Misconduct, Failures, and Miscommunication Contributed to Patient Suicide at Washington VAMC

The US Department of Veterans Affairs (VA) Office of Inspector General (OIG) recently completed a highly critical investigation into allegations concerning the care of a suicidal patient in the Washington, DC, VA Medical Center Emergency Department (ED). The patient committed suicide by gunshot 6 days after an ED visit in which a VA provider reportedly commented, “[The patient] can go shoot [themself]. I do not care.”

In early 2019, the patient, who was in his 60s and had a history of panic attacks, painkiller addiction, and various injuries, came to the ED complaining of alprazolam and oxycodone withdrawal and insomnia. He asked to be admitted for detoxification. The ED resident physician documented that request and recommended outpatient psychiatry follow-up. The attending physician documented agreement with the assessment, and an ED social worker scheduled the patient for a same-day outpatient psychiatry evaluation. However, the patient, along with a family member, told a Veteran Experience Specialist he was dissatisfied with care, and again requested admission for inpatient detoxification. The specialist accompanied the patient and family member to the ED and informed a staff member of the patient’s preference for admission.

Following this, the patient presented to the outpatient psychiatry appointment, where a psychiatrist assessed his suicide risk as “moderate” and recommended admission. He was escorted back to the ED, where the psychiatrist reportedly handed him off both verbally and with an alert in the electronic health record to the attending physician. The family member told the OIG that the outpatient psychiatrist had indicated that the patient was going to be admitted to the detoxification of the psychiatry unit. The family member left, thinking the patient was being admitted.

A physician assistant documented the patient’s chief complaint as anxiety, documented the patient’s suicidal ideation, and placed a psychiatry consult to evaluate the patient for inpatient admission. The consulting psychiatry resident and attending psychiatrist deemed him at mild risk of suicide and didn’t meet the criterial for inpatient admission. They recommended outpatient care, and that the patient be discharged and sent home. The patient, though, refused to leave. A second ED attending physician documented that the patient was “clearly malingering” and “ranting.” Police were called to escort him out. At least 3 hospital staff members said they heard the physician say “I do not care,” if the patient committed suicide. A family member later called the facility’s medical advice line and told the on-call nurse that the patient had died at home 6 days after the ED visit.

The OIG found numerous preventable mix-ups, oversights, and outright misconduct throughout this patient’s health care experience. Notably, the patient navigated 2 transitions between the ED and outpatient Mental Health Clinic and saw 7 providers over the course of 12 hours. The lack of collaboration between the various health care providers, deficiencies in the hand-off process, and ED and inpatient mental health providers’ failure to read the outpatient psychiatrist’s notes led to a “compromised understanding” of the patient’s treatment needs and a failure to enact the outpatient psychiatrist’s recommended treatment plan.

For instance, 2 days after the patient presented to the ED, the outpatient psychiatrist entered a consult for the outpatient substance use treatment program indicating that the patient was informed of the appointment date and time (5 days after the ED visit); however, the OIG found no evidence that staff informed the patient of the appointment date and time. An outpatient nurse closed the consult and added a comment that the patient was to report to the treatment program 5 days after the ED visit. Contrary to Veterans Health Administration (VHA) policy, the OIG report says, the nurse explained that an appointment was not scheduled because it was not program procedure at the time. The nurse mistakenly thought the patient already was receiving outpatient treatment, and because the patient had no scheduled appointment, staff did not follow up when he missed it.

The OIG also found that the facility’s Suicide Prevention Coordinator had failed to complete the suicide behavior report following notification of the patient’s death by suicide, as required by VHA. In fact, the coordinator was unable to locate a suicide behavior report. Moreover, the OIG says, the ED failed to meet VHA’s requirements for a safe and secure evaluation area for patients seeking mental health services. A renovation project begun in 2009 to include 3 mental health examination rooms had been on hold.

Regarding the doctor who was heard making the callous statement, the OIG found that, despite the facility leaders’ awareness of the comment and of the doctor’s “prior pattern of misconduct,” they did not conduct a formal fact-finding or administrative investigation as required by the VA. Instead, they seemed to focus on the physician’s “overall positive clinical outcomes.”

The doctor “was never a VA employee, only worked on a contract basis and is no longer welcome at the facility,” said Dr. Michael Heimall, the center’s director, in a statement to The New York Times.

He added that the episode has prompted the hospital to change its policies. Among the changes: a “comprehensive education program” on employee misconduct and patient abuse has been instituted. Further, now only the Chief of Staff can reverse the outpatient mental health provider’s recommendation for a patient’s admission.

The US Department of Veterans Affairs (VA) Office of Inspector General (OIG) recently completed a highly critical investigation into allegations concerning the care of a suicidal patient in the Washington, DC, VA Medical Center Emergency Department (ED). The patient committed suicide by gunshot 6 days after an ED visit in which a VA provider reportedly commented, “[The patient] can go shoot [themself]. I do not care.”

In early 2019, the patient, who was in his 60s and had a history of panic attacks, painkiller addiction, and various injuries, came to the ED complaining of alprazolam and oxycodone withdrawal and insomnia. He asked to be admitted for detoxification. The ED resident physician documented that request and recommended outpatient psychiatry follow-up. The attending physician documented agreement with the assessment, and an ED social worker scheduled the patient for a same-day outpatient psychiatry evaluation. However, the patient, along with a family member, told a Veteran Experience Specialist he was dissatisfied with care, and again requested admission for inpatient detoxification. The specialist accompanied the patient and family member to the ED and informed a staff member of the patient’s preference for admission.

Following this, the patient presented to the outpatient psychiatry appointment, where a psychiatrist assessed his suicide risk as “moderate” and recommended admission. He was escorted back to the ED, where the psychiatrist reportedly handed him off both verbally and with an alert in the electronic health record to the attending physician. The family member told the OIG that the outpatient psychiatrist had indicated that the patient was going to be admitted to the detoxification of the psychiatry unit. The family member left, thinking the patient was being admitted.

A physician assistant documented the patient’s chief complaint as anxiety, documented the patient’s suicidal ideation, and placed a psychiatry consult to evaluate the patient for inpatient admission. The consulting psychiatry resident and attending psychiatrist deemed him at mild risk of suicide and didn’t meet the criterial for inpatient admission. They recommended outpatient care, and that the patient be discharged and sent home. The patient, though, refused to leave. A second ED attending physician documented that the patient was “clearly malingering” and “ranting.” Police were called to escort him out. At least 3 hospital staff members said they heard the physician say “I do not care,” if the patient committed suicide. A family member later called the facility’s medical advice line and told the on-call nurse that the patient had died at home 6 days after the ED visit.

The OIG found numerous preventable mix-ups, oversights, and outright misconduct throughout this patient’s health care experience. Notably, the patient navigated 2 transitions between the ED and outpatient Mental Health Clinic and saw 7 providers over the course of 12 hours. The lack of collaboration between the various health care providers, deficiencies in the hand-off process, and ED and inpatient mental health providers’ failure to read the outpatient psychiatrist’s notes led to a “compromised understanding” of the patient’s treatment needs and a failure to enact the outpatient psychiatrist’s recommended treatment plan.

For instance, 2 days after the patient presented to the ED, the outpatient psychiatrist entered a consult for the outpatient substance use treatment program indicating that the patient was informed of the appointment date and time (5 days after the ED visit); however, the OIG found no evidence that staff informed the patient of the appointment date and time. An outpatient nurse closed the consult and added a comment that the patient was to report to the treatment program 5 days after the ED visit. Contrary to Veterans Health Administration (VHA) policy, the OIG report says, the nurse explained that an appointment was not scheduled because it was not program procedure at the time. The nurse mistakenly thought the patient already was receiving outpatient treatment, and because the patient had no scheduled appointment, staff did not follow up when he missed it.

The OIG also found that the facility’s Suicide Prevention Coordinator had failed to complete the suicide behavior report following notification of the patient’s death by suicide, as required by VHA. In fact, the coordinator was unable to locate a suicide behavior report. Moreover, the OIG says, the ED failed to meet VHA’s requirements for a safe and secure evaluation area for patients seeking mental health services. A renovation project begun in 2009 to include 3 mental health examination rooms had been on hold.

Regarding the doctor who was heard making the callous statement, the OIG found that, despite the facility leaders’ awareness of the comment and of the doctor’s “prior pattern of misconduct,” they did not conduct a formal fact-finding or administrative investigation as required by the VA. Instead, they seemed to focus on the physician’s “overall positive clinical outcomes.”

The doctor “was never a VA employee, only worked on a contract basis and is no longer welcome at the facility,” said Dr. Michael Heimall, the center’s director, in a statement to The New York Times.

He added that the episode has prompted the hospital to change its policies. Among the changes: a “comprehensive education program” on employee misconduct and patient abuse has been instituted. Further, now only the Chief of Staff can reverse the outpatient mental health provider’s recommendation for a patient’s admission.

The US Department of Veterans Affairs (VA) Office of Inspector General (OIG) recently completed a highly critical investigation into allegations concerning the care of a suicidal patient in the Washington, DC, VA Medical Center Emergency Department (ED). The patient committed suicide by gunshot 6 days after an ED visit in which a VA provider reportedly commented, “[The patient] can go shoot [themself]. I do not care.”

In early 2019, the patient, who was in his 60s and had a history of panic attacks, painkiller addiction, and various injuries, came to the ED complaining of alprazolam and oxycodone withdrawal and insomnia. He asked to be admitted for detoxification. The ED resident physician documented that request and recommended outpatient psychiatry follow-up. The attending physician documented agreement with the assessment, and an ED social worker scheduled the patient for a same-day outpatient psychiatry evaluation. However, the patient, along with a family member, told a Veteran Experience Specialist he was dissatisfied with care, and again requested admission for inpatient detoxification. The specialist accompanied the patient and family member to the ED and informed a staff member of the patient’s preference for admission.

Following this, the patient presented to the outpatient psychiatry appointment, where a psychiatrist assessed his suicide risk as “moderate” and recommended admission. He was escorted back to the ED, where the psychiatrist reportedly handed him off both verbally and with an alert in the electronic health record to the attending physician. The family member told the OIG that the outpatient psychiatrist had indicated that the patient was going to be admitted to the detoxification of the psychiatry unit. The family member left, thinking the patient was being admitted.

A physician assistant documented the patient’s chief complaint as anxiety, documented the patient’s suicidal ideation, and placed a psychiatry consult to evaluate the patient for inpatient admission. The consulting psychiatry resident and attending psychiatrist deemed him at mild risk of suicide and didn’t meet the criterial for inpatient admission. They recommended outpatient care, and that the patient be discharged and sent home. The patient, though, refused to leave. A second ED attending physician documented that the patient was “clearly malingering” and “ranting.” Police were called to escort him out. At least 3 hospital staff members said they heard the physician say “I do not care,” if the patient committed suicide. A family member later called the facility’s medical advice line and told the on-call nurse that the patient had died at home 6 days after the ED visit.

The OIG found numerous preventable mix-ups, oversights, and outright misconduct throughout this patient’s health care experience. Notably, the patient navigated 2 transitions between the ED and outpatient Mental Health Clinic and saw 7 providers over the course of 12 hours. The lack of collaboration between the various health care providers, deficiencies in the hand-off process, and ED and inpatient mental health providers’ failure to read the outpatient psychiatrist’s notes led to a “compromised understanding” of the patient’s treatment needs and a failure to enact the outpatient psychiatrist’s recommended treatment plan.

For instance, 2 days after the patient presented to the ED, the outpatient psychiatrist entered a consult for the outpatient substance use treatment program indicating that the patient was informed of the appointment date and time (5 days after the ED visit); however, the OIG found no evidence that staff informed the patient of the appointment date and time. An outpatient nurse closed the consult and added a comment that the patient was to report to the treatment program 5 days after the ED visit. Contrary to Veterans Health Administration (VHA) policy, the OIG report says, the nurse explained that an appointment was not scheduled because it was not program procedure at the time. The nurse mistakenly thought the patient already was receiving outpatient treatment, and because the patient had no scheduled appointment, staff did not follow up when he missed it.

The OIG also found that the facility’s Suicide Prevention Coordinator had failed to complete the suicide behavior report following notification of the patient’s death by suicide, as required by VHA. In fact, the coordinator was unable to locate a suicide behavior report. Moreover, the OIG says, the ED failed to meet VHA’s requirements for a safe and secure evaluation area for patients seeking mental health services. A renovation project begun in 2009 to include 3 mental health examination rooms had been on hold.

Regarding the doctor who was heard making the callous statement, the OIG found that, despite the facility leaders’ awareness of the comment and of the doctor’s “prior pattern of misconduct,” they did not conduct a formal fact-finding or administrative investigation as required by the VA. Instead, they seemed to focus on the physician’s “overall positive clinical outcomes.”

The doctor “was never a VA employee, only worked on a contract basis and is no longer welcome at the facility,” said Dr. Michael Heimall, the center’s director, in a statement to The New York Times.

He added that the episode has prompted the hospital to change its policies. Among the changes: a “comprehensive education program” on employee misconduct and patient abuse has been instituted. Further, now only the Chief of Staff can reverse the outpatient mental health provider’s recommendation for a patient’s admission.