When Craig and Jane Meeusen first read the detailed report surrounding their son Nick's death it was difficult because they knew "the patient" had a name.
The report was drafted by the Department of Veterans Affairs Office of Inspector General (OIG). It was titled Mismanagement of a Patient at the Tomah VA Medical Center and outlined medical care provided Nick during his 14 hour admission at the Tomah VA in early April 2019. The report, released Aug. 26, referred to "the patient" throughout its entirety. That patient was Nick Meeusen.
"Up until the report we had nothing to back up our story," said Craig Meeusen. "We were just disgruntled parents."
Nick Meeusen's parents insist the report outlines medical errors by Tomah VA staff that contributed to his death.
In explicit detail the couple share the story of Nick checking himself into the Tomah VA in an early April morning in 2019. Nick was a veteran of Operation Iraqi Freedom. He served in Ramadi 2006 to 2007.
Their willingness to share their experience with the Monroe County Herald is not the first with local media since the OIG report became public. But they insist it's a story that needs to be repeated to prevent other families from experiencing similar grief.
"The continued efforts of the VA staff to direct responsibility elsewhere is both deceptive and disingenuous," said Craig Meeusen. "The simple truth is on the morning of April 6, 2019, our son Nick drove to the Tomah VA, parked his car, walked the 200 feet into the facility, and left less than 24 hours later in an irrecoverable coma.
Their son Nicholas never regained consciousness after being treated at the Tomah VA. They are willing to share an emotional story because quite candidly they feel details surrounding Nick's care at the Tomah VA is "being buried."
The deployment took a physical toll on Nick, not unlike other active duty veterans over the decades. Nick dealt with diagnosed post traumatic stress syndrome. Nick sustained injuries when a Humvee he was riding in hit an improvised explosive device (IED).
After his deployment Nick struggled with alcohol abuse, vodka his choice to self medication. But when Nick drove from a Murdock Street apartment in Tomah in early April 2019 to the Tomah VA he was sober. Craig Meeusen said Nick was living in the apartment a few years, on 100% disability from his deployment. The apartment is near the Tomah VA campus.
Jane Meeusen said Nick thought he was having a seizure. Nick's health spiraled downward at the Tomah VA, the Meeusens contend.
Less than one day later he was transported by medical helicopter in a coma to Gundersen Health in La Crosse and eventually the Madison VA where he entered their hospice on April 30. He died May 8, 2019. Nick was 34-years-old. Thirty-three days from the day he checked in to the Tomah VA until he checked out at a Madison VA hospice.
A copy of Nick's Wisconsin death certificate lists the "immediate cause" of death as anoxic brain injury with related consequences cardiopulmonary arrest, delirium tremens (alcohol withdrawal) and alcohol use disorder.
Nick Meeusen was not a stranger to care at the Tomah VA. According to the OIG report primary care services for Meeusen at Tomah started the spring of 2008.
From fall 2011 until summer 2018 Meeusen received intermittent mental health treatment for alcohol abuse, anxiety, attention deficit disorder, PTSD and sleep disorder.
His parents sought answers, but to this day the only communication they received from the Tomah VA was a conference call 37 days later on May 13, the afternoon before Nick’s funeral that left them more questions than answers, Craig adds.
The Meeusen's asked Rep. Ron Kind’s office to look into their son’s death, which fueled the OIG report.
This was the second inquiry by Congressman Kind’s office. The first review by the Acting Veterans Integrated Service Network (VISN) 12 Director completed on February 14, 2020 was unsatisfactory to both Kind’s office and the Meeusen’s. The Meeusen’s are grateful to Kind’s office for their persistence to get at the truth, they said.
Among other things, the OIG report reveals Nick’s Tomah VA doctors and nurses mismanaged his care. His parents say they made too many mistakes.
“For 20 minutes Nick was without oxygen,” Jane Meeusen said, noting that was specified in the report.
The OIG report also notes Tomah VA doctors did not prescribe Meeusen adequate medication, and that nursing staff failed to complete all the required assessments. It indicates at one point Meeusen was placed in four point restraints due to "increased agitation and aggression." The report indicates Meeusen was restrained because he was hitting staff.
“It was very difficult to read,” Jane Meeusen said.
The report cites staff lacked proper training to use the restraints on Nick. Craig and Jane’s frustration increased with a lack of communication from Nick’s doctors and nurses.
“We didn’t hear anything from the Tomah VA until five days after his death, not a follow-up, not a call from his doctors, not asking how he’s doing, nothing,” Craig Meeusen said. “I mean not a word.”
A statement from Karen Long, Tomah VA Medical Center Director, reads, “The Tomah VA staff and I extend our sincere condolences to the family of this Veteran and take this loss personally. While the April 2019 incident doesn’t represent the quality health care our Tomah VA Medical Center professionals provide daily, the OIG team did find opportunities and provided recommendations.
"We take these recommendations seriously and have already implemented process improvements. “It’s important to note that the OIG report did not address the veteran’s entire course of care. Without a comprehensive review, attributing the Veteran’s clinical deterioration to Tomah VAMC is inconclusive. Again, we offer our condolences and remain fully committed to implementing the recommendations and will diligently pursue all measures to ensure safe, high-quality care for the Veterans that we serve.”
In an Aug. 2 letter Long submitted to the OIG in response to the report she wrote, "We would like to note the patient's entire course of care was not discussed in the report. In fact, three different healthcare facilities provided care for this patient in a 32 day period in spring 2019. The report addressed approximately 14 hours of care and with the exception of citing the normal MRI at a local health system, omitted health care events that occurred during two helicopter transfers, the time at the local health system and another VAMC. Without a comprehensive review of this patient's entire course of care we do not know the effects of care received at other facilities."
Former Tomah VA director Victoria Braham also responded to the OIG report. Brahm is now VISN 12 Network director. Brahm wrote, "It is unfortunate we do not know the full impact of this veteran's entire care journey outside the Tomah VAMC since most of the care received did occur external to Tomah VAMC. Focusing only on the short time the veteran was at Tomah does not reflect the complex and lengthy medical care this veteran was provided."
The Meeusens thanked Gundersen Health and the Madison VA for the care provided their son. In the program from Nick's funeral in 2019 it states, "Nick's family would like to thank the doctors and staff at the VA hospital in Madison for the wonderful care they provided for him while he was under their care."
The emotional toll is still an open wound for the Meeusen family that also includes Nick's siblings, older brother Chris and younger brother Mike. They remain unsettled with unanswered questions surrounding Nick's death, the parents nod in agreement. There were rumors to dispel. Craig shares one interaction with someone who thought their son committed suicide.
It's hard for the parents to reflect since those 33 days in April 2019. But positive memories of Nick's life fill that void.
There is a memorial in their living room with a photo of Nick in uniform and the flag received at his funeral.
The couple insist their intention to pursue answers is solely framed around Tomah VA expressing accountability for what happened in their 14 hours of care.
The Meeusens take solace in words shared by their son's platoon leader, Arthur Athens, in a 2007 letter he wrote while serving with Nick.
"I just wanted to write you and tell you how proud and honored I am to serve with your son. Nick is an extremely hard worker and his fellow soldiers respect him a lot. Your son is an American hero and you should be very proud.”
Jane also extended thanks to Al Stevens for words of comfort during their ordeal. Stevens's son, Andy, was killed in action. Very different circumstances, but shared grief still the same. Thoughts of legal recourse? Craig does not dispel that thought, but quickly adds, "This has never been about money (legal action)," Craig Meeusen said.
But 20 minutes without oxygen was a precursor to 33 days of emotional hell, they contend.
"We just want to bring more attention to this," Jane Meeusen said. "It feels like a cover up. Isn't that a crime?"
Said Craig, "Things need to change at the Tomah VA. If they don't have the proper training, resources, and staff to provide urgent care, they should not say they do."
The Monroe County Herald contacted Tomah VA public relations for additional comment for this story. They did not respond in time to meet deadline for this edition.