Institutional Failures Found at VA Facility After Veteran's Parking Lot Suicide

The entrance to the Minneapolis VA Hospital
A sculpture portraying a wounded soldier being helped by a doctor stands on the grounds of the Minneapolis VA Hospital. (AP Photo/Jim Mone)

The Minneapolis Veterans Affairs Health Care System facility where a veteran committed suicide nearly two years ago failed to alert mental health clinicians to the patient's condition, a VA Inspector General report found.

Released last week, the IG report was done at the request of then-Rep. Timothy Walz to investigate the care coordination history of the patient who died by suicide. As lawmakers try to solve a crisis where an estimated 20 veterans kill themselves every day, the report reveals key points during the eight days leading up to the unnamed veteran killing himself while a patient in the VA facility.

The IG staff found issues with the patient's care coordination and said it resulted in inadequate mental health assessments and not enough patient supervision.

"The failure to involve treatment team members following the patient's suicidal 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," the IG report said.

Related: Alarming VA Report Totals Decade of Veteran Suicides

In short, staff found while all the nursing staff in this case had completed the required suicide prevention training, none of them followed the Veterans Health Administration policy to refer the patient's comments about wanting to die to the facility's Suicide Prevention Coordinator.

The patient, whose gender was not revealed in the report, had received previous mental health treatment from a different VA clinic, improving for 10 years while taking antidepressants and antipsychotic medication. The progress seemed to stop when the veteran was diagnosed with a 4-centimeter brain mass and had it surgically removed.

Eventually, in spring 2018, the veteran was admitted to the Minneapolis VA clinic for, among other things, suicidal ideation. The veteran was living alone with easy access to means of suicide and withdrawal symptoms from opiates.

"The patient told the dietician [three days before the suicide], 'I wish that someone could give me a dose of morphine so I could die,'" the IG reports. "The next morning, the resident documented that the patient 'feels much better' but continued to express suicidal thoughts."

The day the patient died, a nurse overheard the veteran telling someone on the phone they would die in the hospital and "I want you to have the seven acres for all the help you have given me."

The report also found issues with reporting lessons learned to various committees, such as the National Center for Patient Safety. IG staff said these issues with internal review effectiveness and sufficiency might have resulted in "gaps in performance improvement and quality assurance processes intended to prevent further adverse events."

In addition to recommending further internal review into the death, the IG suggested the Minneapolis VA Health Care System director consult with human resources and general counsel offices on whether there should be any personnel actions resulting from this tragic event. However, the report notes the chaplain and dietician no longer work at the facility. According to the system's director, a review with HR and general counsel yielded no necessary personnel actions.

While the IG considers all its recommendations still open, the Minneapolis VA Health Care System concurred with all the guidance and presented proposals to reform the system, such as creating an "immediate warm handoff" from consultants to the inpatient clinical care team.

-- Dorothy Mills-Gregg can be reached at Follow her on Twitter at @DMillsGregg.

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