For one whistleblower, getting fired was too much

Donovan Slack | USA TODAY

TOMAH, Wis. – He left a note for the mailman: "Please call 911 – tell them to go to red barn building."

There, officers found the body of Christopher Kirkpatrick, a 38-year-old clinical psychologist who had shot himself in the head after being fired from the Tomah Veterans Affairs Medical Center.

Kirkpatrick had complained some of his patients were too drugged to treat properly, but like other whistleblowers at the facility, he was ousted and his concerns of wrongdoing were disregarded.

Retaliation against whistleblowers has become a major problem at VA facilities across the country. The U.S. Office of Special Counsel is investigating 110 retaliation claims from whistleblowers in 38 states and the District of Columbia.

After Bob McDonald took over as secretary of the Department of Veterans Affairs last year, the agency created a special office to investigate whistleblower claims and retaliation. But VA officials concede more needs to be done to prevent retaliation and embrace criticism that can improve veteran care.

The Kirkpatrick family wants that to happen sooner rather than later. His relatives are speaking publicly for the first time about what happened to him to try to pressure the agency to do more to protect whistleblowers. The following account is drawn from police records, personnel meeting notes, interviews with family members and documents preserved by the family and provided to USA TODAY.

"What happened to Chris is outrageous," brother Sean Kirkpatrick said. "My hope and my family's hope is that people will take action so this doesn't happen to anyone else."

A HEADY SUMMIT

It was his first job out of school.

Christopher Kirkpatrick had earned a doctorate in clinical psychology in August 2008, and he landed at the Tomah VA a month later. It was to be a two-year appointment. During that time, he would need to pass exams and secure a license to practice. Then the appointment could become permanent.

Before the appointment, he had done an internship at a VA facility in Chicago and trained in treating post-traumatic stress disorder, substance abuse and chronic pain.

"I am especially interested in the use of innovative treatments for PTSD," he wrote in a letter at the time. He had started a yoga program to help vets at the Chicago VA.

He seemed a perfect fit for Tomah, which provides residential and outpatient treatment for veterans with PTSD, acute mental illnesses and substance abuse issues. Moving from Chicago to rural south central Wisconsin was an adjustment. A girlfriend he was dating remained in Chicago. But for Kirkpatrick, the job was worth it.

"This was basically the first place where he was able to practice, and he was extremely excited about that," his brother recalled.

The work was tough and stressful, and he still had much to learn. During his 90-day performance review, a supervisor cautioned that he had been late for group-counseling sessions and that had to stop. Kirkpatrick later said he had to learn how to cut off appointments with other patients to be on time for groups, according to detailed notes taken by a union representative who heard him.

"I would be coming to a point in psychotherapy where a traumatized patient was opening up and I couldn't break off the session until after processing," he said, according to the notes. But Kirkpatrick, whom patients and colleagues affectionately called "Dr. K," soon figured out how to cut off sessions.

Some of the other things he was discovering, though, were troublesome. He told his brother some of his patients appeared to be overly medicated by other health care providers at Tomah, and it was preventing him from treating them. It also went against the alternative approach to treatment he preferred.

In early 2009, Kirkpatrick brought up the issue at a meeting about patient care with a team of providers. Instead of considering or addressing the concerns, a physician assistant who was at the meeting and had prescribed medications to some of Kirkpatrick's patients complained to the facility's chief of staff, Dr. David Houlihan.

In April 2009, Kirkpatrick was called to a disciplinary meeting and given a written reprimand.

"Dr. Kirkpatrick was cautioned about engaging in any further criticisms of the PA, advised to focus on his own work, and counseled that he should avoid advising on medications as it is not in his scope of practice," the reprimand stated.

Afterward, a union representative who had represented him at the meeting said in an email to Kirkpatrick the punishment should not have happened, but she advised him to stick it out.

"Try to carry on in your per-usual professional manner and know this, Chris – there is a lot going on here," wrote Lin Ellinghuysen, head of the American Federation of Government Employees Local 0007 who wrote detailed notes about every encounter she had with Kirkpatrick. "Unfortunate but true – there are employees who are suffering a great deal worse … and I don't want you to join their ranks."

A few weeks later, Kirkpatrick wrote a letter to his supervisor stating he and several colleagues had noticed problems with patients' medications, but he didn't intend to pursue the issue.

In an email to Ellinghuysen, he suggested he had been scared silent.

"I'm still really concerned about things but will keep my head down and hope for the best," he wrote.

A VA investigation -- triggered earlier this year by the revelation that a veteran died at Tomah last August from "mixed drug toxicity" -- found Kirkpatrick's concerns had been warranted. Tomah veterans were 2½ times more likely to get high doses of opiates than the national average. And they were almost twice as likely to get them in dangerous combinations with other drugs. The probe found "unsafe clinical practices" that led to patient harm.

But those findings came much too late to save Kirkpatrick.

AN UPHILL CLIMB

Kirkpatrick was the second of six children of a schoolteacher and a businessman, who raised them in Illinois and Colorado. He spent a lot of time babysitting his siblings. He had an affinity for animals and counted among his childhood pets dogs, cats, guinea pigs, birds, reptiles and a skunk.

"A care-taking role has always felt natural to me," he wrote in a VA application essay.

His life was not a glide path to success, though. A friend's suicide traumatized him when he was a teenager. He dropped out of high school. He smoked, and drank too much. But he managed to quickly pull himself together; his siblings don't know how or why. He stopped drinking, and earned his GED, a bachelor of science in clinical psychology at Northwestern University, and a doctorate at the Adler School of Professional Psychology in Chicago.

"He was extremely driven," his older sister, Katy Kirkpatrick, said.

He was a champion kickboxer in his 20s and studied and taught the combat sport Muay Thai. He loved to read and was drawn to the writings of philosopher Friedrich Nietzsche and psychoanalysts Sigmund Freud and Carl Jung. He was quick-witted, the kind of person who can read something complicated and "regurgitate the information to you in a way that was just, it would take you aback," his brother recalled.

While he was in school he worked with at-risk youth in Chicago, with inmates at a correctional center, with preschool children and juvenile delinquents. He also researched public housing residents displaced from the city's Cabrini Green project.

"Experiences have taught me to be grateful for being able to choose my own professional path," he wrote in the VA application. "In reflecting on my life and finding myself closer to finally realizing my goal of becoming a clinical psychologist I am confident that I have chosen a path with heart, grateful that I have the ability to pursue a career that I find interesting and rewarding."

One of his supervisors during his internship at the Chicago VA gave him a glowing reference.

"Mr. Kirkpatrick has my highest recommendation," VA clinical psychologist Sheilah Perrin wrote. "Dr. Kirkpatrick is appreciated and liked very much by vets + staff – all of whom wanted to hire him."

It was one of many positive recommendations he received before he started in Tomah.

THE FALL

In July 2009, three months after Tomah VA officials disciplined him for criticizing medication practices, Kirkpatrick landed in hot water again, according to Ellinghuysen's notes.

Kirkpatrick had reported that one of his veteran patients had threatened to harm him and his dog. A treatment team decided the patient should be discharged, but he never was.

Kirkpatrick wrote about what happened in the patient's record. He was disturbed and took the next two work days off, Friday and Monday. The following morning, he was summoned to another disciplinary meeting. This time, he was fired.

Management said he left an hour early one day, logged a 90-minute leave incorrectly, and took vacation and sick leave disproportionately on Mondays and Fridays. In addition, when he was permitted to bring his dog to work one day, the dog "went to the bathroom and someone other than Dr. K cleaned it up," Ellinghuysen wrote in her notes from the meeting.

Kirkpatrick was devastated and pleaded for another chance.

"I've been in a bad way. I have been taking a few days off for self-preservation. I told you that I should not be taking on so many complex cases, that I needed help," he said, according to the meeting notes. "I don't have the emotional resources to cope with this stress."

He said he had been waking up at night, anxious about patients. Toward the end of the meeting, when it became clear the decision was final, he said, "You are killing me."

"I gave up everything to come here. My girlfriend, my family, everything," he said. "This will devastate me."

And he said he believed he was being retaliated against because he had written in the patient's medical record that the facility had failed to discharge the threatening veteran.

Ellinghuysen believes the reasons go back further, to his criticism of medication practices. She thinks that put him on the radar as someone who would challenge management about treatment provided at the center. His charting the failure to discharge a potentially dangerous patient was another example of that.

As he walked with Ellinghuysen to his office to gather his belongings, he told her he was $185,000 in debt and worried about what he was going to do.

"Lin, will you try to do something for me?" he asked before leaving that day, according to her notes. "Try to get a support system so that no one else has to go through what I did, will you please do that?"

She said she would.

When he got home, evidence suggests he looked online to see what dose of Diazepam – anti-anxiety medication that had been prescribed to him – would kill him. The website he found provided no sure lethal dose.

He emailed his girlfriend in Chicago. "i will always love you dearly," he wrote. She replied, "I love you, too," but he would never see the reply.

He wrote the note for the mailman, took it to the mailbox near the road and put the flag up. He put another on the door of the red barn building where he lived, providing contact information for a kennel he wanted to take care of his dog, Kali.

Then he sat in his living room, put a 9 mm semi-automatic pistol under his chin, barrel toward his brain, and fired a single shot.

THE WRECKAGE

When police found him, he was slumped over in a pool of blood on the couch, the gun still in his right hand, which rested, limp, between his knees.

Police also found marijuana, the anti-anxiety medication that had been prescribed to him, psychedelic mushrooms, and salvia, another hallucinogenic substance.

But drug use appears to have had nothing to do with what happened to him at the Tomah VA. Ellinghuysen said it was never raised as an issue.

His family is now contemplating filing a whistleblower case on his behalf. His siblings want his personnel record and name cleared. They didn't learn the details of his work problems until earlier this year, when another Tomah whistleblower who had heard about the struggles contacted them and put them in touch with Ellinghuysen.

"It is devastating to hear about all of this from Lin only this year," sister Katy Kirkpatrick said.

The family said one of the most unsettling revelations was that Kirkpatrick had a right to appeal his firing under the Whistleblower Protection Act, but he wasn't informed of that option. It wasn't included in his termination notice and Ellinghuysen said it didn't come up at the meeting.

"I'm convinced that if he knew he had the right to appeal the Tomah VA's decision to fire him for the reasons they cited that he would still be here today," Sean Kirkpatrick said. "Chris had sacrificed everything to be there, and he knew that he was being dismissed for retaliatory reasons; had he known he had a way to fight back he most certainly would have."

VA officials said since Kirkpatrick's death, the agency has implemented online whistleblower training for 32,000 managers and executives at the agency, and now requires all employees to take a course every other year that includes a component about whistleblower rights. VA spokeswoman Genevieve Billia said notices of termination should contain language informing the affected employee of those rights. She did not respond to a message asking if that was mandatory.

A bill pending in Congress would codify the requirement that every VA employee be trained on whistleblower protections. It would also establish mandatory penalties for employees found to have retaliated against whistleblowers, and establish a new system to report claims.

The VA opposes the measure. Meghan Flanz, director of the new, whistleblower-focused VA Office of Accountability Review, said in written testimony for a congressional hearing last month that its provisions would be "unworkable."

But members of Congress say the VA has not done enough of its own accord. And Katy Kirkpatrick agrees.

"As Lin wrote in her notes, his dying declaration was to not let what happened to him happen to anyone else," she said. "Legislation must be put into place to help strengthen whistleblower protections."

Whistleblower advocate Tom Devine, the legal director of the Government Accountability Project, said the Washington organization is "flooded" with retaliation complaints from VA employees. There have been more, per capita, from the VA than from any other federal agency in the 36 years he has been helping whistleblowers, he said.

"There's lots of pockets of ugliness at the (VA)," Devine said. And it has earned the agency a dubious distinction: "It's really set the standard for whistleblower retaliation. It's set the pace."