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.

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