A new Veterans Affairs Inspector General report faults the Veterans Affairs San Diego Healthcare System for failing to care for a patient with traumatic brain injury and post-traumatic stress disorder before he took his own life on a California gun range in October 2014.

According to a VA Office of Inspector General report released Jan. 5, the VA doctors treating former Marine Sgt. Jeremy Sears did not follow department guidelines for prescribing opioid medications and ignored his request to discontinue using the painkillers.

The IG also found that VA concluded Sears' benefits ratings review prematurely and, when he was determined to have PTSD and TBI, did not follow up on care.

Sen. Diane Feinstein, D-Calif., requested the VA investigation after learning that Sears, a former sergeant and Iraq and Afghanistan veteran, died by suicide after waiting 16 months to hear from the VA about his disability claim.

When the disability claim response arrived in his mailbox, he learned he did not rate compensation.

"These tragedies are unacceptable," Feinstein said after Sears' death. "It is our moral duty to ensure that the men and women who bravely serve our country have access to the mental health care needed to address serious mental health conditions like depression and post-traumatic stress disorder."

The investigation found that while the San Diego VA benefits office decided the claim without having certain relevant treatment records, it did not find that the office's conclusion was incorrect.

The investigation also found that:

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Sears was prescribed hydrocodone but didn’t see a doctor for nearly 22 months while he took the medication;

His medication levels were not monitored by urine screening, as recommended in the Defense Department/Veterans Affairs Clinical Practice Guideline for Management of Opioid and Chronic Pain, and;

He never received a follow-up plan for managing TBI and PTS after he was diagnosed during his disability exam.

The report comes after several others that found VA facilities negligent in caring for veterans or following up on patients under their care.

In August, the VA inspector general found that the staff at the VA medical center in Tomah, Wisconsin, failed to properly prescribe medications and blundered the medical response when the veteran was found unresponsive.

Officials at the San Diego Medical Center said they largely concurred with the IG's recommendations and have taken steps to improve outreach and care at the facility.

But in a written response to the report, Jeff Gering, director of the VA San Diego Healthcare System, called Sears' death a tragedy but said he had "significant concerns" with the report's methodology and conclusions.

He called the VA and DoD guidelines for opioid prescribing and pain management "guidance" and not "requirements" and noted that the patient rescheduled numerous appointments.

The investigation had found that Sears and his physicians corresponded by email and the veteran missed numerous appointments and did not follow through on recommended treatments, such as physical therapy for a knee injury.

Gering added that disability evaluations are not intended to diagnose new conditions and called it "inappropriate" to characterize the compensation and pension assessments as a "diagnosis of TBI."

House Veterans' Affairs Committee chairman Rep. Jeff Miller, R-Fla., said the report demonstrates that VA continues to "fall short in its mission to provide the best quality care" for veterans.

"Sadly, this report documents a host of failures from medical inattention and inconsistent continuity of care to putting expediency before excellence," Miller said.