A Senate report is blasting the Department of Veterans Affairs and its watchdog group, saying "systemic failures" might've led to the deaths of at least two veterans.
There's actually quite a bit to unpack here, starting with the facility itself. An investigation was launched into issues at the VA medical center in Tomah, Wisconsin, more than a year ago. It found a huge problem with over-prescription; so much so that the facility and its chief of staff were nicknamed "Candy Land" and "Candy Man," respectively.
The Senate report also claims the facility has an issue with abuse of power and found "a culture of fear and whistleblower retaliation," which led to staff members not speaking up when they saw issues.
And the majority of the blame for that culture and other serious issues at Tomah is laid on the VA's Office of Inspector General, an internal agency tasked with conducting independent investigations into VA facilities. The chair of the Senate committee says the office "had lost the sense of what its true mission was."
The investigation found that before a multiyear inspection could be finished, OIG leadership closed it and kept the findings of the report internal, which "compromised veteran care at the facility." Five months later, a Marine Corps vet died of "mixed drug toxicity"; he had just been prescribed his 15th drug.
The VA seems to be accepting the blame and making changes. The VA's deputy secretary said: "VA leadership owns this. We had ample opportunities over the years to fix this." A new inspector general took over the agency in May.
This video includes images from Getty Images and clips from WISC and Fox News.