ATLANTIC CITY, N.J. — A Gulf War veteran who set himself on fire outside a Veterans Affairs clinic and later died went nearly a year without a mental health appointment or medication, one of several serious problems government investigators found with the clinic in a report released Thursday.
The Veterans Affairs Department's inspector general found Charles Ingram III went almost a year without seeing a counselor or taking medications for his mental health problems before his death in March 2016.
He requested an appointment to see his psychologist at the Northfield clinic and was given an appointment date more than three months later. He had lost his job and was on the verge of a divorce.
The report found the clinic did not provide appropriate supervision and oversight in the 11 months before his death.
U.S. Sen Cory Booker, a New Jersey Democrat, said the report "makes clear that important policies and procedures weren't followed in the lead-up to Charles Ingram's death last year. Ingram's death was a tragedy that shook us to the core and reminded us of what's at stake when it comes to providing care for veterans suffering from mental health issues."
Booker, fellow Democratic Sen. Bob Menendez and Republican U.S. Rep. Frank LoBiondo all acknowledged improvements have been made at the clinic since then, including new leadership in the Delaware office that oversaw the New Jersey clinic and the hiring of additional staff.
VA spokesman David Cowgill said the report highlighted "unacceptable problems" that the agency is addressing by replacing the clinic's director; establishing same-day services for urgent mental health cases; hiring additional staff; and prioritizing suicide prevention efforts.
Ingram's mother and sister declined to comment on the report.
According to the report, Ingram walked into the clinic in 2015 asking for an appointment with his psychologist, who assessed him in the waiting room, determined he was not in distress and sent him to the front desk to make an appointment. A date was set more than three months hence.
While he was waiting, the report said, Ingram was experiencing stress including the loss of a job and the deterioration of his marriage. He killed himself shortly before the appointment date by setting himself on fire outside the clinic, which was closed at the time.
"We found that staff failed to follow up on clinic cancellations, patient no-shows, and appointments for approved care in the community, leaving the patient without follow up appointments and refills for prescribed medications," the report read. "We found that clinical staff failed to acknowledge and document the lack of appointments for this patient and failed to reach out to the patient to re-engage him in therapy as required."
They also found that clinic staff failed to make appointments for his care in non-VA community facilities, even though such care had been authorized.
"We were unable to determine whether addressing these issues during the course of treatment would have resulted in a different outcome for the patient," the report concluded. "However, addressing these issues now will help facilitate a more patient-centered environment, especially for veterans with complex (mental health) and psychosocial issues such as the patient discussed in this report."
This story has been updated to correct that Ingram died later, not outside the clinic.