An investigation by the inspector general at the Department of Veterans Affairs has found that deficiencies in care at the Tomah VA contributed to the death of a 35-year-old Marine.

Jason Simcakoski died last August from mixed drug toxicity. A report released Aug. 6 by the inspector general’s office found that the two psychiatrists who prescribed medication to Simcakoski did not discuss the risks of the drugs with him or his family.

In addition, the report found that staff did not immediately perform cardiopulmonary resuscitation or use an in-room emergency call system when they found him unresponsive.

The Tomah VA said in a statement that it’s saddened by Simcakoski’s “avoidable” death and is committed to learning from it and improving care for veterans. The facility is implementing recommendations for improvements.

“My prayers continue to be with the Simcakoski family,” U.S. Rep. Ron Kind (D-WI) said in a statement. “This was a tragedy, and it is one that could have been prevented. It is clear very serious mistakes were made in the course of Mr. Simcakoski’s treatment.  As we move forward the Tomah VA needs to immediately take steps to implement the changes recommended in the OIG report as well as other commonsense solutions to fix the problems we have seen at Tomah and at other VA medical facilities.”