MIAMI (CBSMiami) - Early one morning last year, Mary Zielinski received a call from the VA hospital in Miami telling her that her son was dead.
"I was in such shock that I gave him the phone," she recounts motioning toward her boyfriend, Agim Banushi. "And he was like, `Who is it?' And I said, `It's the VA calling. They're telling me that Nick's passed away.'"
Nicholas Cutter survived fourteen months in Iraq, yet he couldn't survive the rehab center designed to help him. No one told her at the time, but Cutter died of a cocaine overdose.
Zielinski had pushed for Cutter to go to the residential rehab program. When he came back from Iraq in 2010, Cutter was diagnosed with post-traumatic stress disorder. He had trouble being around people; was angry and easily agitated.
He had been attending counseling sessions at the VA center near his home in West Palm Beach, where the doctors had him on more than 20 different medications, according Zielinski and Banushi.
"He was taking upwards of 50 pills a day," Banushi said.
"These are some of his medications," Zielinski said, flipping through a large binder.
The pills, however, weren't helping. His nightmares grew. Afraid to sleep he began using cocaine to stay awake at night. His doctors in West Palm suggested he come here to the residential drug program in Miami - it was supposed to be one of the best. But he didn't want to go and leave his mother behind.
Zielinski recalled how she talked him into going.
"I specifically told him, `Do you trust me honey?' And he said, `Yes mom I trust you.' And I said. `This program will help you. This program is what you need honey.' And he trusted me and I think that's the most painful thing for me. He agreed to go to this program, because I pushed him, because I thought it was something he truly needed and would help him. I didn't know it was going to hurt him."
Zielinski only learned the truth about what happened to her son when CBS4 News provided her a copy of an Inspector General's report that investigated Cutter's death on June 1, 2013.
According to the IG report, in the hours before his death, Cutter was so high on illegal drugs in the rehab center that he had to be helped into bed by other patients. The staff at the rehab center didn't notice his altered state. The next morning he was found dead in his room.
The report, issued last month, was highly critical of the VA's drug rehab program in Miami. Investigators discovered broken security cameras, staff members who failed to check on patients, and lax drug screening. Policies to prevent drugs from being smuggled into the rehab center were not being followed. And a third of the patients in the rehab center tested positive for illegal narcotics.
The IG report garnered national attention. Florida's senators reacted with outrage.
"It's inexcusable," said Democratic Senator Bill Nelson. "Inexcusable."
Added Republican Senator Marco Rubio: "When a veteran who serves our country and puts himself in a treatment center they expect to have the same benefits they would have in a private facility."
When Zielinski read the report last week, she gasped in horror and then broke down in tears. "I feel like I sent him to the dogs, geez," she said. "I sent him to this program to help him. Never did I think this was going to happen, never."
Although the Inspector General investigation was prompted by Cutter's death, his name never appeared in the report. He's referred to only as the "unexpected patient death." CBS4 News learned his identity by digging through a variety of records. We then provided a copy of the IG report to Zielinski.
Both Zielinski and Banushi said they were never told what happened to Cutter. They said they had been given the impression Cutter might have choked to death on a sandwich.
Back in June when they first received the call that Cutter was dead, Zielinski and Banushi drove down to Miami from Palm Beach.
"They brought his belongings out to me in garbage bags," Zielinski recalled.
And all their efforts since then to find out what happened were met with silence.
"We'd call, we'd leave messages, nothing," Banushi said.
It wasn't supposed to end like this. Cutter was eager to serve his country, enlisting in the Army when he was 20.
"He wanted to better himself," Zielinski said. "He was very competitive."
When Banushi was honorably discharged in 2010, he rarely spoke to his mother about his time in Ira. In addition to PTSD, Cutter was diagnosed with a traumatic brain injury. His mother said his son's Humvee had been hit on three separate occasions with IEDs - improvised explosive devices.
"I do know that he had a battle buddy die in his arms and it affected him a great deal," she said.
The VA said they are working to address all of the issues in the IG report. They said Cutter was the first patient to die in the residential rehab program.
"We are striving for excellence and we deliver superior care," said Dr. Spencer Eth, who is in charge of all of the mental health programs at the VA.
He said he was shocked to hear that Zielinski didn't know the truth behind her son's death. He said his staff was devastated by Cutter's death.
Asked if anyone was disciplined following Cutter's death and the IG investigation, Eth responded: "We're not looking to blame; we're looking to provide care."
Pressed for answers Eth said: "He was moving along very well in his path toward recovery, he had a relapse and it was fatal. It was a tragedy that deeply affected our staffs because we are committed to helping our patients. We worked very hard with that patient and the other patients on the unit in trying to combat an extremely problem that not only affects our veterans but society at large."
Zielinski isn't so sure.
"I trusted them to take care of him," she said. "What help did they give him?"
In response to incidents like this one, Senator Rubio recently introduced a bill in the senate that would make it easier for the head of the VA to fire staffers. Rubio said the vast majority of the 300,000 people who work in the VA do an excellent job, but when there are mistakes there is virtually no accountability.
Referring to the death of Nicholas Cutter, Rubio said: "Who is held responsible for it? And can someone lose their job as a result of this sort of mismanagement? And the answer right now is no. It's almost impossible to fire someone in the government and in the VA."
Nicholas Cutter was buried in a family plot in Illinois. Earlier this month Zielinski visited his grave. A picture reveals no head stone or marker on the grave. Nearly a year after Cutter's death, Zielinski is still waiting on the VA to approve it.
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