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Watchdog found deficiencies in care for veteran who committed suicide in Minneapolis VA parking lot

The Minneapolis VA Medical Center

VA.GOV

By NIKKI WENTLING | STARS AND STRIPES Published: September 25, 2018

WASHINGTON — A government watchdog determined a Department of Veterans Affairs mental health unit in Minneapolis didn’t follow VA policies before discharging an Iraq War veteran who committed suicide in the facility’s parking lot less than 24 hours later.

The Office of Inspector General reported Tuesday that VA staff didn’t collaborate on a discharge plan for the veteran, didn’t ensure the veteran had a follow-up appointment about newly prescribed antidepressants, and didn’t adequately document whether they had access to firearms. Though the VA failed in several areas, inspectors said they couldn’t determine whether the mistakes directly led to the veteran’s suicide.

“While the OIG identified these deficits in the care provided to the patient, the OIG team was unable to determine that any one, or some combination, was a causal factor in the patient’s death,” the report reads.

The inspector general initiated its investigation at the request of Rep. Tim Walz, D-Minn., the ranking Democrat on the House Committee on Veterans’ Affairs. The committee is scheduled to discuss veteran suicide and the VA’s suicide prevention efforts at a hearing Thursday morning. 

On Wednesday, a new VA report revealed more young veterans were killing themselves. For every 100,000 veterans ages 18 to 34, 45 committed suicide in 2016, up from 40.5 in 2015. The VA deemed it a "substantial" increase. 

Overall, veterans accounted for 14 percent of suicides nationwide, yet veterans only comprise 8 percent of the U.S. population.

“This is profoundly unacceptable,” Walz said of the IG report. “The findings outlined in the inspector general’s report are deeply disturbing. Our work to hold VA accountable is far from over."

The veteran, who the IG didn’t identify, called the Veterans Crisis Line in February and told a crisis responder that he or she had suicidal thoughts and immediate access to guns. The veteran had just been kicked out of his or her home that day and was feeling overwhelmed and helpless, according to the IG report.

“Other stressors included unhappiness at work and debt related to medical bills from a motor vehicle accident the previous year,” the report reads. “The patient reported having no friends to ‘call on.’ The patient’s mood was ‘down’ and appeared frustrated, discouraged, and tearful at times. Sleep was variable with intermittent awakening and anxiety related to a previous deployment to Iraq.”

Later that day, the veteran went to the emergency department, where he or she was diagnosed with an adjustment disorder and an anxiety disorder. The veteran was then admitted to an inpatient mental health unit at the Minneapolis VA Health Care System.

Three days after being admitted and prescribed antidepressants and sleep medication, the veteran was discharged at his or her request. A nurse practitioner noted the veteran had no evidence of aggressive or dangerous behavior, agreed to continue with outpatient mental health care and denied any suicidal ideation.

“On the day of discharge, the patient described feeling ‘hopeful’ and stated, “It sounds corny but yeah, it is hopeful,’” the IG report states.

The next day, police found the veteran dead in the parking lot of the Minneapolis VA hospital, with a gunshot wound to the head. The local medical examiner determined the death a suicide.

After the IG review, inspectors made seven recommendations, one of which is to require multiple members of a veteran’s care team to decide whether a veteran is high-risk for suicide before discharging them. The IG also wants the VA to make certain that staff correctly documents whether a veteran has access to guns. In this case, three VA staff members wrote the veteran had access to guns, three said no, and three wrote they were uncertain about the veteran’s access to guns or didn’t ask.

The Minneapolis VA made similar errors in 2011, when a Vietnam War veteran committed suicide while under the facility’s care. A VA Inspector General report in 2012 found the hospital was “deficient” in how it handled the situation. Four of the recommendations the IG made after that suicide apply now, the IG wrote in its report.

“The finding that the Minneapolis VA failed to sufficiently sustain relevant recommendations OIG made in 2012 should outrage us all,” Walz said.

Ralph Heussner, a spokesman for the Minneapolis VA, said Tuesday in a statement that the hospital was on track to implement the recommendations by January 2019. In addition, local leaders are reviewing their process for identifying veterans' suicide risk before discharging them.

"It is an opportunity for the Minneapolis [VA Health Care System] to review and implement lasting improvements in the care provided their veterans," Heussner said.

wentling.nikki@stripes.com
Twitter: @nikkiwentling
     

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