VA faulted in case of vet who set himself on fire

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.

In 2015, he requested an appointment to see his psychologist at the Northfield clinic. He was assessed in the waiting room, determined not to be in distress and given an appointment date more than three months later. 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.

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.”

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.

In a similar development, a watchdog arm of the Department of Veterans Affairs criticized record-keeping in PTSD cases at the VA’s facility in Colorado Springs. Patients there often went longer than the department’s stated goals of getting an initial consult within a week and treatment within 30 days, investigators found. In one case, a veteran killed himself 13 days after contacting the clinic, which was supposed to see him within a week.