Citation Nr: 1330482 Decision Date: 09/23/13 Archive Date: 09/30/13 DOCKET NO. 05-12 714 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUE Entitlement to service connection for the cause of the Veteran's death. REPRESENTATION Appellant represented by: James G. Fausone, Attorney ATTORNEY FOR THE BOARD A. Haddock, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1974 to October 1977. He died in February 2002; the appellant is his surviving spouse. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2005 rating decision by the Detroit, Michigan, Department of Veterans Affairs (VA) Regional Office (RO). The Board denied the appeal in March 2008. The appellant appealed that decision to the Veterans Claims Court. In December 2008, the Court Clerk vacated the March 2008 Board decision and remanded the matter to the Board for development consistent with a Joint Motion for Remand. In May 2009 and April 2010, the Board remanded this claim for further evidentiary development. The claim returned to the Board in January 2012 for appellate review, at which time the Board again denied the appellant's claim. The appellant appealed the January 2012 denial to the Veterans Claims Court. In March 2013, the Court again vacated the Board decision and remanded the matter to the Board for development consistent with the March 2013 order. The Board has not only reviewed the Veteran's physical claims file but also the file on the Virtual VA and VBMS system to insure a complete review of the evidence. FINDINGS OF FACT 1. The Veteran died in February 2002. According to a copy of the Certificate of Death, the immediate cause of death was listed as gastrointestinal hemorrhage (duration of 12 days), due to (or as a consequence of) esophageal variance (duration of 12 days), due to (or as a consequence of) cirrhosis (duration of months). 2. At the time of the Veteran's death, service connection was in effect for schizophrenia, paranoid type, rated as 70 percent disabling and a right shoulder disability, rated as 20 percent disabling; for a combined disability rating of 80 percent. He had been awarded a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) from December 1993. 3. Gastrointestinal hemorrhage, esophageal variance, or cirrhosis, did not have onset during active service, and are not shown to be otherwise related to the Veteran's active service or his service-connected disabilities. 4. A disability of service origin did not cause or contribute substantially or materially to cause the Veteran's death. CONCLUSION OF LAW The criteria for service connection for the cause of the Veteran's death have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1137, 1310, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.312 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION To establish service connection for the cause of a veteran's death, the evidence must show that disability incurred in or aggravated by service either caused or contributed substantially or materially to cause death. For a service-connected disability to be the cause of death, it must singly or with some other condition be the immediate or underlying cause, or be etiologically related. For a service-connected disability to constitute a contributory cause, it is not sufficient to show that it casually shared in producing death, but, rather, a causal connection must be shown. 38 U.S.C.A. § 1310; 38 C.F.R. § 3.312. Generally, minor service-connected disabilities, particularly those of a static nature or not materially affecting a vital organ, would not be held to have contributed to death primarily due to unrelated disability. 38 C.F.R. § 3.312(c)(2). Service-connected diseases or injuries involving active processes affecting vital organs should receive careful consideration as a contributory cause of death, the primary cause being unrelated, from the viewpoint of whether there were resulting debilitating effects and general impairment of health to an extent that would render the person materially less capable of resisting the effects of other disease or injury primarily causing death. 38 C.F.R. § 3.312(c)(3). Where the service-connected condition affects vital organs as distinguished from muscular or skeletal functions and is evaluated as 100 percent disabling, debilitation may be assumed. There are primary causes of death which by their very nature are so overwhelming that eventual death can be anticipated irrespective of coexisting conditions, but, even in such cases, there is for consideration whether there may be a reasonable basis for holding that a service-connected condition was of such severity as to have a material influence in accelerating death. 38 C.F.R. § 3.312(c)(4). In such a situation, however, it would not generally be reasonable to hold that a service-connected condition accelerated death unless such condition affected a vital organ and was of itself of a progressive or debilitating nature. In adjudicating a claim, the Board determines whether (1) the weight of the evidence supports the claim or, (2) whether the weight of the "positive" evidence in favor of the claim is in relative balance with the weight of the "negative" evidence against the claim. The appellant prevails in either event. However, if the weight of the evidence is against the claim, the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board must assess the credibility and weight of all the evidence, including the medical and lay evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the appellant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. Lay statements may be competent to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. §§ 3.303(a), 3.159(a); see Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); see also Davidson v. Shinseki, 581 F.3d 1313 (2009) (noting that a layperson may comment on lay-observable symptoms). Turning to the merits of the claim, the basic facts are not in dispute. The Veteran died in February 2002. His death certificate lists the immediate cause of his death as gastrointestinal hemorrhage (12 days), due to (or as a consequence of) esophageal variance (12 days), due to (or as a consequence of) cirrhosis (months). He was 45 years old. An autopsy was not performed. At the time of his death, the Veteran was service-connected for schizophrenia, paranoid type, rated as 70 percent disabling; and a right shoulder disability, rated as 20 percent disabling; for a combined disability rating of 80 percent. He had also been awarded a TDIU from December 1993. The appellant contends that service connection for the Veteran's cause of death is warranted, as such was related to his service-connected disabilities. Specifically, she has asserted that his alcohol and drug abuse was a form of self-medication for his service-connected paranoid schizophrenia, as well as for the pain caused by his service-connected shoulder disability. In the alternative, she has asserted that the various medications he had been prescribed for his paranoid schizophrenia caused liver damage, and ultimately, cirrhosis, which led to his death. At the outset, the Board notes that a review of the Veteran's service treatment records (STRs) is silent for any complaints or diagnoses related to gastrointestinal hemorrhage, esophagal variance, or cirrhosis. Additionally, the Board notes that the STRs are silent for any complaints or diagnoses related to a mental health disability and on July 1977 separation examination his psychiatric evaluation was clinically normal. A review of the medical evidence of record shows that in early 1978, the Veteran sought treatment at a VA facility and was diagnosed with schizophrenia, paranoid complex; drug abuse; and chronic alcoholism. He was admitted, at which time he reported that he had been previously treated at a private hospital for drug and alcohol abuse for one week and that he had last used phencyclidine (PCP) in 1974, and that he had also used "a lot of LSD." The Veteran was transferred to the VA facility where he received 23 days of inpatient treatment. The April 1978 hospital summary noted final diagnoses of schizophrenia, paranoid type; drug dependence, multiple; and alcoholism, alcohol addiction. Routine laboratory testing conducted during his treatment showed elevated serum alkaline phosphatase and serum glutamic oxaloacetic transaminase (SGOT), which was indicative of liver damage secondary to drug and alcohol abuse. During his treatment, he gave a history of significant drug abuse dating back to 1972. He also a reported history of alcohol abuse dating back to 1965, and that his alcohol abuse increased in 1976. He reported that he drank a form of wine and that he drank approximately one gallon per day. In a June 1978 letter, Dr. E.H., a private physician, stated that he treated the Veteran in March 1978. Dr. E.H. reflected that at the time of his admission, the Veteran had admitted to over-indulgence in alcohol and drugs. He further stated that he felt the Veteran had started using drugs while on active service in Korea and that the laboratory tests conducted during the Veteran's treatment indicated that his liver had been damaged by the use of alcohol, and that he thought the Veteran was suffering from cirrhosis, over-indulgence of drugs and alcohol, and had possibly become a schizophrenic. The Board notes that while Dr. E.H. indicated that he thought the Veteran's drug abuse started while on active service in Korea, Dr. E.H. did not indicate what information he used to form this opinion. Here, the Board notes that medical opinions expressed in speculative language do not provide the degree of certainty required for medical nexus evidence. Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992); Bostain v. West, 11 Vet. App. 124, 127-28 (1998) (quoting Obert v. Brown, 5 Vet. App. 30, 33 (1993)). Additionally, a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). Further, the Board notes that the medical evidence of record, specifically, the Veteran's own reports and the reports from his former spouse discussed below, indicate that his drug abuse began several years prior to his active service. As such, the opinion from Dr. E.H. regarding the onset of the Veteran's drug use is assigned less probative value. An October 1989 VA treatment record shows that the Veteran was seen for a psychiatric assessment for the purpose of inpatient treatment. At that time, his then-spouse reported that he had become involved with drugs in 1968. He reported that he had a history of problems with speed and reported that he had last used speed the previous Thanksgiving holiday. He denied any other drug use. He did not discuss any alcohol abuse. He was noted to be very guarded and refused to give sensitive information or even answer some of the questions asked. The remainder of the treatment notes of record indicate that between the mid-1980s and mid-1990s, the Veteran received sporadic mental health treatment, both inpatient and outpatient, for his schizophrenia. These records reflect inconsistent reports regarding his alcohol abuse; however, he primarily reported that he had abused alcohol in the "past," but when he was receiving treatment he denied current use of alcohol or drugs. There are some records indicating the Veteran did not report or discuss alcohol abuse of any kind, and some records which reflect he denied a history of alcohol abuse entirely. Furthermore, these records indicate that when he was evaluated for inpatient treatment a physical examination would be conducted, which included routine lab work. At times, he was noted to have elevated liver enzymes. These records contain no indication that he was using alcohol as a form of "self-medication" for schizophrenia or that schizophrenia and history of alcohol abuse were related. Further, there is no indication from the private or VA treatment notes of record that his history of drug or alcohol abuse was related to service. VA treatment records from October 2000 show that the Veteran was seen for a psychiatric assessment. At that time, he reported that had not been on any medication for the past two years and that his father had died the previous December. He also reported that he had been divorced in February and that his mother had died in April. He indicated that he had been attending Alcoholics Anonymous meetings prior to his mother's death, but had resumed drinking after she had died. He reported that he was drinking a case of beer per week initially, but that had increased to a 12 pack of beer per day, which had been augmented by fifth of vodka per day. It was noted that he was scheduled for admission to the substance abuse unit in mid-October. Subsequent treatment records in December 2000 noted that he suffered from chronic liver disease, hepatitis C, cirrhosis, and elevated liver functions and that he continued to abuse alcohol. A January 2001 VA treatment record, noted that in comparison with October 2000, his liver had progressively gotten worse. He appeared jaundiced, there was a dark yellow discoloration of his skin and mucus membranes and he was strongly advised to stop drinking alcohol. He died in February 2002. In September 2009, according to the Board's May 2009 remand, the Veteran's claims files were sent to the VAMC for a review and medical opinion. In a September 2009 medical opinion, Dr. D.V. opined that the cause of death, gastrointestinal hemorrhage, esophagal variance, and cirrhosis, was at least as likely as not caused by the Veteran's alcohol dependence, which was at least as likely as not secondary to chronic schizophrenia. Dr. D.V. noted that the Veteran had psychosis and schizophrenia while he was in service and that he was service-connected. He further explained that it was not uncommon to see patients with chronic psychotic disorders who also had substance abuse disorders. Dr. D.V. indicated that he performed a review of the claims files, and noted that the Veteran's treatment records showed he had been hospitalized in October 2000 for issues concerning alcohol abuse and he was hospitalized in June 1998 and April 1998 for his schizoaffective disorder. Dr. D.V. further noted that the treatment records documented the Veteran had problems with his schizoaffective disorder and alcohol abuse in June 1997 and that the long history of records showed he at times was either, suicidal, had problems with psychosis, or was heavily drinking. Based on his review of the claims file, Dr. D.V. opined that the Veteran's chronic schizophrenia was co-morbid with his chronic alcohol dependence, and that it was at least as likely as not that his chronic alcohol dependence was secondary to his service-connected schizophrenia. Therefore, it was at least as likely as not that the Veteran's cause of death, which was likely caused by alcohol abuse, was caused by his service-connected schizophrenia. Dr. D.V. further opined that it was less likely than not that the Veteran's cause of death was related to any prescribed psychiatric medications the Veteran had taken for his schizophrenia. Upon review of Dr. D.V.'s opinion, the Board finds that it is inadequate, as it does not appear that Dr. D.V. considered the entirety of the evidence of record. In this regard, the Board notes that there is no evidence of record indicating that the Veteran had psychosis or schizophrenia while on active service. His STRs are silent for any complaints, treatment, or diagnoses of a mental health disability, and his July 1977 separation examination shows that his psychiatric evaluation was clinically normal. Further, the Board notes that the Veteran was awarded service connection for schizophrenia, paranoid complex, effective January 1989, on the basis that such disability became manifest within one year of his separation from active service as there was evidence he was treated for schizophrenia in March 1978, and not because such disability was diagnosed during active service. Therefore, Dr. D.V.'s finding that the Veteran had psychosis and schizophrenia during active service and that he was awarded service connection for such in service is not supported by the evidence of record. Next, the evidence of record strongly suggests the Veteran began abusing alcohol several years prior to his active service and his diagnosis of schizophrenia. This evidence is supported by the April 1978 hospital summary which documents the Veteran's self reports of alcohol and drug use prior to active service, as well as findings of liver damage indicating a history of alcohol and drug abuse. Further, the June 1978 letter from Dr. E.H. states that he thought the Veteran might have cirrhosis at that time. In its May 2009 remand instructions, the Board specifically mentioned the possible diagnosis of cirrhosis in 1978; however, Dr. D.V. provided no indication in his September 2009 opinion that he considered, or even reviewed this evidence. Additionally, while Dr. D.V. identified treatment notes of record indicating the Veteran was treated for alcohol abuse, Dr. D.V. provided no comment regarding many treatment notes of record which show the Veteran was clearly not treated for any issues related to alcohol abuse, and in fact, show that he denied any use of alcohol or show that he was in remission from his alcohol dependence. Therefore, the Board finds that as Dr. D.V. did not consider all the evidence of record prior to forming his opinion, the opinion is assigned less probative value. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). In order to obtain an adequate opinion, the claims files were sent to another VA examiner in September 2009 for a review and medical opinion. After review of the claims file, P.K., a board certified advanced nurse practitioner, opined that the Veteran's cause of death was not related to his service-connected schizophrenia, or the treatment for such, be it physician-directed or self-directed. The reviewer noted that the Veteran had a significant history of mental health disorders with multiple hospitalizations and that the treatment records indicated that he led a path of self destruction, which included alcohol abuse and poor compliance with his prescribed medication. The examiner noted that there was no psychiatric documentation indicating that the Veteran had been self-medicating with alcohol for his psychiatric problems, and he in fact had a history of alcohol abuse since 1965 which was documented in his claims files, which preceded both his service and his diagnosis of a mental disorder. The examiner further explained that there was no means by which to measure whether his mental health symptoms increased his alcohol consumption. The examiner also reviewed the list of medications the Veteran had been prescribed for his schizophrenia, and noted that while all of the drugs the Veteran had been prescribed can cause gastrointestinal upset as an adverse reaction, only two of the drugs he had been prescribed could cause some altered liver function. However, the evidence of record indicated that he had been abusing alcohol, which caused altered liver function, prior to his use of these medications and the medical and psychiatric records showed that he was historically non-compliant with most of his medications and treatment plans, so it was unclear how long of a period he actually took these medications. Therefore, the examiner opined that the Veteran's cause of death was not related to his service-connected schizophrenia, or the treatment for such, be it physician-directed or self-directed. As the September 2009 opinion was predicated on a full reading of the claims file and an explanation of rationale for the opinion stated, as directed by the May 2009 Board remand, it is most probative of the evidence. The Board notes that the examiner indicated that she did not conduct a review of the Veteran's private treatment records or service medical records, but that she did review VA records. However, the Board notes that the claims files, in their entirety, were sent to the examiner for review and in her opinion and rationale she referred to the "C-File" and evidence contained within the record. Therefore, the Board finds that while the examiner stated that she did not review all of the available records, it is clear from her opinion that she conducted a complete review of the claims files. In support of her claim, the appellant has provided product information for three different psychotropic medications that the Veteran had been prescribed during the course of his treatment (Pamelor, Haloperidol, and Tofranil). A review of this information shows that it is general information pertaining to medication side-effects. There was no information specific to his schizophrenia and his medication history, and whether he ever suffered from any complications as a result of his prescribed psychotropic medications. Therefore, this general product information submitted by the appellant is of very little probative value. The appellant has also submitted an October 2000 internet article which discusses research being conducted regarding the potential relationship between schizophrenia and substance abuse. This article discusses possible theories for why the rate of substance abuse is high among people with schizophrenia; however, no definitive conclusions were reached and it was noted that the area was still one of active research. The Board notes that this article provides no information specific to the Veteran's case and medical history, it is simply general research. As it has not been related to the Veteran by a competent medical professional, the Board assigned it less probative value. See Sacks v. West, 11 Vet. App. 314, 317 (1998) ("This is not to say that medical article and treatise evidence is irrelevant or unimportant; they can provide important support when combined with an opinion or a medical professional"). The appellant has argued that the Veteran's statements made during his inpatient treatment in 1978, regarding the onset of his drug and alcohol abuse, cannot be deemed credible as they were made in the midst of a delusional episode. Throughout the course of his treatment, he was historically rather inconsistent when discussing his alcohol and drug abuse with his providers. As noted above, there are treatment notes that reflect his reported a history of substance abuse, but that he was in remission; treatment notes that reflect he did not report a history of substance abuse whatsoever; and treatment notes that reflect he denied substance abuse entirely. While the Board cannot opine as to why the Veteran was so inconsistent in his reports, in the case of his reports made during his inpatient treatment in 1978, the Board finds the reports to be credible. In this regard, while the April 1978 hospital summary notes that he was suffering from auditory hallucinations and delusional ideation his orientation and memory were noted to be good. There is no indication from the hospital summary that his treatment provider found his recounting of his drug and alcohol abuse to be unbelievable or not credible. Further, laboratory testing conducted at the time of his admission revealed liver damage which was indicative of drug and alcohol abuse, which tends to support his reported history. Additionally, the June 1978 letter from the Veteran's treatment provider stated that, at that time, he thought the Veteran may have been suffering from cirrhosis, which further supports the reports of a history of alcohol abuse. Finally, the Board notes that at the October 1989 psychiatric evaluation, his then-spouse reported that the Veteran began using drugs in 1968. While he had reported that he began using drugs in 1972, and using alcohol in 1965, the Board finds that this statement by his former spouse serves to bolster his reports that his substance abuse began prior to his active service. The Board acknowledges that the Veteran and his former spouse were not married in 1968, and as such, she would not have firsthand knowledge of any such drug abuse. However, the Board finds no reason to call her credibility into question, and as she made this statement to his treating physician for the purpose of assisting his treatment, the Board finds her statement is credible evidence supporting the finding that his drug and alcohol abuse began prior to his active service. Therefore, although his 1978 statements were made while he was receiving treatment for a delusional episode, the statements are not inherently not credible, and as they are supported by other evidence of record, the Board finds that they are in fact credible with regard to when his drug and alcohol abuse began. Upon review of the evidence of record, the Board finds that service connection for the cause of the Veteran's death is not warranted. In this regard, the evidence of record does not show that the Veteran was diagnosed with gastrointestinal hemorrhage, an esophageal variance, or cirrhosis as a direct result of his active service. A review of the STR's shows that he never complained of or was diagnosed with any condition related to gastrointestinal hemorrhage, esophagal variance, or cirrhosis while on active service, nor has the appellant alleged or presented evidence of such. Further, while there is evidence that the Veteran may have had symptoms of cirrhosis as early as March 1978, within one year of his separation from active service, the Board notes that cirrhosis is not a condition listed under 38 C.F.R. § 3.309, and therefore presumption of service connection for such a disability is not warranted. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Therefore, service connection for the Veteran's cause of death on the basis that the disabilities leading to his death became manifest during service and continued since is not warranted. Further, while the record reflects that the Veteran indicated that his alcohol abuse increased in 1976 while on active service, the Board finds that service connection for his cause of death, complications of cirrhosis, on the basis that he was entitled to service connection for alcohol abuse is not warranted. In this regard, the Board notes that effective October 31, 1990, the law prohibits payment of compensation for a disability that is the result of a Veteran's own drug or alcohol abuse. Also, with respect to a claim filed after October 31, 1990, an injury or disease incurred during active service will not be deemed to have been incurred in line of duty if the injury or disease was a result of the person's own willful misconduct, including abuse of drugs or alcohol. See 38 U.S.C.A. § 105; 38 C.F.R. §§ 3.1(m), 3.301(d). Further, VA's General Counsel has confirmed that direct service connection for a disability that is a result of a claimant's own abuse of drugs or alcohol is precluded for purposes of all VA benefits for claims filed after October 31, 1990. See VAOPGCPREC 7-99 (1999) (64 Fed. Reg. 52,375) (June 9, 1999); VAOPGCPREC 2-98 (1998) (63 Fed. Reg. 31,263) (Feb. 10, 1998). Therefore, the Board finds, that to the extent the Veteran's cause of death, complications from cirrhosis, was the result of his willful alcohol and drug abuse, service connection for such is not warranted. Additionally, the Board finds that there is no evidence that the Veteran's cause of death is otherwise related to his active service, to include his service-connected disabilities. In this regard, the Board notes that the appellant has provided no evidence or argument suggesting that his service-connected right shoulder disability caused or contributed to his death. As there is no evidence of record that indicates that his right shoulder disability caused or contributed substantially or materially to his cause of death, service connection on such a basis is not warranted. The appellant has argued that the Veteran's prescribed medications for his service-connected schizophrenia caused liver damage, contributing to his cirrhosis, leading to his death. The only competent medical evidence of record that addresses this matter is the September 2009 opinion that found that while some of the Veteran's medications could cause altered liver function, his treatment records showed that he was non-compliant with his prescribed medications and his treatment plans and he had a long history of alcohol abuse, so it was less likely than not that his medications caused his death. As there are no contrary medical opinions of record, the Board finds that the September 2009 opinion is persuasive. As such, service connection on the basis that the medications prescribed for the Veteran's service-connected schizophrenia caused liver damage which led to his cirrhosis, and ultimately, his death, is not warranted. Finally, the Board finds that the evidence does not support a finding that the Veteran's cause of death was otherwise related to his service-connected schizophrenia. In this regard, the appellant's primary contention throughout the course of this appeal has been that his drug and alcohol abuse was a form of self-medication for his schizophrenia, and as such, his cause of death, complications of cirrhosis, should be service-connected. However, the Board finds that the evidence of record does not support the appellant's contention. In this regard, the Board notes that the record reflects that the Veteran's drug and alcohol abuse started prior to his active service and several years prior to the first manifestations of his schizophrenia. At the time he was first treated for symptoms of schizophrenia, he was already showing signs of liver damage caused by drug and alcohol abuse, which supports the evidence of record that he had been engaged in the abuse of drugs and alcohol for a significant period of time. Additionally, the only competent medical evidence of record that addresses the matter of a nexus between the Veteran's alcohol and drug abuse and his service-connected schizophrenia is the September 2009 medical opinion, which, after a review of the claims files, noted that none of the Veteran's treatment providers had indicated that he used drugs or alcohol as a form of self-medication and that he had a long history of alcohol abuse that pre-dated his active service and his diagnosis of schizophrenia, and therefore, his alcohol abuse, and cause of death, was not related to his service-connected schizophrenia. Further, the Board notes that the Veteran indicated that although he began abusing alcohol in 1965, this abuse increased in 1976, while on active service. While the Board has no reason to doubt the Veteran's credibility in this regard, and has already determined that the statements made during his 1978 inpatient treatment were credible, the Board finds that there is no evidence indicating that the increase in his alcohol abuse was related to his service-connected schizophrenia. In this regard, the Board notes that while the reviewer noted in her September 2009 medical opinion, that there was no means to measure whether the Veteran's mental health symptoms increased his alcohol consumption, a review of the Veteran's STRs reveals no treatment for alcohol abuse or a mental health disability in 1976, or at all during his active service. On July 1977 separation examination, his psychiatric evaluation was clinically normal and he denied any history of nervous trouble of any sort, loss of memory or amnesia, and depression or excessive worry. There is no indication that the Veteran suffered from any symptoms of a mental health disability until he was treated for such in March 1978. Therefore, the Board finds that although the Veteran reported an increase in his alcohol abuse beginning in 1976, there is no indication that such was caused by symptoms of his service-connected schizophrenia, as the first documented evidence of such disease is not until 1978. As such, the Board finds that service connection for the cause of the Veteran's death on the basis that his drug and alcohol abuse was a form of self-medication for his service-connected schizophrenia is not warranted. The Board has also considered the appellant's statements asserting a nexus between the Veteran's cause of death and his active service, to include his service connected disabilities; specifically his drug and alcohol abuse and his service-connected schizophrenia. The Board notes that while she is competent to report as to observable symptoms, i.e. that the Veteran abused drugs and alcohol, she is not competent to provide a nexus opinion between his drug and alcohol abuse and his service-connected schizophrenia, and that such was responsible for his cause of death, in the absence of credible medical evidence as she is a layperson without the specialized training necessary to address a complex question with respect to the Veteran's cause of death. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). While she cites to some supporting medical texts or treatises, there is no indication that these texts are specific to the Veteran's medical history and the competent medical evidence of record has indicated that his service-connected schizophrenia was not related to his drug and alcohol abuse, or to his cause of death. In sum, there is no competent evidence of record that the Veteran's gastrointestinal hemorrhage, esophagal variance, or cirrhosis were related to his active service or that the Veteran's service-connected disabilities caused or contributed substantially or materially to his death. Accordingly, the Board finds that the preponderance of the evidence is against the claim and entitlement to service connection for the cause of the Veteran's death is not warranted. Finally, as provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). When VCAA notice is delinquent or erroneous, the "rule of prejudicial error" applies. See 38 U.S.C.A. § 7261(b)(2) (West 2002). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. In the context of a claim for DIC benefits, § 5103(a) notice must include (1) a statement of the conditions, if any, for which a veteran was service connected at the time of his or her death; (2) an explanation of the evidence and information required to substantiate a DIC claim based on a previously service-connected condition; and (3) an explanation of the evidence and information required to substantiate a DIC claim based on a condition not yet service connected. Hupp v. Nicholson, 21 Vet. App. 342, 352-53 (2007). While there are particularized notice obligations with respect to a claim for DIC benefits, there is no preliminary obligation on the part of VA to conduct a predecisional adjudication of the claim prior to providing a § 5103(a)-compliant notice. Here, the VCAA duty to notify was satisfied by way of a letter sent to the appellant in June 2004 that addressed the notice elements of a service connection claim and was sent prior to the initial RO decision in this matter. The letter informed her of what evidence was required to substantiate the claim and of her and VA's respective duties for obtaining evidence. However, the June 2004 letter did not provide the appellant notice in compliance with Hupp. The Board notes that a subsequent letter, sent in June 2009 although sent following the initial RO decision in this matter, fully addressed all notice elements. The June 2009 letter also provided the appellant with notice of how disability ratings and effective dates were established, in compliance with Dingess. Thereafter, the appellant's claim was readjudicated, as reflected in a September 2009 supplemental statement of the case (SSOC). Therefore, any lack of notice pertaining to Hupp or Dingess is not prejudicial to the appellant's claim. Next, VA has a duty to assist a claimant in the development of the claim. This duty includes assisting him or her in the procurement of service treatment records and other pertinent records, and providing an examination when necessary. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2013). In determining whether a medical opinion be obtained, there are four factors to consider: (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing an in-service event, injury, or disease, or manifestations during the presumptive period; (3) an indication that the disability or symptoms may be associated with service; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006). After a careful review of the claims files, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the claimant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained VA and private treatment records and VA medical opinions were obtained in September 2009. As discussed above, the initial September 2009 medical opinion was inadequate and as such a subsequent opinion was obtained. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Therefore, the available records and medical evidence have been obtained in order to make an adequate determination as to this claim. Significantly, neither the appellant nor her attorney has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). (CONTINUED ON NEXT PAGE) ORDER Service connection for the cause of the Veteran's death is denied. ____________________________________________ L. HOWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs