A 33 year-old veteran with suicidal thoughts goes to the VA for help. He is admitted and receives treatment for four days. Then he is discharged. A few hours later he is found dead in his car. He had killed himself with a gun. Our investigative blog will reveal facts known in the VA healthcare system but overlooked in the formal reports produced by the Office of Inspector General (OIG).
Suicide claims the lives of our veterans at up to three times the rate of the civilian population. Yet despite this grim statistic, there are actions that healthcare providers can take to minimize the risk. The VA actually leads the private sector in terms of the specialized screening devoted to identifying patients at risk. They do this by asking veterans questions about depression, PTSD, and alcohol use, when they present for care — any care, not just at a mental health unit. It is well known that many patients will come into contact with their primary care provider a few weeks before attempting suicide.
The patient, identified as Justin Miller from Minnesota by CNN news reporter Zachary Cohen, presented to the VA Minneapolis mental health unit for help with dangerous thoughts of suicide. Per the Office of Inspector General (OIG report) the veteran, who had been previously deployed to Iraq, felt overwhelmed with life. Work wasn’t going well, debt was accumulating from prior medical bills, and he had no support system — friends were absent and one parent who busy helping their spouse who was ill.
Most significantly, Mr. Miller had a plan to commit suicide and access to a gun. In the past, he had felt helpless and put a gun to his head. The emergency department physician promptly called a psychiatrist who admitted the patient to an observational unit.
Here’s the first mistake overlooked by the OIG. Why would you expect a young man with an active suicide plan to be cured in a twenty-four hour observational unit? VA facilities aren’t HMOs and don’t have the pressure to discharge patients before they are ready. And if the VA inpatient service is full, they are able to transfer the patient to a civilian hospital. Most VA Directors abhor this option because these costs aren’t always budgeted. In fact, Most VA’s run a deficit year after year and this can negatively affect the Director’s bonus. But we digress….
The patient was later converted into a traditional inpatient mental health admission based on the nurse practitioner’s evaluation. He was followed there for about a day or so before being discharged.
Now, some of you may be asking why wasn’t the patient seen by a psychiatrist during his admission.
Mental health is a team effort and this patient was seen by nurses, the nurse practitioner, a suicide prevention coordinator, and a social worker — but no physician. This may have been due to a scarcity in recruitment because of the low salaries offered by some VAs — salaries wildly range by ten’s of thousands of dollars for similar position at different VA facilities. Ultimately, this is under the control of the Director of that VA in conjunction with the Chief of Staff. But this is speculation. We don’t know why they didn’t have a treating psychiatrist, only that they didn’t.
And while many nurse practitioners are eminently qualified to care for complex psychiatric patients depending on their training and experience, we’re not given any history on this particular provider. Were they a brand new graduate? Did they have a background in mental health work? What was their caseload? Did they have adequate back-up for supervision? None of this is mentioned.
The VA OIG concluded with a variety of system recommendations such as strengthening the team collaboration and doing a suicide risk assessment prior to a patient’s discharge. This is commonsense and doesn’t take a team of investigators to deduce — a patient who is admitted for suicidal concerns should have a full suicide risk assessment before they leave.
Yet what the OIG glossed over was the fact that similar recommendations were made for the Minneapolis VA in 2012! Specifically, they required the director of the facility to implement these recommendations and after a brief time, the OIG closed their review.
Unfortunately, everyone is responsible but no one is accountable. The directorship has turned over since 2012 we’re hoping the new medical center leadership will take these changes seriously. Our veterans lives depend upon it.