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#VAFail: Unacceptable care deficiencies may have resulted in veteran’s suicide at VA facility

Hospital Emergency sign with VA Fail Text on it

By Concerned Veterans for America

Veteran suicide is an epidemic, with an average of at least 17 veterans taking their lives every day. There are questions about whether that is a reliable number, but if anything, it’s likely higher. 

A particularly tragic part of this epidemic is the scourge of suicides at Veterans Affairs facilities.  

A 2020 Government Accountability Office report found around 55 suicides had taken place at VA facilities from just 2018 to 2019. (Though, again, that number may be unreliably low.) 

In 2021, a St. Louis area veteran joined these tragic statistics. His death might have been prevented if not for the delays and unacceptable lack of care from VA staff. 


Veteran arrives at VA; two hours later, he died 

Here are the facts as determined by the VA Office of the Inspector General:  A veteran in his 60s arrived at the emergency department of his local VA facility in St. Louis around 5:00 a.m.  

He was a regular patient at this facility and had even been admitted a few times for suicidal thoughts and substance use. In addition, he had a history of post-traumatic stress disorder, depression, and “deliberate self-harm” according to his charts. 

That morning, he entered the ER complaining of urinary retention (he struggled with prostate issues) and depression. His notes from the triage nurse included the veteran’s words “I don’t want to die” and that he was depressed and “dissatisfied with life.” 

The nurse conducted a suicide screen which was documented as negative. 

A doctor was alerted that the patient was there, and another nurse was directed to complete a bladder scan. The veteran still hadn’t been seen by the doctor at 7:30 a.m. when the first nurse reported the incoming shift replacement. 

A few minutes later, an ER technician found the veteran dead in his examination room.  

His death was later ruled a suicide by hanging. He had strangled himself with a cord hanging from some medical equipment in the room. 

How was this allowed to happen?  


VA failed veteran with delays and deficiencies 

The VA Office of Inspector General noted several deficiencies in care that could have prevented the veteran’s ultimate death.  

First, the initial nurse may not have properly administered the suicide risk assessment at the outset of the patient’s appointment. Those screenings are standardized, and questions are supposed to be asked in specific order using the specified language.  

The OIG report notes the nurse did the assessment from memory, without a computer, and then filled the answers in later in the veteran’s notes. The OIG questioned whether administering the suicide screen the right way could have changed the conclusion that the suicide risk assessment was negative. 

Second, a doctor never actually showed up to examine the veteran. 

The VA uses a metric called “door to doc”, which measures the time from when a patient arrives at the ER to being assigned and evaluated by a doctor. The target time for seeing a patient should be 25 minutes or less. 

In this case, the veteran wasn’t found in his room for around two hours after his arrival at the ER. 

The nurse’s notes said a doctor was contacted to evaluate the patient, but an administrative investigation found video footage didn’t support the nurse going to where the doctor was to alert them. 

The OIG then found the doctor was alerted about an hour later by a different nurse. At that time, the doctor was in another room resting because of a long shift and recovery from a vaccine that caused the doctor to be “slow to move”. 

The doctor saw a few other patients after returning to work, but by that time, the veteran was already dead. 

Finally, the first nurse failed to monitor the veteran after triaging his condition.  

The OIG report states that after the initial exam, the first nurses didn’t have any more contact with the veteran. A second nurse did complete the ordered bladder exam, but that seems to be the last contact with the veteran until he was found dead just after 7:30 a.m. 

To make matters worse, the VA failed this veteran in death as well. 


VA failed veteran in death 

According to the OIG, the VA facility started several investigations after the event, but there was soon confusion and deficiencies.  

Investigations were ongoing at the same time and key individuals were left out, including individuals directly involved with the incident that weren’t interviewed. 

The OIG also found that facility leadership didn’t complete a timely “institutional disclosure” to the veteran’s family. This required disclosure is an alert to the family that something went wrong during the patient’s care–like the fact that the facility didn’t check on a potentially suicidal patient for nearly two hours.  

Institutional disclosures are supposed to take place within 72 hours, generally.  

In this case, the facility’s Chief of Staff waited seven months to contact the veteran’s family about its errors. The facility also failed to follow VA requirements to report the first nurse to the state licensing board in the three states where the nurse was actively licensed. Instead, the facility started an administrative investigation into the nurse’s potentially inadequate “clinical actions, judgements, and/or decisions.” But the nurse resigned before the investigation was complete.  

A small, almost buried note from the OIG, which speaks to the depth of coverup and VA self-centeredness, stated “the OIG also identified a concern related to the chief of the Emergency Department’s conduct attempting to direct staff responses during the OIG inspection.” 

The investigation showed the VA screwed up the investigations, didn’t alert family members about the investigations until seven months later, failed to report the nurse, and then tried to steer employees’ responses to external investigations from behind the scenes. 


Veterans deserve more choices 

Veterans deserve better than a health care system with dozens of facility suicides on their record. They deserve better than to be left waiting in a room alone in a mental health crisis for hours on end before dying alone in that same room. They deserve better than a VA who is more concerned with its own image and staff than securing justice for the veteran they failed. 

This veteran served his country and his government. In return, his government failed him. 

If there is a better example of why veterans who use the VA for health care benefits need options in where they seek their care, we’d like to see it. 

The VA has a problem with facilities suicides. Read more.