Feds find failures at Minneapolis VA over veteran's suicide

He took his own life 24 hours after being discharged from a mental health unit.
Publish date:

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.

Next Up

coronavirus, SARS-CoV-2

Minnesota confirms America's 1st case of Brazil P.1 COVID strain

The strain was found in a Twin Cities metro resident who recently traveled to Brazil.


Gov. Walz announces education plan aimed at eliminating disparities

The plan covers seven categories, including closing the racial education gap and improving opportunities in rural Minnesota

Tax forms

Charges: Otsego cleaning business underreported sales

An Otsego woman is accused of owing more than $20,500 in sales tax, penalties and interest.

Screen Shot 2020-04-17 at 2.58.26 PM

Walz gives vaccine providers 3-day, 7-day deadlines to use doses

Those that don't use their allocation will be given less in the future.


Border officers seize more than $550K in counterfeit designer goods

The shipments of fake goods were seized on Jan. 22.

Landfill plastic bags

4 Twin Cities landfills seek to expand capacity

This comes as the area's waste-to-energy facilities are operating at capacity.

Marcus Carr

3 of 10 finalists for NCAA's top point guard award have MN ties

Not a bad way to represent the State of... Basketball?

Justice, court

Minnesota grants unconditional pardon to grandmother facing deportation

Gov. Tim Walz says it's the first full pardon granted by the state in 35 years.

covid-19, vaccine

Minnesota changes vaccine appointment process, here's what to know

Walz also announced plans for a mass vaccination event at Xcel Energy Center.

covid-19, coronavirus

Here is Minnesota's COVID-19 update for Monday, Jan. 25

The latest figures from MDH have been released.

covid-19, vaccine

Minnesota health leaders say state's vaccine progress better than figures suggest

Minnesota is lagging behind national vaccination rates, but MDH leaders say this is because it's holding 2nd doses in reserve.


Suicide hotline Crisis Connection to shut down at end of month

Hope for a lifeline of its own was ended when Gov. Mark Dayton vetoed the supplementary budget bill.

Hennepin County Jail

Inmate at Hennepin County Jail dies in 'apparent suicide'

He died on Thursday, almost a week after being found unresponsive.

Figures show worrying rise of suicides in Minnesota

Suicides have increased 40 percent since 1999.

police lights

Man found dead in car in Minneapolis, police say he shot himself

The discovery was made in the early hours of Saturday.

Charges: Minneapolis VA worker hid camera in hospital bathroom

He drilled a hole into a trashcan and placed a camera inside.