Army Ranger Cole Schuler died of a heroin overdose in the domiciliary at the Clement J. Zablocki Veterans Affairs Medical Center in Milwaukee, WI last November. He was being treated for a substance abuse disorder and was found slouched over in a seated position at his desk in his room on VA premises. An extensive review of the program revealed wide security and safety violations, including; numerous instances of resident veterans having alcohol on the property, staff not following a variety of protocols and a number of clear safety violations. Sixteen recommendations were forwarded and the hospital’s administrative staff noted that measures to improve violations and lapses in security and safety issues. The State of Wisconsin’s VISN system has experienced a number of egregious administrative problems in recent years, most notably the scandals at the Tomah facility. Such problems have not by any means been confined to the State of Wisconsin, however. Multiple, similar incidents have been reported and documented at facilities across the United States.
One month before a U.S. Army veteran died of a heroin overdose last fall at the inpatient drug rehabilitation unit of the Clement J. Zablocki Veterans Affairs Medical Center, an investigative team found alarming safety and security issues inside the facility.
Investigators were able to enter the domiciliary on Oct. 7 without being stopped, noted that it was unlikely staff was making rounds every 30 minutes as required and the security camera was out of order, according to an Administrative Investigation Board memo.
While the investigation was being held, there was a report that two veterans in the facility had alcohol in their rooms and another veteran had tried to commit suicide. In their report, investigators concluded the domiciliary “environment is not secure and safe.”
Cole Schuler, a 26-year-old former U.S. Army Ranger from the Fox River Valley, died of a heroin overdose Nov. 9. He was found slumped under his desk in his bedroom at the facility.
The Administrative Investigation Board issued its report in a memo dated Nov. 10. The investigation was initiated because of complaints received by U.S. Sen. Tammy Baldwin (D-Wis.) as well as top VA officials. Baldwin’s office requested the report in December.
After reviewing the report, Baldwin wrote in a Jan. 21 letter to Secretary of Veterans Affairs Secretary Robert McDonald that she was “alarmed” by the conclusions. Baldwin said the findings highlighted “concerns that have been brought to me by my constituents over the past year.” Baldwin’s Republican counterpart, U.S. Sen. Ron Johnson, also recently raised questions about security problems at the facility.