AUGUSTA — The Marine shot and killed by police outside Togus Veterans Affairs Medical Center last summer had repeatedly complained about the hospital’s poor communication, discontinuity of care and a prescription regimen that denied him needed drugs.

So James F. Popkowski grew increasingly depressed — and eventually made threats against staff where he was treated, and where he would eventually be gunned down in an armed standoff.

The findings are part of an intensive U.S. Department of Veterans Affairs report released last week that offered a rare glimpse into the VA system, acknowledged deep failures in Popkowski’s treatment and recommended changes to how veterans’ care is administered.

“By all accounts, he enjoyed a successful military career until it was cut short by a devastating disease and serious complications resulting from the treatment of that disease,” the report’s author, Assistant Inspector General Dr. John Daigh Jr., wrote. “The veteran’s experience with the VA had a difficult start, followed by alternating periods of smooth and difficult interactions.”

Popkowski, 37, of Medway, was a first lieutenant in the U.S. Marine Corps when his service was cut short in 2003 by a rare form of leukemia.

He left the Marines with an honorable discharge and later complained of Graft vs. Host Disease from a stem cell transplant he received as part of the cancer treatment.

Popkowski died July 8 from a single gunshot wound to the neck after a confrontation with a Veterans Affairs police officer and two game wardens near the entrance to the VA Medical Center at Togus, where he’d received treatment in the past.

Armed at the time of his death, Popkowski also allegedly left a painted note on his property accusing doctors of “killing him” by depriving him of his stem cell medication.

The Office of the Maine Attorney General is continuing to investigate, spokeswoman Kate Simmons said Monday.

Simmons declined to comment further, but investigators have said preliminary information indicates officers felt threatened by Popkowski, who was armed with what witnesses said looked like a rifle.

Officers responded to reports of gunfire coming from the woods, and a witness walking in a Togus parking lot said after the shooting he’d heard bullets flying in the direction of the hospital.

U.S. Rep. Mike Michaud, D-2nd District, requested the U.S. Department of Veterans Affairs Office of the Inspector General investigate Popkowski’s care. Results of the probe were released in a report Dec. 9.

“The death of Lt. James Popkowski was a tragedy,” Michaud said. “His family deserves to have all the answers, and all veterans stand to benefit from a thorough review of what happened.”

Communication faulted

The investigation recommends review and changes to Togus’ policy for assigning case managers and coordination of care.

It also urges Togus to improve internal communications and develop better procedures to assess and communicate risks associated with veterans who exhibit disruptive behavior.

“Whether addressing these three issues previously would have resulted in a different outcome for (Popkowski) is unknown,” Daigh wrote. “However, addressing these issues now will help facilitate a more patient-centered environment, especially for those veterans with complex and unique medical, mental health and psychosocial issues.”

The report includes Togus’ plans to address the recommendations by the end of February 2011.

“While we cannot comment specifically on any patient’s treatment due to medical privacy laws, any situation of this importance warrants a review of the system of health care delivery and focus on ensuring that the system works well for patients,” Togus spokesman Jim Doherty said in a prepared statement. “The delivery of high-quality health care to Maine veterans, while ensuring the safety of all patients, staff and volunteers that visit our sites of care each day, remains our highest priority.”

Michaud said he will push for the report recommendations to be implemented across the VA medical system.

“In the weeks and months ahead, I’ll be working to keep up the pressure on the VA to get this done,” Michaud said. “If it’s found that any recommendations in this report require legislative changes, I will introduce legislation to accomplish them.”

First Togus visits

Popkowski first went to Togus in December 2005 after cancer treatment during the previous year.

At the time, he was being treated at other facilities for cancer, depression and chronic pain, according to Daigh.

Problems began to arise almost immediately. Over the next four years, Popkowski would be assigned at least four primary care physicians at three facilities, and struggle with frustration over what he perceived to be inadequate care.

“There were times, especially early on in his treatment, that the veteran was fully engaged and proactive in communicating his health care needs,” Daigh wrote. “There were other times when he disengaged from his health care providers, declined needed services and missed scheduled appointments.

“Unfortunately, there is no way to know if the veteran’s disengagement was the result of his frustration with the VA system, a consequence of his disease process, a response to other challenges in his life, his way of coping with a terminal disease, or a combination of all these factors.”

Popkowski visited a community-based outpatient clinic affiliated with Togus and was assigned a primary care physician. His second visit, a month later, was canceled by staff, but Popkowski was never informed.

He saw his physician in February and was referred to a mental health provider for ongoing depression.

He made an appointment at the clinic for March, but he later canceled it.

Popkowski wrote a letter to Michaud in May 2006 expressing “dissatisfaction with the timeliness of obtaining prescription medication refills at the medical center, the assignment of a physicians assistant as his primary care physician and the ‘low caliber’ of VA medical employees.”

“In late June, leadership at the medical center also received a letter from a member of Congress about the veteran’s concerns,” Daigh wrote. “Following these letters, the medical center assigned the veteran to a new primary care physician and made him an appointment with a mental health provider at the main facility.”

Unreturned messages

But Popkowski sent a letter to Togus in June again complaining about delays in receiving his prescription medication and communication difficulties with the staff at the community-based outpatient clinic. He asked that the clinic contact him via fax or electronic or traditional mail.

“According to the veteran’s medical records, medical center staff frequently left messages on the veteran’s phone without getting replies,” Daigh wrote. “We could not determine if the veterans nonresponsiveness to these calls was due to his frequent travel to another care provider, poor cell phone reception or an unwillingness to respond.”

The unreturned messages and missed appointments continued. Popkowski was assigned a new primary care physician after missing three appointments in March 2007.

In February 2008, Popkowski requested treatment at a clinic closer to his home.

“He was seen by his new (physician) in February, however, he missed his next clinic appointment … in early March,” Daigh wrote. “Community-based outpatient clinic staff sent the veteran a letter requesting he call them concerning the missed appointment. There is no evidence in the record that the veteran returned the call.”

A social worker visited Popkowski in March 2008 to offer more mental health services beyond medication and management.

“He reportedly refused to schedule an appointment, stating that he was ‘sick of it’ and that would not be coming to the VA anymore,” Daigh wrote.

Meanwhile, medical health care providers noted Popkowski’s worsening symptoms.

Suicide risk foretold

A mental health provider at the clinic said in October 2008 that Popkowski might need admission if there was no improvement with the medication.

“He considered the veteran a high risk for suicide due to, among other circumstances, cancer, a shortened military career and isolation,” Daigh wrote. “The provider requested to see the veteran again in one month.”

Popkowski continued to see the mental health provider through May 2009 with no change in his depression. Symptoms including insomnia, decreased eye contact and “tearfulness” increased.

The clinic called Popkowski’s outside care provider, who recommended increasing his medication. There is no indication Popkowski was referred to a psychiatrist.

“The veteran’s last (clinic) visit was in late May 2009,” Daigh wrote. “According to medical records, the veteran was to call his provider to schedule an appointment when he returned to the area, but he did not.”

Popkowski called the clinic in June 2009 to complain about delays in receiving his medication. During that call, he reportedly made threatening comments, which were reported to VA Police and local law enforcement.

Prior threats known

The VA’s Disruptive Behavior Committee discussed Popkowski’s threats, and in March 2010 sent Popkowski a letter informing him he could only be treated at Togus’ main campus.

“The letter also stated that his medications would be renewed for 30 days only and that if he missed appointments, his medications would be discontinued,” Daigh wrote.

Popkowski met with a new primary care physician at Togus in May 2009.

“According to the provider’s notes, the veteran became upset when he found out that the provider was not fully aware of his past medication history,” Daigh wrote. “He left before the visit was complete.”

Throughout his treatment, Popkowski sought compensation from the Veterans Benefits Administration for numerous conditions. The process for receiving those benefits included a compensation and pension medical examination.

The benefits administration requested another exam in March 2010 due to “possible worsening” of Popkowski’s depression.

But he missed a scheduled exam in April, prompting officials to reduce his benefits involving care for depression.

“In late June 2010, VBA sent a letter to the veteran notifying him of the reduction in benefits,” Daigh wrote. “An excerpt from the letter stated … because you did not report for a required examination, the law says we must change the evaluation of your service-connected disability that is subject to improvement … Your (cancer) which was 100 percent, is now considered 0 percent disabling.”

Popkowski was dead less than a month later.