Veteran Charles Ingram set himself on fire in March 2016, and a subsequent VA investigation found he was not provided with proper mental health care.
Ingram, who was a 51-year-old Gulf War veteran with mental health issues, self-immolated at a New Jersey VA medical center after appointment cancellations and the lack of any follow-up at the VA, USA Today reports.
Ingram had an appointment at the VA in 2015, but staff abruptly canceled it. No one followed up with Ingram to reschedule. Despite Ingram finally walking in to directly schedule an appointment, staff didn’t book it until three months later. During the time he was waiting, Ingram lost his job, and his marriage was falling apart.
“(S)taff failed to follow up on no-shows, clinic cancellations, termination of services, and Non-VA Care Coordination consults as required,” the inspector general wrote Wednesday. “This led to a lack of ordered (mental health) therapy and necessary medications… and may have contributed to his distress.”
Ingram had been receiving treatment for mental health at the facility since 2011, but no provider had seen him in the year before he died. He also hadn’t received any medication for almost a year. According to the inspector general, providers are supposed to routinely check in on those sorts of patients.
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