Department of Veterans Affairs 

Office of Inspector General 

Healthcare Inspection 

Quality of Care of Two 

Deceased West Virginia Veterans 

Report No. 08-01377-185 August 14, 2008

VA Office of Inspector General 

Washington, DC 20420 
To Report Suspected Wrongdoing in VA Programs and Operations 

Call the OIG Hotline – (800) 488-8244 
Quality of Care of Two Deceased West Virginia Veterans 

Executive Summary 

The VA Office of Inspector General (OIG) was asked by Senator Rockefeller to review 

the care of two West Virginia combat veterans who were being treated for severe posttraumatic stress disorder (PTSD) and who died in their sleep. The Senator asked that the 

review take into account the medications prescribed and explore the possibility of any 

pattern in these tragic deaths. 

We reviewed these patients’ medical records and visited the Huntington VA Medical 

Center (VAMC), Charleston Community Based Outpatient Clinic and Vet Center, and 

the Cincinnati VAMC PTSD Residential Program. We interviewed the families of the 

patients and the providers at each site who had been involved in the care of these patients. 

We reviewed the autopsy and toxicology reports for both patients and discussed the 

findings with the Chief Medical Examiner for the State of West Virginia. We concluded 

that the care provided for these patients at the Charleston community based outpatient 

clinic, and the VA facilities in Huntington and Cincinnati met community standards of 

care. 

VA’s Pharmacy Benefits Management Services program and its Center for Medication 

Safety (VAMedSAFE) conducted a nationwide data pull of all-cause mortality during 

1998–2008 for patients prescribed the combination of quetiapine, paroxetine, and 

clonazepam. Additional analyses examined other combinations of mental health 

medications, including an analysis by age of patients with and without PTSD. There was 

no apparent signal to indicate increased mortality for patients taking the combination of 

quetiapine, paroxetine, and clonazepam when compared with patients taking other similar 

combinations of psychotropic medications. The direct impact of non-prescribed 

medications in these patient deaths cannot be determined. VA mental health providers 

describe the use of non-prescription medications as growing area of concern in the 

treatment of young veterans. 

Returning war veterans may have multiple mental health conditions in addition to PTSD. 

Restriction of admission to the Clarksburg Residential PTSD Program for patients taking 

clonazepam and related medications may decrease access to appropriate treatment. We 

recommended that management evaluate exclusion criteria for admission related to 

medications for newly-diagnosed patients to the Residential PTSD Program. 

VA Office of Inspector General i 
DEPARTMENT OF VETERANS AFFAIRS

Office of Inspector General 

Washington, DC 20420 

TO: Director, Veterans Integrated Service Network (10N4) 

SUBJECT: Healthcare Inspection – Quality of Care of Two Deceased West 

Virginia Veterans 

Purpose 

The VA Office of Inspector General (OIG), Office of Healthcare Inspections was 

requested by Senator Rockefeller to review the care of two West Virginia combat 

veterans who were being treated for severe post-traumatic stress disorder (PTSD) and 

who died in their sleep. The Senator asked that the review take into account the 

medications prescribed and explore the possibility of any pattern in these tragic deaths. 

In addition, patients’ families expressed the following: 

• Patients worsened while on medications and an inappropriate dose of a medication 

was prescribed. 

• Physical complaints and medication side effects were not adequately addressed. 

• The PTSD Residential Program at Clarksburg, West Virginia, did not accept 

patients who were taking certain medications. 

Background 

In 2008, two veterans (Patient A and Patient B) unexpectedly died in their sleep. Both 

were men under the age of 35 who had recently served in Iraq. Prior to their deaths both 

patients had been taking three prescribed psychiatric medications—paroxetine, 

clonazepam, and quetiapine. 

Scope and Methodology 

We interviewed the families of Patient A and Patient B. We visited the Huntington VA 

Medical Center (VAMC), Charleston Community Based Outpatient Clinic (CBOC) and 

Vet Center, and the Cincinnati VAMC PTSD Residential Program. We interviewed 

providers at each site who had been involved in the care of these patients. We reviewed 

the autopsy and toxicology reports for both patients and discussed the findings with the 

VA Office of Inspector General 1 
Quality of Care of Two Deceased West Virginia Veterans 

Chief Medical Examiner for the State of West Virginia. We also reviewed VA medical 

records and Vet Center progress notes. For Patient A, we interviewed his private 

psychiatrist and the non-VA psychiatrist who cared for him during hospitalization at a 

state hospital; we also reviewed non-VA medical records. 

In May 2008, in response to media reports of the death of these patients, the Veterans 

Integrated Service Network (VISN) 10 patient safety officer asked mental health clinic 

managers to review the medical records of patients who were currently prescribed the 

combination of quetiapine, paroxetine, and clonazepam to determine if any adverse drug 

events had occurred. We reviewed the facility responses and interviewed the psychiatrist 

who had performed these chart reviews for the patients at the Cincinnati VAMC. 

In response to these deaths, VHA conducted an analysis of all deaths from any cause 

among patients who were prescribed the medications addressed in this report, and we 

reviewed that analysis in detail. We also searched the medical literature for reports of 

unexpected deaths in young adults related to these medications and general studies on 

accidental drug-related deaths. 

We conducted the inspection in accordance with Quality Standards for Inspections

published by the President’s Council on Integrity and Efficiency.

Case Histories 

Patient A

Patient A was initially seen for a mental health evaluation at the Charleston CBOC in 

2007. The patient had served a 9-month tour of duty in Iraq in 2005. After this 

deployment, he experienced chronic depression, severe anxiety, social withdrawal, 

feelings of emotional distance, hyper-vigilance, sleep disturbance, intrusive thoughts of 

combat, poor anger control, alcohol misuse, and inability to maintain stable employment. 

Prior to evaluation at the CBOC the patient’s family physician had prescribed an 

antidepressant, but this was discontinued after one week due to sedation. At the CBOC, 

the patient was treated with citalopram and trazodone for depression, anxiety, panic, and 

insomnia. Because of nausea, citalopram was discontinued after one week and 

paroxetine was prescribed. Trazodone was felt to be ineffective and was discontinued. 

He subsequently presented with suspiciousness, agitation, irritability, and insomnia, and 

quetiapine was prescribed. 

Although paroxetine was somewhat effective, after a few months it was discontinued 

because of side effects and mirtazapine was prescribed. After he reported tearfulness, 

poor sleep, nightmares, and feeling that his “medicines were not right,” mirtazapine was 

discontinued and paroxetine was re-started. Several weeks later, the patient reported 

extreme anxiety and admitted having had past thoughts about killing himself. 

VA Office of Inspector General 2 
Quality of Care of Two Deceased West Virginia Veterans 

Clonazepam was prescribed to be taken at bedtime and quetiapine was discontinued. At 

a subsequent conversation, the patient admitted that he was still taking the quetiapine and 

his psychiatrist agreed to continue/re-start the medication. 

By the fall of 2007 the patient on his own increased his dosage of quetiapine to 1200 

milligrams (mg). At that time he was also taking paroxetine 40 mg per day and 

clonazepam 3 mg per day. His psychiatrist documented “...reinforced the plan to 

eventually become med. free, although will allow him [the patient] to play a major role in 

determining when. I did inform him that there are limits to the amount of medication he 

can depend upon.” 

In late 2007 and early 2008, the patient saw a private psychiatrist. His psychiatrist 

increased the paroxetine dose to 60 mg and later to 80 mg; he also increased quetiapine to 

1600 mg and clonazepam to 4 mg per day. Valproic acid was started by the private 

psychiatrist for irritability and explosive outbursts. Although he was reportedly less 

irritable and his anger was better controlled, he also reported diarrhea and valproic acid 

was discontinued. 

Subsequently, the patient was reportedly non-compliant with medications. He displayed 

increasing irritability and isolation and spent an excessive amount of time alone in his 

room. During that time, he presented to a non-VA facility. He became agitated after 

waiting several hours in the emergency department and was involuntarily admitted to a 

state hospital for two weeks. During that hospitalization, the patient was treated for a 

bipolar disorder with psychotic features and PTSD. Paroxetine was discontinued, 

escitalopram was initiated, the quetiapine dose was reduced to 800 mg per day, and 

clonazepam was discontinued. In addition, while at the state hospital he was started on 

oxcarbazepine. 

On the day after discharge from the state hospital, he was seen by a psychologist and a 

psychiatrist at the Huntington VAMC. The psychiatrist noted that the “...Pt. and his 

mother believed he was responding better to former medications so I agreed to return him 

to previous medications.” In addition, the patient had apparently developed a tremor 

after initiation of oxcarbazepine. The oxcarbazepine dose was tapered off, clonazepam 

was restarted, the quetiapine dose was continued at 800 mg, escitalopram was 

discontinued, and paroxetine was re-started. A week later the patient was seen by a 

Huntington VAMC psychologist for individual therapy. At that visit he did not report 

side effects related to his medications and indicated compliance with his regimen. The 

patient was found dead at his home less than one week later. 

The autopsy report of the Chief Medical Examiner of the State of West Virginia stated 

that the patient died as a result of combined drug intoxication. The involved drugs 

included paroxetine, quetiapine, and a non-prescribed medication. No contributory 

natural diseases or physical injuries were identified. 

VA Office of Inspector General 3 
Quality of Care of Two Deceased West Virginia Veterans 

Patient B

Patient B was deployed to Iraq in 2003. After his return home, he attended group 

sessions at the Charleston Vet Center and in mid-2006 was referred to the Charleston 

CBOC for mental health evaluation. He reported having nightmares and feeling 

paranoid, anxious, depressed, and irritable. He endorsed difficulties with anger and 

feeling constantly on guard. He described himself as a different person since his return 

home. He was started on paroxetine, quetiapine, and clonazepam. A few weeks later the 

patient reported feeling better and having a new full time job at a manufacturing plant. 

Over the next nine months, the patient’s therapist spoke with him by phone noting the 

patient’s concern that the policy of his employer was that new employees were allowed to 

miss only 3 days of work during the initial year or face termination. The patient represented in the summer of 2007. At a mental health appointment with his therapist, he 

reported feeling “ready to explode.” He discussed significant marital stress and 

complained of headaches. Primary care and psychiatric medication appointments were 

arranged. Laboratory work was obtained at a primary care appointment. Paroxetine and 

quetiapine were re-initiated. In the fall of 2007, he was seen by a primary care provider 

for chronic knee pain. Physical therapy was recommended and he was prescribed 

gabapentin. 

The patient told a provider that he was taking 30 mg of paroxetine a day instead of the 20 

mg prescribed. He had also increased his quetiapine dose; the higher dose helped him 

sleep. The patient was irritable and reported getting into fights. The dose of paroxetine 

was increased to 30 mg and the quetiapine to 300 mg, and he was continued on 

clonazepam. At that time, the patient was seeing a social worker at the Charleston CBOC 

for therapy and attending group sessions at the Vet Center. 

The patient experienced difficulty sleeping, and increased nightmares, anxiety, anger, and 

irritability. He expressed concern that he might lose his temper and end up in jail. He no 

longer had a job and reported financial stress and feeling desperate to find work. His 

paroxetine dose was increased and valproic acid was started to target his irritability and 

anger outbursts. He was seen by primary care because of frequent headaches, and 

ibuprofen was prescribed. His family reported that he had gained weight and that his face 

and hands appeared swollen. 

In late 2007 the patient entered the 8 week Residential PTSD Program at the Cincinnati 

VAMC. A nurse practitioner performed a baseline history and physical examination and 

an electrocardiogram, chest x-ray, urinalysis, and thyroid blood test were obtained. Prior 

blood work from the Charleston CBOC was reviewed. 

His paroxetine dose was increased in week 3 due to ongoing depressive symptoms. The 

quetiapine dose was reduced several times after the patient reported over-sedation. At 

VA Office of Inspector General 4 
Quality of Care of Two Deceased West Virginia Veterans 

one point, because of ongoing difficulty with sleep and nightmares, the patient reincreased the dose on his own to 400 mg. 

Early in the program the nurse practitioner discontinued the gabapentin because it was 

felt that it might be contributing to dry mouth and the patient did not feel that it had been 

effective for his chronic leg pain. Later, the nurse practitioner ordered ibuprofen and 

Tylenol. 

The clonazepam dosage was decreased during the first week and then ordered to be given 

at bedtime only if needed. The valproic acid dose was increased and, during the 6th week 

of the program, the patient admitted taking more than prescribed when he felt anxious. 

He was advised against this practice and was told that an extra dose would not provide 

any immediate benefit. 

Also during the 6th week of the program, the patient complained of ongoing difficulty 

with nightmares and sleep paralysis. He was prescribed prazosin at bedtime and reported 

resolution of nightmares during the last week of the program. The patient reported some 

improvement in mood, but more improvement in irritability, energy, interest, and 

concentration. Toward the end of the program a reduction in PTSD symptoms was noted 

on the Clinician Administered PTSD Scale (CAPS) and the PTSD Checklist (PCL). 

His family reported that when he was home for Christmas, he had tremors; and he 

appeared tired, heavily medicated, forgetful, and “foggy,” with slurred speech at times. 

In addition, his voice was described as deep and raspy, different from his normal voice. 

The patient met with the nurse practitioner a few days before completion of the program 

to review discharge planning. He reported plans to follow-up with his primary care 

physician at the Charleston CBOC. Progress notes written during the program do not 

indicate problems with sedation, hoarseness, cognitive impairment, or nausea. 

On the day of discharge, he had a few episodes of vomiting after arriving home. He 

reportedly took 2 quetiapine pills (dosage unclear) and fell a sleep on the couch, where 

early the next morning he was found unresponsive. 

The autopsy report of the Chief Medical Examiner of the State of West Virginia stated 

that the patient died as a result of combined intoxication with paroxetine, quetiapine, and 

two non-prescribed medications “...under circumstances significant for fatal over-use of 

prescribed paroxetine...” with apparent misuse of non-prescribed medications of 

uncertain intentionality. 

VA Office of Inspector General 5 
Quality of Care of Two Deceased West Virginia Veterans 

Inspection Results 

Issue 1: Quality of Care for Two Veterans: 

The care provided for these patients at the Charleston CBOC, Huntington VAMC, and 

the Cincinnati VAMC met community standards of care. 

Patient A 

Medical record progress notes indicate that the patient and his providers discussed 

medication options, dosing, desired and adverse effects, as well as possible drug-drug and 

food-drug interactions. Providers documented medication side effects. 

Food and Drug Administration-approved prescribing information for quetipaine states 

that in clinical trials “...the majority of patients responded between 400 to 800 mg/day. 

The safety of doses above 800 mg per day has not been evaluated in clinical trials.” 

However, depending on a patient’s presentation, in clinical practice it is not unusual for 

psychiatrists to prescribe medications in doses above the recommended dose range. In 

the fall of 2007, the patient’s VA psychiatrist agreed to increase the quetiapine dose to 

1200 mg after the patient had self-increased the dose. The dose was again increased 

while the patient was under the care of a non-VA psychiatrist. After hospitalization at the 

non-VA hospital, the patient was seen again by the VA psychiatrist, at which time the 

prescribed quetiapine dose was 800 mg. 

The patient was seen by a primary care physician at the CBOC and at the Huntington 

VAMC multiple times, and was evaluated by a non-VA physician in Huntington. He was 

also seen by a social worker for therapy and case management at the CBOC, and he 

attended individual and group sessions at the Vet Center. 

The patient’s social worker reported that he was frequently difficult to engage in the 

treatment process. Treatment was also complicated by the patient’s other mental health 

issues. The social worker reported that she had frequently suggested hospitalization or at 

one point admission to the Residential PTSD Program at the Clarksburg VAMC, but the 

patient declined. 

After he was committed to a state hospital, there was discussion between the patient’s 

family and Huntington VAMC staff about possible transfer to a VA hospital. However, 

the only VA hospital in West Virginia with a locked inpatient psychiatry unit, which the 

patient required, is in Martinsburg, more than 350 miles away. 

During the hospitalization, a Vet Center therapist told a family member that patients 

taking clonazepam or similar medications would probably be ineligible for admission to 

the Clarksburg PTSD Residential Program. During the patient’s stay at the state hospital, 

his psychiatrist discontinued the clonazepam after learning that it might interfere with his 

acceptance in the PTSD program. Ultimately, the patient was not accepted because he 

VA Office of Inspector General 6 
Quality of Care of Two Deceased West Virginia Veterans 

was felt to be not stable enough to participate in the intensive trauma-focused program. 

Toward the end of his stay at the state hospital, there was discussion about possible 

admission to another non-VA psychiatric hospital, but the patient declined. 

After discharge from the state hospital, the patient was seen by a psychologist at the 

Huntington VAMC. The psychologist noted that the patient had limited coping skills for 

self-management of PTSD symptoms; consequently, he planned to see the patient weekly 

to begin cognitive-behavioral therapy. 

The Associate Chief of Staff at Clarksburg verified to the OIG that the Residential 

Program at Clarksburg historically does not admit patients on benzodiazepine 

medications (clonazepam is a benzodiazepine). 

Patient B 

The patient participated in an 8-week Residential PTSD Program at the Cincinnati 

VAMC. The focus of the program is improvement through structured individual and 

group evidence-based psychotherapies. Medication is viewed as serving an adjunctive 

role to reduce symptoms so that patients are better able to engage in therapy. For 

example, difficulty sleeping not only negatively impacts quality of life but also interferes 

with participation in therapy. At initial evaluation and as patients progress through the 

program, staff reported that they aim to eliminate medications, reduce doses, and simplify 

regimens if clinically appropriate. Our review of treatment records for this patient 

showed that staff did attempt to reduce medication doses. 

Several clinical providers told us that the patient actively participated in therapy, did not 

appear sedated or ill, interacted appropriately with peers, and appeared committed to 

recovery. Blood and urine tests, an electrocardiogram, and a chest x-ray revealed no 

heart or kidney disease. 

Issue 2: Role of Medications in Death of Two Veterans 

The Medical Examiner found that these patients died from combined drug intoxication 

involving prescribed and non-prescribed medications. In the presence of PTSD, other 

mental health conditions, and uncertain use of medications by patients, we are unable to 

draw conclusions about the relationship between medication regimens and these deaths. 

The toxicology report for one of the patients showed a markedly elevated blood level of 

paroxetine, even though the patient was prescribed an appropriate dose. The patient did 

not display signs of suicidal ideation in the weeks prior to his death. Paroxetine is not 

known to be substantially affected by the presence of the other prescribed medications, 

and genotyping of liver tissue revealed no significant abnormality in the ability of the 

liver to metabolize paroxetine. Paroxetine can adversely interact with one of the nonprescribed medications. However, the impact of this potential interaction is unclear. 

VA Office of Inspector General 7 
Quality of Care of Two Deceased West Virginia Veterans 

In May 2008, the VISN 10 patient safety officer asked mental health clinic managers to 

review the charts of patients currently prescribed the combination of quetiapine, 

paroxetine, and clonazepam for documentation of any adverse drug effects. No deaths or 

significant adverse events were reported. 

VHA’s Pharmacy Benefits Management (PBM) Services program and its Center for 

Medication Safety (VAMedSAFE) conducted a nationwide analysis of all-cause 

mortality during 1998–2008 for patients prescribed the combination of quetiapine, 

paroxetine, and clonazepam. Additional analyses examined other combinations of mental 

health medications, including an analysis by age of patients with and without PTSD. The 

VA analysis was essentially a series of data queries, and is limited by inability to 

determine specific cause of death or adjust for medical co-morbidities. There was no 

apparent signal to indicate increased mortality for patients taking the combination of 

quetiapine, paroxetine, and clonazepam when compared with patients taking other similar 

combinations of psychotropic medications. 

VHA researchers are studying mortality in elderly patients taking antipsychotic 

medications in combination with other psychotropic medications. They will be able to 

determine cause of death using National Death Index data. VHA’s VAMedSAFE is 

working with the primary investigator to expand the study and has recently applied for 

funding to include younger patients. 

Although antipsychotic medications have been identified as possible causes of cardiac 

rhythm disturbances, a 2001 review in the medical literature found no association with 

olanzapine, quetiapine, or risperidone and Torsades de Pointes (a fatal arrhythmia) or 

sudden death. The authors did caution that all antipsychotic medications may cause 

serious adverse events, and balancing risks and benefits is a challenge for psychiatrists. 

The authors also recommended that clinicians ask patients if they have had fainting or 

have relatives who died suddenly at a young age. For elderly patients, especially those 

with known heart disease or those already taking non-psychiatric drugs that prolong the 

QT interval (part of the heart electrical conduction cycle), a pretreatment 

electrocardiogram would be appropriate.1

 In the absence of known cardiac disease, we 

are unaware of any clinical practice guidelines recommending baseline or periodic 

electrocardiogram monitoring in young, healthy patients on quetiapine. 

Clinicians have described a tendency of young returning veterans to self-medicate using 

non-prescribed prescription medication obtained from friends, family members, and coworkers. These behaviors have also been observed among non-veteran patients treated 

for mental health conditions at private facilities. In addition, media reports during the 

past year describe the use of non-prescribed prescription medications by patients at 

military treatment facilities. 

 

1

 Glassman, Alexander H.,M.D., and Bigger, Jr., J. Thomas, M.D., Antipsychotic Drugs: Prolonged QTc Interval, 

Torsades de Pointes, and Sudden Death, The American Journal of Psychiatry, 158: 1774-1782, November 2001. 

VA Office of Inspector General 8 
Quality of Care of Two Deceased West Virginia Veterans 

Conclusions 

These two Iraqi war veterans served honorably in Iraq. After returning from the Middle 

East they suffered with symptoms of PTSD and other mental health conditions. Their 

deaths are tragic. 

The health care provided for these patients met community standards of care. 

VHA’s Pharmacy Benefits Management Services program and its Center for Medication 

Safety (VAMedSAFE) conducted a nationwide data pull of all-cause mortality during 

1998–2008 for patients prescribed the combination of quetiapine, paroxetine, and 

clonazepam. Additional analyses examined other combinations of mental health 

medications, including an analysis by age of patients with and without PTSD. There was 

no apparent signal to indicate increased mortality for patients taking the combination of 

quetiapine, paroxetine, and clonazepam when compared with patients taking other similar 

combinations of psychotropic medications. The direct impact of non-prescribed 

medications in these patient deaths cannot be determined. 

Returning war veterans may have multiple mental health conditions in addition to PTSD. 

Restriction of admission to the Clarksburg Residential PTSD Program for patients taking 

clonazepam and related medications may decrease access to appropriate treatment. 

VA mental health providers describe the use of non-prescription medications as growing 

area of concern in the treatment of young veterans. 

Recommendation 

We recommend that the VISN Director ensure that the Clarksburg VAMC Director 

evaluate exclusion criteria for admission related to medications for newly-diagnosed 

patients to the Residential PTSD Program. 

Comments 

The VISN and Medical Center Directors agreed with our findings and recommendations 

and submitted an acceptable improvement plan. (See pages 10–12 for the full text of 

comments.) We will follow up on the planned actions until they are completed. 

 (original signed by:)

JOHN D. DAIGH, JR., M.D. 

Assistant Inspector General for 

Healthcare Inspections 

VA Office of Inspector General 9 
Quality of Care of Two Deceased West Virginia Veterans 

Appendix A 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum

Date: August 6, 2008 

From: Network Director, VISN 4 (10N4) 

Subject: Healthcare Inspection – Quality of Care of Two Deceased West 

Virginia Veterans 

To: Deputy AIG for Healthcare Inspections (54) 

1. Attached please find my approved plan to address recommendations 

identified by the Office of Inspector General (OIG) to improve the quality 

of care provided to veterans residing in the State of West Virginia. The 

action item identified by OIG has been completed. 

2. The insights and observations provided by OIG are appreciated and a 

valuable resource for improving services provided. If you have any 

questions, please do not hesitate to contact me. 

(original signed by Bradley P. Shelton, 

Deputy Network Director) 

MICHAEL E. MORELAND, FACHE 

VA Office of Inspector General 10 
Quality of Care of Two Deceased West Virginia Veterans 

Appendix B 

Medical Center Director Comments 

Department of 

Veterans Affairs Memorandum

Date: August 6, 2008 

From: Director, Louis A. Johnson VA Medical Center, Clarksburg, 

WV (540/00) 

Subject: Healthcare Inspection – Quality of Care of Two Deceased West 

Virginia Veterans 

To: Deputy Chief of Staff, VA Central Office, Washington, DC 

(10B) 

Thru: Network Director, VISN 4 (10N4) 

1. Attached please find the Louis A. Johnson VA Medical Center’s 

approved action plan to address the recommendation identified by the 

Office of the Inspector General (OIG) in their draft report regarding Quality 

of Care to Veterans residing in West Virginia. 

2. The insights and observations provided by OIG are appreciated and a 

valuable resource for improving services provided. If you have any 

questions, please do not hesitate to contact me at (304) 623-7602. 

(original signed by:) 

WILLIAM E. COX 

Attachment 

VA Office of Inspector General 11 
Quality of Care of Two Deceased West Virginia Veterans 

Louis A. Johnson VA Medical Center, Clarksburg, WV 

Director’s Comments 

to Office of Inspector General’s Report 

The following Director’s comments are submitted in response to the 

recommendations in the Office of Inspector General’s report: 

OIG Recommendation

Recommendation. We recommend that the VISN Director ensure that 

the Clarksburg VAMC Director evaluate exclusion criteria for 

admission related to medications for newly diagnosed patients to the 

Residential PTSD Program.

Concur Target Completion Date: October 1, 2008 

Actions: 

Louis A. Johnson VA Medical Center has reviewed the admission criteria 

for PRRTP and is revising the criteria to eliminate barriers to access related 

to medication profiles. A new policy is being developed and all staff 

associated with the residential rehabilitation programs will be educated on 

the revised criteria for admission. We will also inform VA Medical 

Centers who refer patients to our programs of the changes in admission 

criteria. 

VA Office of Inspector General 12 
Quality of Care of Two Deceased West Virginia Veterans 

Appendix C 

OIG Contact and Staff Acknowledgments 

OIG Contact Michael Shepherd, M.D., Medical Consultant 

(202) 461-4660 

Acknowledgments Patricia Christ 

Jerome Herbers 

Christa Sisterhen 

VA Office of Inspector General 13 
Quality of Care of Two Deceased West Virginia Veterans 

Appendix D 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VISN 5 

Director, VISN 6 

Director, VISN 9 

Director, VISN 10 

Non-VA Distribution

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

U.S. Senators: Robert C. Byrd, John D. Rockefeller IV 

U.S. Representatives: Shelley Moore Capito, Nick J. Rahall II, Alan B. Mollohan

This report is available at http://www.va.gov/oig/publications/reports-list.asp. 

VA Office of Inspector General 14