Patient who was denied admittance for treatment at VA center dies six days later.
Six days after a suicidal patient visited the Department of Veterans Affairs and was dismissed, the person committed suicide. And the VA doctor who saw the patient reportedly said they “can go shoot (themselves). I do not care.” The unidentified patient whose gender was not disclosed was in their 60s and had a history of panic attacks and addiction to both opioids and tranquilizers. A new report from the VA’s Inspector General indicated the patient had walked into the VA Medical Center in Washington, D.C. and instead of being taken seriously, was released before receiving any mandatory suicide prevention planning.
Less than a week after the visit, during which the patient sought admission, the patient died from a self-inflicted gunshot wound. The medical center’s director, Mike Heimall, called the incident “isolated” and said it “does not represent the quality health care tens of thousands of D.C.-area veterans have come to expect from our facilities,” adding, “the center grieves the loss of this veteran and extends our deepest condolences to their loved ones.” The hospital, Heimall said, “has made improvements that include random audits of 20% of suicide-related emergency room visits to make sure staff followed policy and checking that staff monitors emergency-room patients who express suicidal thoughts.”
The patient came in after reportedly “having trouble sleeping because of withdrawal from prescription drugs,” according to the report. An outpatient psychiatrist indicated the individual was at “moderate” risk for suicide. But after referring the patient to ER staff, another psychiatrist rated the suicide risk as “mild” because the individual evidently denied thoughts of suicide when asked. Home care, rather than admission into the hospital, was suggested.
When the patient was briefed accordingly, the person refused to leave. That’s when unidentified “physician 2” wrote that the patient was “ranting” and “clearly malingering.” VA police officers were called to escort the patient out. Later, the doctor was told the patient wished to return complaining of knee pain and that’s when the doctor commented that the individual can “go shoot (themselves).” The statement was heard by at least three other staff members, the report states.
Though rated as having effective in-patient outcomes, the doctor was known to have a bad attitude, the chief of staff told the inspector general’s office. Last fall, the chief of staff assured “the doctor would have practice privileges suspended if another complaint was received.” However, “no formal fact-finding or administrative investigation was conducted against the doctor as required by the VA because of a ‘pattern of misconduct,’” the report indicates. After another complaint was filed against the same physician, the doctor resigned.
“The doctor who dismissed the veteran’s suicide warnings was a contract worker who is no longer welcome at the facility,” Heimall said. “The doctor’s conduct was unacceptable and does not represent the dedication and compassion our employees exhibit daily.”
“Emergency Department staff’s failure to manage this patient’s care, according to Veteran Health Administration suicide prevention policies, contributed to an inadequate assessment of suicide risk,” the report stated, noting there was a lack of coordination, too, between the initial assessment and the ER staff’s assessment of the patient’s suicide risk.