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#VAFail: South Carolina VA facility did not provide quality care, potentially leading to veteran’s suicide

Hospital Emergency sign with VA Fail Text on it

By Concerned Veterans for America

According to Stop Soldier Suicide, veterans are 57% more likely to die by suicide than people who have not served in the military. Suicide is the second-leading cause of death for post-9/11 veterans, accounting for nearly a quarter of all deaths.

Veterans and their families — who already have sacrificed for this country — deserve better.

An inspector general’s report released in May 2023 shows they are not getting quality care from the Department of Veterans Affairs. That report examined the circumstances that led to the death of a veteran in South Carolina.


Veteran had history of mental, physical health struggles

According to the Office of the Inspector General (OIG), in fall 2021, a veteran in their 60s committed suicide at the Aiken Community Based Outpatient Clinic in South Carolina.

Clinicians at the facility knew about the patient’s mental health struggles.

At a visit to Aiken in spring 2021, a primary care physician reported screenings for alcohol use and depression were both positive. The OIG report said the veteran also self-reported “suicidal ideation, including thoughts of wishing they were dead, wishing they could go to sleep and not wake up, and thoughts of suicide.” The primary care physician also noted the patient was suffering from several physical ailments, including chronic neck and back pain.

The patient returned to VA facilities several times throughout the spring, summer, and fall.

Cracks in the VA system emerged right away.

At a second visit in spring 2021, for example, a different primary care physician failed to follow up on the reported alcohol use and suicidal ideation. According to the OIG report, that doctor “did not discuss” the positive alcohol and depression screens with the patient at all even though VA guidelines “require follow-up” on these matters.

The patient died by self-inflicted gunshot wound in the parking lot of Aiken months later.


“The patient received deficient clinical care”

The OIG began looking into this case after an anonymous source alleged the VA failed to “provide services,” delayed care for the patient, and then “covered up” the suicide.

The inspector general could not substantiate the claim that the suicide was covered up, but it did find the patient received “deficient clinical care.” During its review, the OIG also identified concerns related to Veterans Crisis Line (VCL) referrals and emergency department communication, suicide prevention documentation, and quality management reviews.

Specifically, the OIG identified these deficiencies:

  • Primary care providers failed to follow-up on the patient’s positive mental health screenings and to order recommended testing;
  • Facility staff failed to ensure the patient received a timely pain management appointment;
  • Pain management clinic providers failed to perform the patient’s required mental health screenings;
  • A nurse did not communicate the patient’s urgent VCL referral prior to the emergency department encounter; and
  • Suicide prevention staff failed to act after the patient’s urgent VCL referral.

On its own, the failure to provide timely help with pain management could have contributed to the veteran’s suicidal ideation.

According to Healthline, chronic pain can be “debilitating on a physical and mental level” and is “known to intensify suicidal ideation.” Healthline cited a study of 123,000 people who died by suicide between 2003 and 2014 that found 9% were dealing with chronic pain at the time of their suicide.

During a call to the VCL in summer 2021, the veteran reported suffering from “severe chronic pain and suicidal thoughts but denied a plan to complete suicide.” Despite the veteran’s obvious past struggles, “the VCL responder assessed the patient as ‘moderate to low risk,’ for suicide,” but did tell the veteran to go to the ER.

The veteran complied, but, according to the OIG, Aiken “facility suicide prevention staff failed to contact the patient” after the visit “and did not provide follow-up per VHA requirements.”


Veterans cannot afford to wait

While the OIG concluded Aiken’s staff did not cover up the suicide, the facility still made mistakes. The OIG said staff “did not initiate a timely investigation into the factors that led to the patient’s death” and “once the investigation was initiated, it did not align with VHA policy.”

Mental health care is life and death. With the United States’ daily wave of veteran suicides, and suicides at VA facilities no less, the goal should be to get veterans the treatment they need as quickly as possible, whether that is at the VA or out in the community.

Veterans cannot afford to wait. Read more about how we can reform the VA.


If you or someone you know is struggling with mental health issues, learn more about suicide prevention resources from our sister organization, Concerned Veterans for America Foundation.