Vietnam War veteran Rodger Holmes became ill in 2014, at the height of a national scandal over long patient wait times at care centers and allegations of negligence at the Department of Veterans Affairs. Holmes, who sought care for his Hepatitis C liver disease at the Grand Junction VA Health Care System, was among those to complain.
"He lost a tremendous amount of weight," said Chris Blumenstein, who served as a VA social worker to Holmes. "He was losing his mental clarity, his mental sharpness, he couldn't remember things."
Holmes died in December 2014, but in response to concerns, the VA's national Office of Inspector General launched an investigation and released recommendations May 11, 2016.