Federal investigators are taking a close look at the Minneapolis VA Health Care System after a patient committed suicide 24 hours after he was discharged.

Fox 9 obtained a report released Tuesday by the Veterans Affairs Office of Inspector General criticizing the way the Minneapolis hospital handled a patient seeking help for depression and suicidal thoughts.

The report highlights a number of times where a local team of healthcare professionals mismanaged follow-up treatment for a veteran who committed suicide back in February. It was in the parking lot of the Minneapolis VA hospital that police found the Iraq war veteran had shot himself.

The review came after a request from Representative Tim Walz, who’s a ranking member on the Veterans Affairs Committee. He's also running for Governor of Minnesota.

In a statement to Fox 9, Walz says in part, "the findings outlined in the Inspector General’s report are deeply disturbing. The finding that the Minneapolis VA failed to sufficiently sustain relevant recommendations [the Office of Inspector General] made in 2012 should outrage us all."

The report says the treatment team failed to manage medication follow-up procedures, did not educate the patient on access to firearms and never provided suicide behavior report training to clinical staff.


“One in five adults have a mental illness or a mental health concerns," said Trevor Johnson, senior director of behavioral health for Lutheran Social Services.

The organization has partnered with the Department of Veterans Affairs in Minnesota for 10 years to provide support for veterans struggling with a number of issues, including PTSD. Last year, they assisted more than 800 veterans and their families.

“There are still so many barriers out there and my message to anyone is if you tried to reach out and things didn’t go as planned, please do it again,” Johnson said.

The director of the Minneapolis VA hospital system declined an interview but said in a statement, "Minneapolis VA Health Care System will execute the following improvements:

•A focused review of communication and documentation across the continuum of care to minimize gaps in the delivery of care

•A comprehensive review of the current process of identifying suicide risk prior to discharge from the inpatient mental health service..."

Tim Walz's office said a suicide prevention hearing will be held on Thursday to focus on what happened. To read the full report, click here.