WASHINGTON — A veteran committed suicide by setting himself on fire in front of a New Jersey VA clinic after staff at the clinic repeatedly failed to ensure he received adequate mental health care, an investigation of the death found.

Department of Veterans Affairs staff canceled an appointment Charles Ingram had in fall 2015 because a provider was unavailable, didn’t follow up to reschedule, and when he walked into the clinic to ask for an appointment, they didn’t schedule it until three months later, the VA inspector general found.

Ingram, a 51-year-old Gulf War veteran, had been approved to receive treatment at a non-VA facility, but no one at VA contacted him or scheduled the appointment.

In March 2016, shortly before his VA appointment, Ingram went to the clinic in Northfield, N.J., doused himself in gasoline and lit himself on fire. The clinic was closed at the time.

“(S)taff failed to follow up on no-shows, clinic cancellations, termination of services, and Non-VA Care Coordination consults as required,” the inspector general wrote in a report released Wednesday. “This led to a lack of ordered (mental health) therapy and necessary medications… and may have contributed to his distress.”

After the death, VA Secretary David Shulkin allocated more clinical resources to the clinic, removed the hospital director overseeing the facility and directed regional officials to take over clinic management. He also instituted same-day mental health services for urgent cases.

But the report provides a tragic glimpse of how appointment-scheduling failures, which have plagued VA facilities across the country for years, can leave veterans desperate and without treatment.

Received mental health care

Ingram had received mental health treatment at the clinic since 2011 but repeatedly had to wait more than a month for appointments. He didn’t see a therapist in the year before his death.

When patients go a year without seeing anyone, VA policy dictates that mental health providers reach out to them.

“We found no attempts to follow this process,” the inspector general said.

In early 2015, Ingram's VA psychologist asked that he be approved to get outside treatment for neurological impairment. VA administrators approved several therapy sessions. He never got them.

In response to the report, VA officials said schedulers at the Northfield clinic have received more training and new supervisors and managers have been hired. They said regional and local officials also are reorganizing non-VA care coordination.

“The new structure…ensures high-quality and timely care,” wrote Robert Boucher, acting director of the Wilmington VA Medical Center.

Members of Congress from New Jersey, who asked the inspector general to investigate Ingram's death, applauded improvements at the clinic.

“Ingram’s death was a tragedy that shook us to the core and reminded us of what’s at stake when it comes to providing care for veterans suffering from mental health issues," Sen. Cory Booker, D-N.J., said.

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