TOMAH, Wis. (AP) — An investigation by the inspector general at the Department of Veterans Affairs has found that deficiencies in care at the Tomah VA contributed to the death of a 35-year-old Marine.

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Jason Simcakoski died last August from mixed drug toxicity.

A report released Thursday by the inspector general's office found that the two psychiatrists who prescribed medication to Simcakoski didn't discuss the risks of the drugs with him or his family.

In addition, the report found that staff did not immediately perform cardio pulmonary resuscitation or use an in-room emergency call system when they found him unresponsive.

The Tomah VA said in a statement that it's saddened by Simcakoski's "avoidable" death and it's committed to learning from it and improving care for veterans. The facility is implementing recommendations for improvements.