Report: Veteran died by suicide
Death is latest grim chapter in story of Memphis VA hospital
A government investigation declared a military veteran ended their life after trying without success to get mental health drugs from the Memphis VA hospital. The VA Office of Inspector General disclosed the 2019 death on Thursday in a report outlining its investigation into allegations of substandard care for the unidentified veteran seeking mental health care.
Investigators did not directly link the Memphis Veterans Affairs Medical Center and the suicide, but they did describe inadequate processes in the hours before the death. They headlined their report: “Deficiencies in Care, Care Coordination, and Facility Response to a Patient Who Died by Suicide.”
The account is the latest grim chapter for a major hospital labeled in 2018 as one of the five worst in the network of 148 hospitals in the nation operated by the federal U.S. Department of Veterans Affairs. In 2017, the department brought in career U.S. Army officer David Dunning to improve Memphis VA, which serves more than 68,000 patients each year residing in Memphis and nearby Arkansas, Mississippi and Tennessee.
Asked about the incident by The
Commercial Appeal, the Memphis VA released a statement Friday afternoon in which Dunning described measures undertaken by the hospital to bolster services. He also expressed condolences. “The Memphis VA Medical Center grieves for the loss of this Veteran and extends our deepest condolences to their loved ones,” the statement says. Although the VA hospital, located in the Memphis Medical District near Downtown, has outlined broad efforts to improve services, the suicide investigation by the VA Office of Inspector General focused only on the single incident and not widespread practices in the hospital. A summary of the report made available to the public does not identify the veteran by gender, hometown or military branch.
An article in the military-oriented publication Stars and Stripes said the veteran, in their 30s, had been a patient four years and had been diagnosed with posttraumatic stress disorder. In the inspectors’ report, the summary says the veteran one day last year entered Memphis VA, told medical staff about insomnia and the need to refill psychiatric medicine prescriptions, and met with an emergency room physician.
According to the inspectors’ report, the doctor evaluated the patient for suicidal thoughts and deeming the person fit to leave the ER, discharged them “with instructions to go to the facility’s outpatient mental health clinic immediately for medication management.” However, inspectors said no documents were found that show the patient registered at the clinic or received any treatment. The inspectors’ report concludes Memphis VA “did not have a clear referral process for patients discharged from the emergency department who needed to be seen the same day in the outpatient mental health clinic.”
The report notes the veteran had relied on mental health and medical care at the Memphis VA, including sessions with counselors. However, “counseling sessions were not authorized timely due to deficiencies in coordination of care between the facility’s community care staff, community care providers, and the thirdparty administrator,” the report says. When the veteran attempted to refill prescriptions, the medicines were denied, the report says, pointing out “facility community care staff did not obtain medical record documentation for community care treatment and did not ensure care authorizations were current, resulting in the patient’s inability to receive several medication refills from the facility pharmacy.” Stars and Stripes’ account details more vividly the veteran’s apparent steps after leaving the ER doctor.
“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 newspaper reported. “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 a self-inflicted gunshot wound.”
After the death and related investigation, the Office of Inspector General made 16 recommendations to Dunning, the Memphis VA director. By Thursday, 13 recommendations had been fulfilled at the Memphis hospital, Stars and Stripes reported, noting Dunning had put in place a new process “for an emergency room patient to be escorted by an ER mental health provider to the mental health clinic for same-day care.” In response to The Commercial Appeal’s inquiry, Memphis VA released a statement Friday in which Dunning described measures undertaken by the hospital to bolster services.
“Under the close supervision of VA Midsouth Healthcare Network Director Cynthia Breyfogle, I have been working for the last 13 months to personally ensure this incident brings lasting change and real improvement to our facility,” Dunning’s statement says. “Memphis-area Veterans deserve no less .... The Memphis VA Medical Center grieves for the loss of this Veteran and extends our deepest condolences to their loved ones. According to the Memphis VA, measures taken to improve patient care include:
h Provided emergency department mental health staff and licensed independent practitioners with a formal referral process for same-day mental health treatment.
h Created templates to document communication between providers, including a discussion of disposition to ensure continuity of care between emergency department services.
h Revised the “Emergency Department Mental Health Handbook” with clear instructions on psychiatric medication management for emergency department medical providers.