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Institutional Failures and Veteran Suicide

Just last week, the Office of the Inspector General released a report that was conducted at the request of then Rep. Timothy Walz to investigate the care coordination history of patients with mental health concerns and/or suicidal ideations. The report focused on the care coordination history of a patient who died by suicide at the Minneapolis VA medical center in 2018 and it revealed several key points during the eight days leading up to this unnamed veteran committing suicide while a patient at the VA facility.

Specifically, the report found that the Minneapolis VA health care providers failed to alert mental health clinicians to the patient’s condition, which resulted in inadequate mental health assessments and not enough patient supervision. The report suggested that “the failure to involve treatment team members following the patients statements or to follow up on the consult documentation resulted in missed opportunities for a clinical provider to further evaluate the patient’s condition and provide treatment that may have prevented the patient’s suicidal behavior.”

In sum, while all the nursing staff in this case had completed the required suicide prevention training, none of them complied with the Veterans Health Administration policy to refer the patient’s comments about wanting to die to the facility’s Suicide Prevention Coordinator. In fact, the patient, who remained anonymous, had received previous mental health treatment from a different VA clinic and saw improvement for 10 years while taking medications; but, that progress seemed to stop when the veteran was diagnosed with a 4-centimeter brain mass, which had to be surgically removed. Eventually, the veteran was admitted to the Minneapolis VA clinic for, among other things, suicidal ideation. At this time, the veteran was living alone, had easy access to means of suicide, and had made several comments expressing a desire to die. Yet, despite such signs, there were not any reports made to mental health providers, who could have stepped in.

Unfortunately, the failure to prevent and/or address the issue of veteran suicide remains a serious problem nationwide. Between 2008 and 2017, at least 60,000 veterans died by suicide with little sign that the crisis is abating, despite suicide allegedly being the VA’s top priority. While the VA claims that suicide prevention is its number one priority, their actions – or should I say inactions – speak louder than words.

The VA needs to seriously review its policies and procedures to address the deficient care being provided to our nation's veterans. It’s time to start appreciating the sacrifices that our veterans have made for all of us and to appropriately and time address the issue of veteran suicide. These are tragic yet preventable deaths and the VA needs to be held accountable.



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