A new report from the Veterans Affairs inspector general states that the Hampton VA Medical Center in Virginia didn’t take proper care of a veteran, and he died six weeks after his last admission at the facility in 2012.
“The veteran’s reported attempt to commit suicide was not managed as required by Veterans Health Administration (VHA) policy,” the report found. “We found that although all but one of the clinical staff members in the facility’s Emergency Department and Mental Health clinics had completed suicide risk management training, they did not identify the veteran’s suicide risk factors and did not report his recent suicidal behavior as required by VHA.”
According to the report, the veteran had had mental and sleep problems for more than four years. About two months before his death, he tried to commit suicide by mixing several medications prescribed to him. The “night of the attempt, he was discovered, assessed at a community hospital, and sent home.”
Two days later he went to the Hampton VA Medical Center’s Emergency Department once again to get help for his insomnia. He did tell the triage nurse about his suicide attempt, but the specialist who saw him did not note write about the suicide attempt. Instead, “he was prescribed sleep medication and a small supply of tranquilizers for treatment, and advised the veteran to follow up with his primary provider in 2–3 days” or return to the ED should suicidal thought return.
During his next few visits, the veteran simply received an adjustment of his medication rather than the care he should have received, investigators found: “Clinicians documented his reported suicide attempt in progress notes; however, because the veteran lacked current suicidal ideation, they did not perceive him to be at risk and thus did not report his recent suicidal behavior to the [Suicide Prevention Coordinator) for management as [Veterans Health Administration] required.”
In addition, a battery of tests failed to reveal atherosclerosis on his heart despite complaints of chest pain and shortness of breath on his part, and even though he “was known to have several risk factors for heart disease” like obesity and elevated blood fat. This heart blockage precipitated his death during his next medication overdose.
To reduce future accidental deaths like these at VA hospitals, the report recommends that all care providers follow the VHA suicide risk management training and that the facility director develops tools to assess the effectiveness of such training.
At the end of the report, the Hampton VA hospital assured the inspector general that 100 percent of its providers had received the suicide risk management training by Feb. 6.
