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.

“If Rodger were with us, he would be thrilled with that change,” said Chris Blumenstein, a social worker who quit the hospital to protest Holmes’ treatment. “When staff is insufficient, there needs to be a plan for that. The clinics can’t just wing it like they did with Rodger.”

Blumenstein challenged the report’s finding that Holmes had recovered when he was sent home in September 2014, saying his friend was a very sick man when he and others launched a Saving Veteran Rodger Holmes campaign that fall.

He plans to appeal on the grounds that the inspector general failed to hold the hospital fully responsible.

The VA’s medical director in Grand Junction, Marc Magill, disputed the finding that Holmes’ treatment was inadequate.

“We believe the review of encounters below supports appropriate clinical care was provided to this veteran,” he responded. “The veteran’s issues were appropriately addressed at each encounter, including medication adjustments, emergency room treatment and IV fluids, and hospitalization when appropriate.”

He concurred, however, with the recommendation to make sure specialty care will be available as needed for veterans in Grand Junction.

Medical center spokesman Paul Sweeney said the hospital has hired a cardiologist and neurologist and is contracting with other specialty care doctors. Hepatitis patients are treated through a telehealth program, he said, but the Western Slope still lacks a liver specialist.

Jenny Davies, one of Holmes’ supporters, recalled helping him start to use e-mail and Facebook in the campaign to save his life.

“He was kind, funny and very humble about the whole thing — while he did want to improve his own health care, his feeling was that he’d already had a nightmare experience and this effort was to improve the care for all the veterans coming after him,” she said. “Little did we know that all that mismanaged care was going to continue and he wouldn’t survive.”

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