A newly released watchdog report contains shocking details of the St. Louis Department of Veterans Affairs (VA) and its mishandling of a 69-year-old schizophrenic patient, who ended up fatally shooting himself.

The inspector general report, which examined the treatment of numerous patients, concluded that health officials failed to properly investigate the circumstances and care behind the elderly schizophrenic patient who killed himself.

From 2011-2014, the patient, who was diagnosed with prostate cancer, slowly started to degenerate in health, but despite this downward trend, the patient either canceled or failed to show up to appointments.

During that time, he was in psychiatric treatment. In 2014, a nurse noted that the patient experienced traumatizing auditory hallucinations, in which he was commanded to shoot himself. The patient asked for a suicide hotline card.

A senior psychiatrist at the facility that same day encouraged the patient to take his medications and authorized extra medication to treat what the psychiatrist referred to as his “persistent dysphoric mood.”

Although the psychiatrist scheduled a follow-up appointment, the patient decided to cancel it, citing weather.

Just two months later, after failing to reach the veteran over the phone, the facility sent him a letter providing him with test results of his kidney function.

The letter noted that the state of his kidney was “getting worse,” adding that he was “slightly anemic” and that other results were similarly abnormal.

Two weeks after the patient received the letter, he killed himself.

A nurse involved in treating the patient signed off on initiating a review process, but the suicide prevention coordinator did not sign off, meaning that no review started until inspectors tasked with investigating the incident arrived on the scene. And inspectors didn’t perform this action until four months later. Then, the suicide prevention coordinator signed off on review.

Separately, a leadership team member (LTM) asked for an internal management review a week after he discovered the patient had died, as the member did not want to have to wait for a full peer review.

He described the case as a “pretty serious miss.”

Two psychiatrists tasked with reviewing the patient’s psychiatrist told the team member verbally that they had no real concerns.

“The LTM acknowledged to us that not asking for written feedback from the psychiatrist reviewers was an oversight,” according to the inspector general report.

One of the last major scandals at the St. Louis VA took place in 2010, when hospital administrators informed 1,800 veterans that they may have been infected with hepatitis or HIV after receiving dental work. Dental technicians decided to handwash tools and then put them in the cleaning machine, instead of following protocol and placing them directly into the cleaning machine.

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