A newly released government investigation has found that three Veterans Affairs health clinics “missed opportunities” to prevent a Vietnam veteran’s suicide, with failures ranging from “communication breakdowns” to completely ignoring his “multiple suicide risk factors.”
The unnamed sixty-something patient, who had previously attempted suicide in 1989, shot himself in the head in 2013. He’d been receiving treatment for chronic shoulder, neck and back pain; osteoarthritis, degenerative discs in his lower back, low bone density and a variety of nerve conditions exacerbating pain and weakness in his neck and back, and had had cervical spine surgery in the fall of 2012.
The patient bounced around from clinic to clinic beginning in 2011, when the VA reassigned him from his usual primary care clinic to one nearer his home. A year later he requested another transfer, and another six months after that.
He was also diagnosed with PTSD related to his service in Vietnam, depression, anxiety, “intermittent explosive disorder,” bipolar depression, steroid-induced mood disorder and alcohol abuse.
According to the investigation, “the patient was generally compliant and motivated for MH [mental health] treatment and medication management; he rarely cancelled an appointment.”
Yet by the winter of 2013, his condition had deteriorated significantly. His wife called a VA telephone triage during that time, telling them that her husband was in “excruciating pain,” even saying that he was “ready to blow his brains out.”
The telephone triage nurse sent a note to Suicide Prevention Staff about the call, but while they received it they did not contact her, the patient’s primary care provider or mental health care provider about his suicidal statements.
Three days later he visited a VA clinic, where a nurse noted that he said he “cannot take this pain much longer.”
“He is crying today,” wrote another VA health care provider at the time. “He has a lot of history of post-traumatic stress disorder and depression and generally not doing well.”
Despite this, the report “found no evidence PCP C [the health care provider] assessed the patient’s suicide risk or contacted the patient’s MH provider [who was co-located with PCP C] or Suicide Prevention Program staff after documenting that the patient was crying and ‘generally not doing well.’ Although we noted PCP C documented a plan to place a MH consult, the consult was not placed.”
Soon after he was admitted to a non-VA hospital for his unmanageable pain, where he stayed for over three weeks. During this time he again talked repeatedly about wanting to harm himself because of the pain, even saying he wanted to jump out a window. Despite receiving three psychiatric evaluations at the hospital before he was discharged (one psychiatrist noted “the patient endorsed suicidal and homicidal ideation”), hospital staff never contacted VA mental health services about his condition.
He committed suicide just a few days after he was discharged from the hospital.
Despite the man’s complicated health situation, requiring treatment at a variety of VA and non-VA facilities, it was not case managed, which “provides a formal process for planning, managing, and communicating a patient’s health care needs in an interdisciplinary setting.”
“We determined that, had the patient’s care been case managed, his medical and psychiatric needs may have been recognized and communicated to a [VA Mental Health] provider prior to his Hospital A discharge,” the report explained. “Additionally, had a case manager been assigned, a social worker or suicide prevention professional may have been alerted to the patient’s psychiatric state during his hospitalization and at discharge. Finally, we determined that had a case manager with a MH background been assigned, the case manager may have better appreciated the significance of the patient’s chronic pain, mental health diagnosis, and psychosocial stressors.”
Overall, the report concluded that “communication breakdowns and providers’ failures to review information available in the patient’s EHR [electronic health record] during care transitions compromised the patient’s MH and primary care. The exchange of health care information was particularly important for this high-risk MH patient with a complex psychosocial background and chronic pain history who was treated by multiple clinicians.”
Most damningly, the investigators “found no indication in the EHR that VA providers analyzed the patient’s multiple suicide risk factors: high-risk age group, history of trauma (PTSD), chronic pain, a diagnosed mental illness, a history of aggressiveness, a previous suicide attempt, loss of a family relationship [his daughter had recently moved away], and easy access to firearms.”
In what will be little comfort to the grieving widow, the report said that “VHA has extensive policy specifications to help ensure a patient’s MH course is comprehensively and continuously monitored but, in the totality of this case, the policy was more abstract than applied.”
