Veteran Died by Suicide After Not Receiving Needed Care at Memphis VA, IG Report Says

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The Memphis VA Medical Center in Tennessee. Department of Veterans Affairs photo
The Memphis VA Medical Center in Tennessee. Department of Veterans Affairs photo

WASHINGTON -- A veteran died by suicide one day after seeking treatment at the veterans hospital in Memphis, Tennessee, where the patient "did not receive the care needed," an investigation found.

The incident was the subject of a report released Thursday by the Department of Veterans Affairs Office of Inspector General. The report does not identify the patient and omitted identifying factors, such as gender.

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The veteran, in his or her 30s, sought treatment at the Memphis VA Medical Center in summer 2019. He or she had been diagnosed with post-traumatic stress disorder, was suffering from insomnia and was out of psychiatric medications. An emergency room doctor discharged the veteran with instructions to go to the facility's outpatient mental health clinic, but there was no evidence the patient received treatment there.

A family member who accompanied the veteran to the hospital told inspectors that they went to the mental health clinic, where they waited an hour before being told that the next available appointment was in one month. The veteran was able to get a 10-day refill of one antidepressant that day but did not receive refills for a medication that prevents nightmares or another that treats insomnia.

The next day, the veteran died by suicide.

The IG's office found that the hospital didn't have a process to refer emergency room patients who needed to be seen the same day in the mental health clinic.

"Without a clear referral process, patients are at risk for receiving inadequate care," the report states.

A family member of the veteran emailed the hospital 11 days after the suicide, describing concerns about inadequate care. The IG found fault with how hospital leaders responded.

"The family member's email was shared with several facility leaders, but no facility staff member assumed responsibility to contact the family to address or resolve the complaint," the report states.

In addition, the IG's office looked through the patient's treatment history and found other problems with care.

The veteran was treated by the VA and a community provider from 2015 to 2019. The IG discovered that in 2017 and 2018, the patient didn't have access to several community care counseling sessions because of "deficiencies in coordination" between the VA and the providers.

In total, the IG's office issued 16 recommendations to the Memphis hospital. As of Thursday, the hospital had fulfilled 13 of those. Because of the suicide, the facility created a process for an emergency room patient to be escorted by an ER mental health provider to the mental health clinic for same-day care, David Dunning, medical center director, wrote to the IG.

In July, the Inspector General released a report about another veteran's suicide after visiting the Washington, D.C., VA Medical Center. A veteran battling opioid withdrawal and suicidal thoughts begged to stay at the Washington veterans hospital one night in early 2019. Instead, a doctor had the veteran escorted out by police and said the patient could "go shoot [themself]. I do not care."

Six days later, the veteran died from a self-inflicted gunshot wound.

September is the national Suicide Prevention Awareness Month. Through its "Be There" campaign, the VA is encouraging people to reach out to the veterans in their lives.

Veterans in crisis can call the Veterans Crisis Line any time at 800-273-8255 and press 1, or text 838255.

Related: VA 'Negligent' in Veteran's Parking-Lot Suicide, Mother Says

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