The Minneapolis VA Health Care System has been cited for failures surrounding the suicide of a veteran 24 hours after he was discharged from hospital.
The VA Office of Inspector General launched an investigation into the veteran's February death at the request of 1st District Congressman Tim Walz.
It came after the Iraq War veteran was found dead from a self-inflicted gunshot wound in the parking lot of the Minneapolis VA Hospital, less than 24 hours after he'd been discharged from the same facility.
The veteran had initially come to the attention of the VA's mental health unit after calling a crisis line reporting having suicidal thoughts as well as access to guns, adding that he felt "overwhelmed, helpless and didn't know what to do," according to the Inspector General report.
He told a psychiatrist that he'd been kicked out of the home he shared with his partner of two years, and had other stressors including unhappiness at work and debts related to a medical bill he incurred after a car accident the previous year.
He was admitted to the VA's emergency department, where he was evaluated and admitted to the mental health unit, staying there for four days.
On the third day, the veteran requested he be discharged, with a nurse practitioner writing in a handoff note 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."
The nurse practitioner assessed his suicide risk as "intermediate/moderate risk."
The next day, as he was due to be discharged, the nurse practitioner assessed his suicide risk to be "low," with the patient stating he was feeling "hopeful."
He was found dead the next day by VA Police in the parking lot of the Minneapolis VA's main hospital building.
The VA was cited by the Inspector General for several reasons in relation to his care.
The failures included:
- 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.
In a statement on Tuesday, Rep. Walz said he found the Inspector General's report "deeply disturbing."
He went on to say that the Minneapolis VA's failure to follow recommendations on patient care made by the Inspector General's office in 2012 "should outrage us all."
National statistics for 2015 found that veterans accounted for 14.3 percent of all suicides among U.S. adults. The suicide rate was 2.1 times higher among veterans compared with non-veteran adults.
If you or a loved one is experiencing depression or a suicidal crisis, call The National Suicide Prevention Lifeline at 1-800-273-8255.
Also, each Minnesota county has an Adult Mental Health Crisis Response phone line. You can find them here.