Report verifies complaints about Phoenix VA hospital suicide care

An independent federal watchdog agency says whistleblowers at the Department of Veterans Affairs hospital in Phoenix were right last year when they warned that potentially suicidal patients in the emergency room were not being cared for appropriately.

In letters to the White House and Congress, the Office of Special Counsel said investigators have verified complaints filed in 2015 by Brandon Coleman and Jared Kinnaman, two counselors at the Carl T. Hayden VA Medical Center. The employees alleged that the ER lacked mental health professionals and safeguards to prevent “elopement” — a term describing patients who walk out even though they present a danger to themselves or others.

The VA’s Office of Medical Inspector confirmed several allegations by the whistleblowers, but disputed or failed to substantiate others. Among the key findings: At least 10 patients who were deemed “at high risk of suicide” eloped in late 2014 and early 2015.

After Coleman went public with his concerns, Phoenix VA officials installed time-delayed door releases and took other steps to prevent endangered patients from walking out. No additional elopements occurred. However, Coleman subsequently reported similar concerns for potentially suicidal patients elsewhere in the hospital.

Phoenix VA Health Care System officials subsequently developed new suicide-training protocols and improved communications with non-VA detox centers that serve veterans suffering from substance abuse.

But according to the Office of Special Counsel, they also shut down Coleman’s program for substance-abusing veterans, placed him on administrative leave and unlawfully inspected his medical files.

Coleman lodged a retaliation complaint.

He won a settlement in May that included assignment to a new VA job outside of Phoenix and undisclosed compensation.

Special Counsel Carolyn Lerner praised Coleman and Kinnaman in a news release, saying they “likely saved lives by speaking up for veterans in the Phoenix VA’s care. We owe them a debt of gratitude,” she added. “They prompted long overdue changes to better protect veterans . ... I urge the Phoenix VA to keep working with whistleblowers to improve veterans’ care.”