A proud Marine veteran is dead, and according to report from the VA Office of Inspector General (OIG), a “series of failures” at the Tomah VA Medical Center in Wisconsin is to blame.

At the request of Wisconsin state senators Tammy Baldwin and Ron Johnson, an investigation was conducted, and this is what they found (via News 8 — La Crosse, Wisconsin):

Jason Simcakoski, 35, died at the Tomah VA Medical Center Aug. 30, 2014. The medical examiner determined the cause of death was mixed drug toxicity.

The OIG enlisted the services of a non-VA forensic toxicologist, who agreed with the medical examiner’s cause of death.

The investigation determined that Simcakoski died in the facility, and he was prescribed a mix of medications with the potential to cause respiratory depression. The report from the OIG shows that in the 72 hours before Simcakoski passed, he was given 54 doses of 13 different drugs.

The family of the veteran is glad they have closure to the situation, but are understandably devastated. Their hope is that the tragedy will bring better care to military service members in the near future.

“It takes something bad usually to make something good happen. Unfortunately, it was our son for this, but hopefully, we’ll be able to save a lot of other veterans out there in the future from this,” Jason Simcakoski’s father Marv said.

To echo the family’s sentiments, the VA facility said publicly that they’re “learning from this tragedy”.

More on what he was given by the VA’s mental health professionals from News 8:

The OIG report found that Tomah VA staff prescribed drugs, which, when combined, most likely led to his death. One of the drugs is called Suboxone. The report found that the Veteran’s Health Administration requires written informed consent for administering “hazardous” drugs. The OIG investigation did not find any evidence of written informed consent. Both psychiatrists involved in the ordering of the “hazardous” drug given to Jason Simcakoski acknowledged they did not discuss the risks with him.

Curiously enough, one of the psychiatrists who dosed the former Marine was fired in July, while the other one involved is currently under investigation.