VA OIG confirmed allegations that one VA psychiatrist refused to admit a suicidal veteran hours before he committed suicide.

Why?

The inpatient unit was full.

Had VA not failed to follow certain protocol prior to the suicide, the psychiatrist may not have rejected the veteran’s request but instead admitted him right away.

How is it that despite hundreds of millions of taxpayer dollars allocated to suicide prevention, tons of public scrutiny, and numerous protocol improvements, is VA still getting it wrong?

IG Investigation Of Suicidal Veteran

The facility in question is the Iowa City VA Medical Center. The IG investigation determined the agency provided Ketchum with inadequate services but stopped short at finding that the deficiencies caused the suicide.

In July 2016, veteran Brandon Ketchum asked a VA psychiatrist to admit him for inpatient care but the psychiatrist refused. Early into the appointment, the veteran then became distraught and left the facility. Hours later, he was dead from an apparent suicide.

According to IG, “It is difficult to determine the degree, if any, to which these shortcomings contributed to the patient’s death by suicide.” Had VA properly evaluated the veterans psychosocial struggles, that knowledge may have altered the course of care.

The Iowa City facility failed to adhere to VHA policies on no-shows, treatment planning, and the use of principal MH providers. But again, IG stopped short of concluded these failures contributed materially to the suicide much less refusing to admit the veteran when the veteran asked hours before the suicide.

Lawmaker Statement

IG investigated the suicide at the behest of lawmakers that pressured the agency to look into the matter.

Iowa Senators Grassley and Ernst, Wisconsin Senator Johnson, and Iowa Representative Loebsack released the following statement about the findings in the review:

This case is a tragic example of why we must do better for our veterans. It also illustrates the importance of having independent watchdogs at federal agencies. Inspectors general review agency work and point out problems that need to be fixed and ensure that policies and procedures in place are adequate. In this case, the inspector general report made four recommendations to improve mental health treatment for veterans going forward, but could not determine if these shortcomings impacted Brandon’s care. With an average of 20 veterans committing suicide a day, the VA must do everything in its power to extend help before it is too late. When it comes to caring for these brave men and women, there is no room for error. We expect the VA to implement the recommendations thoroughly and carefully, and we intend to make sure the VA does so. The VA should go beyond the recommendations if necessary. We all have to work as hard as possible to make sure all veterans receive the care they need and deserve.

Anyone interested in the course of treatment and protocol VA is supposed to follow for suicidal ideations and suicide prevention should reach this IG report closely.

It does provide a great deal of insight into what should happen.

Source: https://www.va.gov/oig/pubs/VAOIG-16-04535-329.pdf