The Minneapolis Veterans Medical Center was "deficient" in its handling of a suicidal Vietnam War veteran who killed himself while under the agency's care last year, according to a critical report into the man's death by the national VA office that investigates wrongdoing.
Even though the one-time Marine had survived a recent suicide attempt and medical records noted that he said killing himself would be "the easiest way to take care of all the problems," the hospital did not properly follow up when mental health staff warned of a heightened risk that the man, depressed and feeling numb, might try to kill himself again, according to the report from the VA Inspector General's Office released last month.
The hospital's former patient safety manager responsible for keeping track of suicidal patients learned of the man's death two weeks after he died. The head of the mental health unit did not know the man had killed himself until shortly before investigators from the Inspector General's office arrived to conduct interviews in March of this year, nine months after his death, the report said.
"While we cannot say whether implementation of [recommended] measures would have changed the outcome of this case, the facility nonetheless did not adhere to [VA] guidelines on managing this patient at high risk of suicide," the 24-page report said.
U.S. Rep. Tim Walz, D-Minn., whose office requested the investigation, said he was "deeply troubled" by its findings.
A nationwide problem
It is one of the latest criticisms of the VA's handling of some of its most vulnerable patients. VA officials estimate that nearly 1,000 veterans within the system attempt suicide each month. Every day, 18 of them are successful. One in four veterans who commit suicide were receiving VA care, either in a hospital or through outpatient programs.
Under pressure from a growing veteran population after a decade at war, the VA has launched an aggressive campaign to beef up its suicide prevention programs. It's hiring more mental-health professionals, requires a suicide prevention coordinator at each of its hospitals and has developed a national telephone crisis hotline for veterans and family members.
Earlier this year, another VA Inspector General's report found that a 75-year-old veteran who committed suicide while living in VA-supported housing in Port Charlotte, Fla., went without seeing or speaking to a case manager during nine of the 18 months he had been in the program, including the almost five months before his death.
Last year, the office was critical of a West Palm Beach, Fla., VA medical center after an Operation Desert Shield/Desert Storm veteran was able to attempt suicide twice while under its care.
"We don't know the magnitude of the problem and the VA knows this," said Rene Campos, deputy director of Government Relations for the Military Officers Association of America, an organization representing current and former military officers that has lobbied Congress for stronger suicide prevention funding. "They haven't even touched the full breadth and depth of this challenge. These are issues that will continue to manifest themselves for decades to come."
The recent Inspector General's report is also the second time in a year that the Minneapolis VA has faced criticism for how it has handled suicidal veterans. Last summer, the Minneapolis VA turned away an Iraq war veteran who came to them hearing voices and feeling suicidal.
Four days later, while still hearing voices, he stole a car and was struck and injured after running in front of a van. VA doctors who had examined him had determined he was not a threat to himself or others. A court-appointed psychologist would later say it was perplexing why the VA had not admitted the man.
A spokesman for the Minneapolis VA said it appreciated the review and already has instituted a number of the recommendations in the report.
'We trusted them'
The local investigation was launched after the widow of the Vietnam-era Marine questioned his treatment and suggested that his medications contributed to his death. She complained that the VA tried to send him to a nursing home against the family's wishes.
Veteran Raymond Schwirtz is not named in the report, but family members confirmed the investigation was launched at their request.
"This man was my life. I saw the changes. We trusted them. We knew things were getting worse," said his wife, who requested that her name not be used.
Even though the report is critical of the Minneapolis VA, family members said they are dissatisfied with the limits of its findings and are attempting to change the cause of death as suicide. His wife believes medications he was prescribed combined to cloud his judgment.
Walz's office requested the investigation after the family contacted him as constituents. He is a member of the House Veterans Affairs Committee, which oversees the VA.
"I always say I am the VA's strongest advocate and their sharpest critic. Today, I am their sharpest critic," he said. "The mistakes outlined in the report are unacceptable and I will hold the VA accountable to make certain the recommendations outlined in the report are implemented."
Schwirtz served in the Marines from 1971 to 1975. He was on full disability from illnesses that included multiple sclerosis, depression, chronic pain, diminished vision and dysfunctional bowel and bladder. He had lost his wheelchair-accessible van, his belongings and his home in a flood outside Hammond, Minn., in Wabasha County in southeastern Minnesota in September 2010, and had been living with family in Rochester since the flood.
In mid-January last year, Schwirtz told a VA therapist at an MS support group he was feeling depressed and hopeless but that he wasn't likely to harm himself because of the effect it might have on his family. Five days later, he was brought to a hospital emergency room, where he admitted that he had cut his throat.
Two days after he left the hospital, he went to the Minneapolis VA for a routine checkup. When a nurse asked about the wound, Schwirtz confirmed the suicide attempt, and he was admitted. Two staff members completed suicide risk assessments and both described his risk level as "heightened."
Over the next three weeks, psychiatric medications were prescribed and he attended therapy sessions. He was discharged after 21 days and had periodic contact with the VA over the next several months. In early June, his wife called the VA to schedule an annual physical. In early July, a case manager contacted Schwirtz's wife to coordinate the annual exam. She told the case manager that Schwirtz had died.
On June 21, 2011, Schwirtz returned to his abandoned home near Hammond, where, police reports indicate, he likely poured gasoline on himself and lit himself on fire inside the attached garage. He was airlifted to Regions Hospital in St. Paul, where he later died with burns over 65 percent of his body.
The Inspector General report faults the VA hospital's suicide prevention coordinator for failing to consult with Schwirtz's treatment team and found that the clinical team did not reassess Schwirtz's risk level when he was discharged in mid-February. Nor did the hospital continue to follow up. The last time there were any mental-health contacts with Schwirtz was 17 days after his February discharge.
A spokesman for the Minneapolis VA said the hospital has strengthened communication between departments about high-risk patients and has updated its suicide prevention training and policies.
"Every veteran's suicide is a tragedy and we appreciate the review of this incident," said VA spokesman Ralph Heussner, who would not comment on whether anyone was disciplined in the Schwirtz case. "We will use this information to improve our system of flagging potential risks."