This article contains descriptions of mental illness and suicide.
A veteran with a known history of suicidal thoughts showed up at a St. Louis hospital before dawn one morning and was left unmonitored in an exam room for hours.
Another was deemed at risk of suicide by a hospital psychiatrist in Washington, D.C., then forcibly discharged, even as he tried to stay, by the same hospital’s emergency department.
Another still in Pittsburgh was assigned a behavioral health nurse who failed to complete thorough suicide screenings or review his suicide safety plan, and didn’t follow up when he said he wished he was dead.
In all three cases, independent inspectors documented serious failures by the Department of Veterans Affairs. And in all three cases, the veterans involved went on to kill themselves or other people.
The lapses were similar to ones examined by ProPublica last week in an investigation of the VA’s handling of two veterans with serious mental disorders. Both suffered for years with inadequate care from the same clinic in Northern California, they told reporters. Their stories ended in tragedy.
The problems appear to be systemic. Over and over, the hospitals and clinics in the VA’s sprawling health care network have fallen short when it comes to treating people with mental illness.
That conclusion emerges from a ProPublica review of all of the reports published by the VA’s inspector general since 2020. That includes 162 regular surveys of facilities and 151 investigations that were triggered by a complaint or call to the office on a wide variety of alleged health care problems.
Issues with mental health care surfaced in half of the routine inspections. Employees botched screenings meant to assess veterans’ risk of suicide or violence; sometimes they didn’t perform the screenings at all. They missed mandatory mental health training programs and failed to follow up with patients as required by VA protocol.
One in 4 of the reports stemming from calls or complaints detailed similar breakdowns. In the most extreme cases, facilities lost track of veterans or failed to prevent suicides under their own roofs.
Sixteen veterans who received the substandard care killed either themselves or other people, the review revealed. An additional five died for reasons related to the poor care, such as a bad drug interaction that the reports say could have been prevented. Twenty-one such deaths is a meaningful count even for a health care system that has more than 9 million people enrolled, in the view of Charles Figley, a Tulane University professor and expert in military mental health. The VA has struggled with mental health care for decades, he said. “It’s a national disgrace.”
For grieving family…
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