Minneapolis VA Faulted for Suicide Policy Lapses
It didn’t follow up on despondent patient who killed himself while under the agency’s care, the VA Inspector General’s Office said
by Mark Brunswick
Star Tribune, Aug. 28, 2012
The Minneapolis Veterans Medical Center was “deficient” in its handling of a suicidal Vietnam War veteran who killed himself while under the agency’s care last year, according to a critical report into the man’s death by the national VA office that investigates wrongdoing.
Even though the one-time Marine had survived a recent suicide attempt and medical records noted that he said killing himself would be “the easiest way to take care of all the problems,” the hospital did not properly follow up when mental health staff warned of a heightened risk that the man, depressed and feeling numb, might try to kill himself again, according to the report from the VA Inspector General’s Office released last month.
The hospital’s former patient safety manager responsible for keeping track of suicidal patients learned of the man’s death two weeks after he died. The head of the mental health unit did not know the man had killed himself until shortly before investigators from the Inspector General’s office arrived to conduct interviews in March of this year, nine months after his death, the report said.
“While we cannot say whether implementation of [recommended] measures would have changed the outcome of this case, the facility nonetheless did not adhere to [VA] guidelines on managing this patient at high risk of suicide,” the 24-page report said.
U.S. Rep. Tim Walz, D-Minn., whose office requested the investigation, said he was “deeply troubled” by its findings.
A nationwide problem
It is one of the latest criticisms of the VA’s handling of some of its most vulnerable patients.
VA officials estimate that nearly 1,000 veterans within the system attempt suicide each month. Every day, 18 of them are successful.
One in four veterans who commit suicide were receiving VA care, either in a hospital or through outpatient programs.
Under pressure from a growing veteran population after a decade at war, the VA has launched an aggressive campaign to beef up its suicide prevention programs.
It’s hiring more mental-health professionals, requires a suicide prevention coordinator at each of its hospitals and has developed a national telephone crisis hotline for veterans and family members.
Earlier this year, another VA Inspector General’s report found that a 75-year-old veteran who committed suicide while living in VA-supported housing in Port Charlotte, Fla., went without seeing or speaking to a case manager during nine of the 18 months he had been in the program, including the almost five months before his death.
Last year, the office was critical of a West Palm Beach, Fla., VA medical center after an Operation Desert Shield/Desert Storm veteran was able to attempt suicide twice while under its care.
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Filed under: Resources Tagged: | Congressman Tim Walz, Iraq, Lance Cpl. Jonathan Schulze, Minneapolis Veterans Medical Center, PTSD, Raymond Schwirtz, Suicide prevention, VA Inspector General Office, Veterans Affairs, Vietnam Veterans