One Veteran's Preventable Death

How did this all come about?
Justin had come from Las Vegas, to Los Angeles, around Thanksgiving. He had decided to do his rehab, because he had spent a lot of time doing drugs since he'd come from Iraq. He wanted to get clean, to get his life together, is what he told me.

We went to a couple of places but ended up at the VA Hospital because it was free and they seemed to have a good rehab program. He checked in on November 28. He spent only two weeks in evaluation when he was supposedly going to spend 30 days in evaluation and I never understood why his time there was so short. The moment he got out of evaluation, he told me they had put him on methadone.

That got me worried and I called his doctor and his social worker and told him that Justin had overdosed in the past, two of the times were nearly fatal. I told him that he should not have been unsupervised with medications like methadone, that in fact, he should have been supervised with all of his medications, especially Xanax, because he would take too much of it. There were records of him improperly self-medicating, in his medical records, all they would have to do is take a look at them. I was ignored.

Justin had a non-fatal overdose on December 15. They called me from the emergency room at USC and I immediately called the social worker again and I begged her to notify his doctor because that was a clear sign of his problem self-medicating, it was a wake up call. Because next time he could overdose and that could be it, the end. He needed to be supervised.

What happened next?
Well, I thought everything was under control until two weeks before he died, he was really high on methadone when we went to see a movie. He told me that and I asked permission to speak to his doctors and Justin was going to sign a release form for me. We didn't get around to the release form because two weeks later, when I went to pick him up to see another movie, he was dead on his bed. They found him dead on his bed from an accidental overdose.

What really shocks me the most was he was the fifth death that had to take place before the administration changed the way they administered the meds. Five people had to die. In the same rehab facility. And there was a sixth person right after Justin.

A few months after he died, I called his social worker, the one I'd warned three times, to tell her my pain and my sorrow and the difference she would have made if she had listened and made a couple of phone calls. Saved his family grief, me grief. She hung up the phone on me.

Really?
Yeah. When I called again, I immediately redialed, her supervisor said that my telephone calls were redundant and tedious, and they have nothing to do with their department and any further communication should addressed to the Dean of Staff.

I said that I had not warned the Dean of Staff about Justin, his social worker was in charge of his case and I warned her and talked to her personally. This was why I had called her. They hung up on me again.

Had Justin been in other rehab facilities before?
Yeah, but he had always checked himself out two or three weeks before rehab would end. He had been hospitalized for non-fatal overdoses or from having withdrawal symptoms, running out of his medications then have withdrawal symptom as a result, many times before he'd checked into the VA Hospital.

They knew all that and still they let him self-medicate, totally unsupervised. Which was ludicrous.

None of his drug usage or overdosing happened while he was in the military?
All of this happened when he came back from Iraq. He had gotten into drugs and drinking to forget, he was unable to deal with the things he'd experienced in Iraq. The killing of innocent people was something that weighed heavily on him. He had a lot of regrets about what they did.

Had he been officially diagnosed with Post Traumatic Stress Disorder?
Yes. And the social worker that I notified, she is the specialist in charge of Post Traumatic Stress Disorder patients.

I found out that Justin's mom was making efforts to make sure he wasn't allowed to self-medicate, to alert his doctors and nurses. Also, the other patients were voicing their concerns. The six weeks he was in rehab, the other patients would see him falling asleep and being incoherent, falling down. They would notify the staff and nobody would do anything.

They would take him to his bed and leave him there. I count about 17 warnings that they received between me, his mother, and his fellow patients, there were about 17 warnings, if not more. They ignored all of them.

Photo provided by Dmitris Rentzis