VA Settles Overdose Medical Malpractice Death Claim For $2.3M

A federal judge has approved the $2.3 million medical malpractice wrongful death settlement involving the Tomah VA Medical Center in Tomah, Wisconsin. The victim, a Marine Corps veteran, died on August 30, 2014 after he was administered sixteen different opiates in addition to other sedating medications at the Tomah VA Medical Center.


The medical examiner concluded that the patient’s cause of death was mixed drug toxicity. The patient was prescribed medications with potential for respiratory depression, including the additive respiratory depressant effects of buprenorphine and its metabolite norbuprenorphine, along with diazepam and its metabolites, which the medical examiner determined were the plausible mechanism of action for a fatal outcome.

An investigation by the Department of Veterans Affairs Office of Inspector General (“OIG”) determined that when the patient was seen at the VA during 2006–2014, his VA providers prescribed medications to treat his severe and complex mental health issues, which included suicidal ideation and threats of harm to self and others, and the patient frequently adjusted and/or discontinued medications on his own. The patient also reported obtaining oxycodone and other drugs “off the street” and that he was treated for overdoses at non-VA facilities on several occasions.

On July 29, 2014, the patient was evaluated in the Tomah mental health clinic and the following medications were renewed:

Clonidine patch, 0.2 mg/24 hour
Diazepam, 20 milligrams (mg) three times per day
Diphenhydramine, 50 mg at bedtime as needed for allergies or itching
Duloxetine, 60 mg two times per day
Dydroxyzine, 50 mg two times per day as needed for itching
Omeprazole, 20 mg/day
Quetiapine, 50 mg two times per day and 100 mg at bedtime as needed for mood
Temazepam, 30 mg at bedtime
Tramadol, 50 mg four times per day as needed for pain

On August 10, 2014, the patient presented to the Tomah VA Medical Center with suicidal ideation and was admitted to the acute psychiatric unit.

On August 30, 2014, the patient was found unresponsive in his room and cardiopulmonary resuscitation (CPR) was initiated but unsuccessful.

During the last 48 hours of his life, the patient received multiple regularly scheduled and “as needed” medications. The drugs administered from 12:01 a.m. on August 28 until he was found in an unresponsive state at approximately 2:45 p.m. on August 30, are as follows:

August 28, 2014:

4:41 Quetiapine 50mg
7:39 Diazepam 20mg
7:39 Omeprazole 20mg
7:39 Atomoxetine 80mg
7:39 Duloxetine 60mg
7:40 Hydroxyzine 50mg
7:40 Tramadol 50mg
7:44 Nicotine Resin 2mg
11:36 Diazepam 20mg
11:36 Cholecalciferol 1000Unit
11:37 Nicotine Resin 2mg
11:39 Quetiapine 50mg
11:39 Tramadol 50mg
17:16 Nicotine Resin 2mg
17:16 Quetiapine 50mg
19:58 Duloxetine 30mg
19:59 Diphenhydramine 50mg
19:59 Tramadol 50mg
19:59 Quetiapine 100mg
19:59 Temazepam 30mg
19:59 Diazepam 20mg

August 29, 2014:

2:19 Tramadol 50mg
2:19 Quetiapine 50mg
7:06 Omeprazole 20mg
7:06 Diazepam 20mg
7:08 Tramadol 50mg
7:09 Nicotine Resin 2mg
9:03 Duloxetine 60mg
9:50 Suboxone 8mg/2mg
9:52 Atomoxetine 40mg
12:25 Cholecalciferol 1000Unit
12:25 Diazepam 20mg
12:27 Nicotine Resin 2mg
12:29 Tramadol 50mg
12:30 Hydroxyzine 50mg
18:51 Nicotine Resin 2mg
18:55 Hydroxyzine 50mg
18:56 Quetiapine 50mg
20:32 Diazepam 20mg
20:34 Duloxetine 30mg
20:36 Temazepam 30mg
20:36 Suboxone 8mg/2mg
20:41 Tramadol 50mg
20:41 Quetiapine 100mg
22:20 TB Skin Test 0.1 ml (5TU)

August 30, 2014:

0:56 Diphenhydramine 50mg
0:56 Quetiapine 50mg
0:57 Nicotine Resin 2mg
0:58 Tramadol 50mg
7:35 Diazepam 20mg
7:36 Duloxetine 60mg
7:36 Omeprazole 20mg
7:38 Tramadol 50mg
8:09 Suboxone 8mg/2mg
8:59 Fioricet 1 Tablet

The OIG faulted the Tomah VA Medical Center for deficit cardiopulmonary resuscitation efforts including role confusion between unit staff and facility firefighters who responded to the medical emergency as well as delays in initiating cardiopulmonary resuscitation (about ten minutes), calling for medical emergency assistance both within the unit and from facility emergency response staff, and applying defibrillator pads to determine cardiac rhythm for possible intervention (nearly a half hour). The OIG also faulted the VA because certain medications used in emergency situations to reverse effects of possible drug overdose (naloxone and flumazenil) were not available on the unit.


If you or a loved one suffered injuries (or worse) as a result of opioids or other prescription drugs at a VA medical center, you should promptly seek the legal advice of a VA medical malpractice claim lawyer in your U.S. state who may investigate your VA medical malpractice claim for you and represent you or your loved one in a medical malpractice claim involving the VA, if appropriate.

Visit our website or call us toll-free in the United States at 800-295-3959 to be connected with medical malpractice attorneys in your state who may assist you with your medical malpractice case.

Turn to us when you don’t know where to turn.

This entry was posted on Tuesday, December 5th, 2017 at 5:24 am. Both comments and pings are currently closed.

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