Com­plaint prompts changes in VA pol­icy

Flag­ging sys­tem for sui­cide risk up­dated


An in­ves­ti­ga­tion by the U.S. Of­fice of Spe­cial Coun­sel into a whistle­blower’s al­le­ga­tions that care for sui­ci­dal vet­er­ans at Al­bu­querque’s Ray­mond G. Mur­phy VA Med­i­cal Cen­ter was in­ad­e­quate found pol­icy vi­o­la­tions within an un­der­staffed depart­ment and a need for change in agen­cy­wide poli­cies.

A uniden­ti­fied whistle­blower at the Al­bu­querque Vet­er­ans Af­fairs hos­pi­tal claimed in 2016 that the sui­cide preven­tion co­or­di­na­tor “reg­u­larly failed to ful­fill her as­signed du­ties ac­cord­ing to VA reg­u­la­tions, re­sult­ing in un­sat­is­fac­tory care for sui­ci­dal vet­er­ans,” ac­cord­ing to a let­ter from Henry J. Kerner of the OSC to the pres­i­dent sent on Nov. 30.

Among other al­le­ga­tions, the whistle­blower claimed the co­or­di­na­tor failed to man­age the hos­pi­tal’s “high risk for sui­cide” list by not flag­ging pa­tient records as high risk in a timely man­ner.

The flag­ging sys­tem was put into place in 2012 and re­quired VA med­i­cal cen­ters to cre­ate a list of those at high risk for sui­cide and a sys­tem for flag­ging pa­tients’ records. The flag would then be vis­i­ble to VA staff ac­cess­ing the pa­tient’s records, ei­ther at a lo­cal or na­tional level.

There was a dead­line for flag­ging in place at the VA.

Kerner noted that “a lack of re­quire­ments leads to de­lays and de­lays lead to vet­eran deaths,” and the OSC rec­om­mended the VA change pol­icy to in­clude a dead­line for the f lag­ging process.

The VA agreed and is re­vis­ing the di­rec­tive to re­quire that high-risk pa­tients’ files be flagged within 24 hours.

The in­ves­ti­ga­tion re­vealed that the co­or­di­na­tor did not per­form re­quired 90-day eval­u­a­tions for some vet­er­ans placed on the high-risk list. The in­ves­ti­ga­tion also found in­stances of de­layed re­sponses to calls to the Vet­er­ans Cri­sis Line. In one case, a re­fer­ral to the hos­pi­tal from the cri­sis line was not re­sponded to for eight days.

“OSC found the agency’s con­tention that (redacted) suc­ceeded in car­ry­ing out her du­ties re­lated to re­spond­ing to calls from the Vet­er­ans Cri­sis Line sur­pris­ing, as it si­mul­ta­ne­ously noted that (redacted) had de­layed re­sponses to mul­ti­ple calls from sui­ci­dal vet­er­ans,” Kerner wrote.

Sonja Brown, as­so­ci­ate direc­tor of the Al­bu­querque hos­pi­tal,

said the co­or­di­na­tor re­mains in her po­si­tion.

The re­port also said staffing at the hos­pi­tal was a con­cern and rec­om­mended that the hos­pi­tal en­sure the co­or­di­na­tor’s po­si­tion is ad­e­quately sup­ported.

Brown said that there are cur­rently a psy­chol­o­gist, so­cial worker and ad­min­is­tra­tive as­sis­tant staffing the sui­cide preven­tion of­fice, and that a sec­ond so­cial worker is ex­pected to join the staff in a month.

Two ad­di­tional so­cial worker po­si­tions have been ap­proved, Brown said, and the fa­cil­ity direc­tor has ap­proved staff to work over­time if needed.

Six vet­er­ans re­ceiv­ing care at the Al­bu­querque fa­cil­ity com­mit­ted sui­cide in the 2014 fis­cal year, fol­lowed by 10 in 2015 and five from Oc­to­ber 2015 to March 2016, ac­cord­ing to the re­port.

VA spokesman Cur­tis Cashour said in an email that the agency ap­pre­ci­ates the work of the OSC.

“VA be­lieves ev­ery vet­eran sui­cide is a tragedy, that’s why Sec­re­tary Shulkin has made sui­cide preven­tion the depart­ment’s num­ber one clin­i­cal pri­or­ity,” Cashour said.

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