Editorial: Missed signals at Minneapolis VA

It's difficult to comprehend the physical pain and mental anguish that Vietnam veteran Raymond Schwirtz must have endured in the years leading up to his suicide in 2011. And it's impossible to know whether better care from the Minneapolis Veterans Medical Center could have prevented his death.

What is disturbingly clear, though, is that the VA failed to follow up on multiple warning signs because of an unacceptable lack of coordination among key caregivers, including the former manager responsible for keeping track of suicidal patients. As the Star Tribune's Mark Brunswick reported this week, the missteps are especially troubling because the VA has tried to bolster suicide prevention programs nationwide in response to estimates that nearly 1,000 vets in the system try to commit suicide every month.

Schwirtz, a 57-year-old former Marine, suffered from multiple sclerosis, depression, chronic pain, diminished vision, and bowel and bladder problems. In 2010, he lost his wheelchair-accessible van, home and belongings in a flood outside Hammond in southeastern Minnesota.

A few months later, he told a VA therapist in an MS support group that he was feeling depressed and hopeless, but that he would not harm himself. Just five days later he was brought to an emergency room at a private hospital, where he admitted that he had tried to cut his throat.

When a nurse at the VA asked about the wound during an exam two days later, Schwirtz confirmed the suicide attempt. He was admitted, and two staff members completed suicide assessments that described his risk level as "heightened."

During the 21 days of treatment that followed, Schwirtz received psychiatric medications and attended therapy sessions. His wife called the VA in June to schedule an annual physical, but by the time a case manager returned that call Schwirtz had died from burns suffered when he poured gas on himself and lit himself on fire in the garage of his abandoned home.

An investigation launched after the Schwirtz family contacted U.S. Rep. Tim Walz, D-Minn., found that the hospital failed to follow up with Schwirtz despite the risk warning noted by the two staff members after his first suicide attempt.

The inspector general's investigators also found that the hospital's suicide prevention coordinator failed to consult with Schwirtz's treatment team. The report paints the disconcerting picture of a hospital in need of basic training on communication, patient monitoring and best practices in suicide prevention.

The Schwirtz case represents the second time in a year that the Minneapolis VA's treatment of a suicidal veteran has been criticized. An Iraq war vet who sought care at the hospital last summer was turned away even though he said he was hearing voices and felt suicidal. Just days later, he stole a car and was struck and injured in an accident. A court-appointed psychiatrist later questioned why the vet had not been admitted.

A spokesman for the Minneapolis VA would not tell Brunswick whether anyone was disciplined in the Schwirtz case. The spokesman added that the VA had already implemented some of recommendations made by the inspector general.

No one should expect the VA to work mental health miracles. In many cases, hospital staff must treat deeply disturbed patients whose lives are in tatters. The growing problem of vets needing intensive mental health care is a daunting national challenge, and to its credit the VA has increased staffing and attempted to improve its suicide prevention programs.

Clearly that system failed Raymond Schwirtz, who served his country honorably during his four years in the Marine Corps. His suicide might not have been prevented if he had received the kind of treatment the VA seeks to provide mental health patients.

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