The Inspector General for the Veterans Administration criticized the San Diego Veterans Affairs Health Care System for the handling of the death of a veteran, who died by suicide in 2018.
The inspector general was critical of the process the VA used to remove a red flag from his file that would indicate whether a patient was at high risk for suicide. The report is also critical of the national Veteran Health Administration for not outlining a specific policy for when the flags should be removed.
The San Diego VA was treating an unnamed veteran in his 20s who had earlier attempted suicide by asphyxiation. The veteran had sought treatment on and off at the VA since 2017, both in the VA hospital system and through a private psychologist and psychiatrist clinician paid for by the Veterans Choice program.
In the fall of 2017, his psychologist assessed him at being high risk for suicide, after the patient admitted he had attempted suicide in the summer. The patient was never involuntarily admitted to the VA, but he was called repeatedly by staff, when he missed several appointments.
In the summer of 2018, the patient came to the ER complaining of suicidal thoughts. He was evaluated by a psychiatrist. After turning down voluntary in patient treatment, he was allowed to leave. Five days after he left the ER, his outpatient psychiatrist attempted to call him but he did not respond. The veteran died of asphyxiation two days after a medical support assistant mailed a letter, after being unable to reach the patient by phone.
The Inspector General’s report was critical for the San Diego VA’s decision to remove the flag that showed the patient was at high risk for suicide sometime in the spring of 2018.
“It is possible that if staff outreach occurred in spring 2018, the patient may have re-engaged in care . . . and the monitoring of the patient would have been more intensive,” the IG report states.
The report points to the lack of a consistent policy throughout the VA system to determine when the high risk status should be removed. The report indicates the VA is in the process of developing guidelines under the National Suicide Prevention Program.
The report also recommends the San Diego VA strengthen its process for accurately documenting the medications being taken by its patients.
In a statement, the San Diego VA said they are “working with the VA Office of Mental Health and Suicide Prevention to assure that consistent processes are developed and implemented for the management of flags alerting staff to the presence of Veterans who may be at higher risk for suicide.”
