Poor care at the Grand Junction VA medical center in Colorado likely “contributed” to the death of Rodger Holmes, a veteran of the Vietnam War, according to an inspector general report.

Holmes had suffered through homelessness and beat it. He also managed to recover from an alcohol addiction, but Hepatitis C is what ended up wreaking havoc on his body in the form of liver disease, The Denver Post reports.

This disease tore through him, and his health spiraled downward. He checked in with the Grand Junction medical center starting in 2014, but the care was so poor that he had to be further hospitalized because the drugs doctors gave him led to liver failure. The specialty care provider suddenly vanished, “leaving not a single note in Roger’s chart assessing or treating his liver disease,” Chris Blumenstein, a social worker at Grand Junction, told Congress in 2015.

He died in December 2014. An inspector general report is only now beginning to bring his case to light, following a request from legislators in Colorado.

The report didn’t outright say the VA killed him, mostly because his final hospitalization was declared “timely.”

“We substantiated the allegation that followup care was inadequate and led to further hospitalization,” the inspector general report noted. “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 hospital had reduced the available hours of a hepatitis C specialist.

Unsurprisingly, Marc Magill, the medical center director at Grand Junction, said the report was wrong and claimed the hospital provided the veteran with proper care.

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

But Magill agreed with the IG’s recommendation to increase hours for specialty care at the facility.

So controversial was the VA’s treatment of Holmes that Blumenstein quit in protest. While Magill downplayed inspector general findings, Blumenstein said the report didn’t go far enough and is appealing the findings. According to Blumenstein, the report stated that Holmes was fully recovered in September 2014, but in reality, he was still incredibly sick.

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