A veteran died by suicide at the Minneapolis Veterans Medical Center parking lot in February, less than 24 hours after being discharged from its mental health unit.
Now, a federal agency has cited the hospital for numerous failures in the case, including not adequately documenting the patient’s access to firearms.
The report by the VA Office of Inspector General is deeply disturbing, said U.S. Rep. Tim Walz, a ranking member of the House Committee on Veterans’ Affairs who requested the review.
“This is profoundly unacceptable,” he said in a written statement. “Our work to hold VA accountable is far from over. The House Veterans’ Affairs Committee is holding a Suicide Prevention hearing this Thursday, and this tragic, systemic failure will be central to our focus.”
The Minneapolis VA said Tuesday it’s implementing the report’s recommendations and reviewing how it identifies suicide risk before discharge. It’s also reviewing ways to minimize gaps in the delivery of care.
Walz said it’s an outrage that the Minneapolis VA failed to follow some of the recommendations made by the inspector general in 2012.
The report, initiated by that office in March, cited a number of failures by the staff of the inpatient mental health unit. It also cited several failures by the system’s suicide prevention coordinator.
While the VA was cited for these failures, the investigating team was unable to determine that any one issue, or some combination, caused the patient’s death.
The report notes the rate of suicide by veterans exceeds that of U.S. civilian adult males — 37.2 per 100,000 for veterans compared to 25 per 100,000 for civilian adult males. In 2014, the number of veteran deaths by suicide averaged 20 a day, according to the Veterans Health Administration.
In 2007, the VA established a suicide prevention hotline in an effort to provide emotional support and intervention to veterans and their friends and families. Collaboration among health care professionals and treatment teams is a key in improving health care and patient safety, the report noted.
According to the inspector general’s report, the veteran in this case called the crisis line, reporting suicidal thoughts and having “immediate access to guns.” The crisis worker and the veteran, who isn’t identified in the report, developed a safety plan that included going to the VA’s emergency department.
The veteran was seen the same day at the hospital, and was evaluated and admitted into the mental health unit. By the fourth day, a nurse practitioner documented that the patient requested to be discharged and wrote that the “patient does not currently meet dangerousness criteria for a 72-hour hold or petition for commitment because [the patient] denies intent to kill or harm self or others … and is agreeable to continuing with outpatient care.”
According to the report, the patient described feeling hopeful, and the discharge summary said the patient was a low risk for suicide. The veteran denied having immediate access to a firearm but said he could obtain one.
The next day, VA police found the vet dead from a self-inflicted gunshot wound in the hospital’s parking lot.
The report cites the VA for failures such as:
• Not including the patient’s outpatient treatment team in the discharge planning.
• Not scheduling an outpatient medication management follow-up appointment.
• Not adequately documenting a firearms assessment.
• Not documenting that the patient declined to engage family in treatment and discharge planning.
“Proper documentation is necessary for sound clinical decisionmaking,” the inspector general report said.