Citation Nr: 21064273 Decision Date: 10/19/21 Archive Date: 10/19/21 DOCKET NO. 15-46 057 DATE: October 19, 2021 REMANDED Entitlement to service connection for the cause of the Veteran's death under 38 U.S.C. § 1151 is remanded. REASONS FOR REMAND The Veteran has verified active duty service in the United States Navy from August 1962 to August 1970, and from October 1970 to February 1977. The Appellant is the Veteran's surviving spouse. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2013 rating decision by the Milwaukee, Wisconsin Pension Management Center of the United States Department of Veterans Affairs (VA). The Appellant and her witness testified at a November 2018 hearing held before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing is associated with the claims file. The matter was previously before the Board, most recently in June 2021, at which time it was remanded for additional development. The Board finds there was not substantial compliance with its June 2021 remand order and another remand of this issue is necessary. See Stegall v. West, 11 Vet. App. 268 (1998). In its June 2021 remand directives, the Board requested an opinion to determine whether the Veteran's death was caused or hastened by VA carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA furnishing treatment or was an event not reasonably foreseeable. The examiner was asked to discuss whether the Veteran's diagnoses of glioblastoma multiforme and MRSA were not timely, or if they caused and contributed to the Veteran's death, and to discuss if the diagnosis of MRSA in combination with the Veteran's service-connected disabilities and with observed and documented treatment, including lack of treatment and attested mistreatment, may have had any impact on the cause of the Veteran's death. The examiner was directed to address the statements and conclusions of the private examiner. An opinion was provided in July 2021. While the opinion addressed the Veteran's diagnoses of glioblastoma multiforme and MRSA as related to the cause of the Veteran's death, the opinion failed to discuss whether the attested mistreatment of the Veteran had any impact on the cause of the Veteran's death, nor did it address the statements and conclusions of the private examiner. The opinion is therefore inadequate, and remand is required. The matters are REMANDED for the following action: 1. Return the file to a VA examiner for an addendum opinion. The claims file must be reviewed by the examiner. Based on a review of the claims file, the examiner must provide an opinion as to whether the Veteran's death was caused or hastened by VA carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA furnishing treatment or was an event not reasonably foreseeable. The statements and conclusions of the private examiner must be addressed. Statements regarding the presence of MRSA pneumonia, and regarding the failure to timely diagnose glioblastoma multiforme when focal neurological deficits were first observed, must be addressed. A complete rationale for all opinions must be provided. 2. Then, readjudicate the claim. If the matter remains denied, issue a supplemental statement of the case, and return the appeal to the Board for further consideration. WILLIAM H. DONNELLY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Margaret M. Lunger, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.