GRAND JUNCTION, Colo. (CBS4) – A report has been released on the death of a veteran that his former caseworker blamed on the VA hospital in Grand Junction.

Vietnam veteran Rodger Holmes died in 2014. A newly-released report confirms he received inadequate care and it recommends changes Holmes fought for at the VA clinic where he was treated, even though he knew it would be too late for him.

Just before Holmes passed away in December of 2014 his VA caseworker, Chris Blumenstein, made a promise to him.

“I told him literally as he was dying I would continue this campaign in his honor,” Blumenstein said.

Rodger Holmes (credit: CBS)

Rodger Holmes (credit: CBS)

What started as the Saving Veteran Rodger Holmes campaign became the Remembering Rodger Holmes campaign. Convinced his care had been botched at the VA Medical Center in Grand Junction, community members, including Blumenstein, who turned whistleblower, persuaded lawmakers to intervene.

U.S. Sen. Michael Bennet was among those who called on the inspector general to investigate. That investigation has now found on several occasions the clinic “did not provide the care or assess the patient thoroughly … (which) may have contributed to his progressive decline.”

Bennet said he will ensure the clinic follows through on recommended changes.

“I can tell you we are constantly evaluating what we can do to try to improve care inside the VA system and outside the VA system for our vets,” Bennet said.

Rodger Holmes (credit: CBS)

Rodger Holmes (credit: CBS)

The report is now Holmes’ legacy

“He would take enormous satisfaction that it wasn’t for nothing, that he did make a change,” Blumenstein said.

While the report identified problems, it didn’t definitively link those problems to Holmes’ death. Blumenstein says it doesn’t go far enough in holding the clinic accountable. The clinic director thinks it goes too far. He still insists Holmes’ care was adequate. Nevertheless, the clinic did implement the changes recommended by the inspector general.

LINK: Remembering Veteran Rodger Holmes Campaign

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