 2, complaining of severe abdominal pain, and died 18 days later from complications of a severe infection and liver disease.

” Rodger was a truly special individual who had truly turned his life around. It is what has made his treatment so heartbreaking,” said Chris Blumenstein, a VA social worker who resigned in protest of Holmes’ care.

“That’s the most painful part to me,” he said. “Anybody can make a mistake. But to deny making a mistake and to continue that denial, especially in light of the rhetoric of improved VA accountability coming out of D.C., is what I find profoundly disturbing. On the ground level, on the front lines, it’s the same old story.”

David Olinger: 303-954-1498, dolinger@denverpost.com or twitter.com/dolingerdp