A veteran sought help at a Department of Veterans Affairs hospital in Washington, D.C. last year to detox from prescription pills he was dependent on.
When staff tried to discharge him, he refused to leave. A VA doctor had him removed by police and was heard shouting that they did "not care" if he killed himself.
He did, six days later.
A watchdog report from the VA Office of the Inspector General released Tuesday outlined multiple failings at the Washington, D.C. VA Medical Center, including inadequate emergency care, doctor misconduct and failure to follow suicide prevention policies. The doctor, a VA contractor, was not removed for nine months.
In early 2019, the veteran in his 60s came to the hospital's emergency room with a "long history" of panic attacks, prescription drug dependence, seizures, osteoarthritis and multiple other medical concerns. He complained of medication withdrawal after running out of his prescriptions and said he was unable to sleep. He wanted to be admitted to detox from the prescription medication he was on, which included strong painkillers.
A psychiatric assessment found the veteran was at risk for suicide and recommended he be admitted to the hospital. But after being handed off several more times to other medical staff at the hospital, the man learned he was being discharged. He refused to leave, the report said.
Reports from the emergency department accused the man of "ranting" and "malingering" and an ER doctor called VA police to remove him from the hospital. The doctor said they believed the veteran was having "mental health problems" and "did not believe the patient required medical management," the Inspector General's report said.
At least three staff members – two VA police officers and a physician assistant – reported hearing the ER doctor shout: "(the patient) can go shoot (themself) I do not care," the report said. But none of the three reported what they heard to leadership before the end of their shifts, as required. And none of them characterized the doctor's comments as patient abuse, the report said.
The veteran was picked up by a family member and left the hospital. VA staff never followed up with him about additional appointments or care, according to the report.
Then, six days later, a family member of the veteran called the hospital's medical advice line and told a nurse the man died at home of a self-inflicted gunshot wound.
The doctor who shouted about him was not removed until about nine months later, after further "verbal misconduct." The doctor was allowed to continue treating patients during the nine months between the suicide death and their removal, despite multiple warnings from investigators.
That doctor had a "history of verbal misconduct" but hospital leaders did not conduct an investigation or report them to the state licensing board or National Practitioner Data Bank. On Tuesday, D.C. VA officials told connecting vets they were "reviewing all of our options" for reporting the doctor to the data bank, which tracks misconduct by healthcare professionals.
When confronted about their comments to the veteran, the doctor denied it, though they did not deny making the statements when asked by hospital leaders previously.
"I do not recall exactly what I said, but given what was likely misinterpreted, if I had to guess, I probably said something along the lines of 'unless (the patient) says (they are) suicidal, I don't care, (the patient) can be seen tomorrow.,'" the doctor said, according to the report.
The doctor's last day at the VA hospital was in late 2019, the report said. The doctor resigned from the contracted group, Medical Faculty Associates, Inc., three days later.
"Failure to follow VHA and facility policy in response to incidents of employee misconduct and patient abuse undermines the public interest and presents an ongoing risk to VHA patients and staff," the report said.
Investigators cited communication breakdowns and a failure to follow suicide prevention policies among the hospital's failings.
“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 said.
The doctor's actions "could also be considered misconduct according to VA policy and patient abuse according to facility policy," according to the report."
The doctor was not named in the report but they worked at the D.C. VA on a contract with George Washington University Hospital.
The D.C. VA's suicide prevention coordinator also did not complete a suicide behavior report for the veteran, a requirement at VA, telling investigators it was an "oversight."
"Failure of staff to consistently complete suicide behavior reports compromises the accuracy of VHA’s suicide-related events data that may be used to identify trends of self-directed violence behaviors and determine suicide prevention efforts," the report said.
Since the veteran's death, D.C. VA leaders told the Inspector General's Office that they "instituted a comprehensive educational program for clinical staff working in the ER to ensure staff's understanding" of VA policy on suicide prevention.
D.C. VA officials said Tuesday the report reflected an "isolated incident" that didn't represent the quality of care at the medical center but prompted changes, including weekly audits of suicide-related emergency care and additional ER monitoring for patients at risk of suicide.
"I have been working for the last 18 months to personally ensure this incident brings lasting change and real improvement to our facility. D.C.-area veterans deserve no less," D.C. VA Director Mike Heimall said in a statement to Connecting Vets.
The Washington, D.C. VA has been a subject of previous criticism. In 2018, the VA Inspector General reported management failures. Last year, a Navy veteran and senior Congressional advisor on women veterans said she was sexually assaulted at the D.C. That case was closed with no charges, at least partly because a camera in the area was not working, sources told Connecting Vets. VA Secretary Robert Wilkie is currently under review amid allegations he sought to discredit the woman over her report.
The Inspector General report released Tuesday comes a few weeks after VA Secretary Robert Wilkie praised his department and President Donald Trump for their veteran suicide prevention efforts, saying Trump is the first president since the 1890s to recognize "the scourge of veteran suicide."
The veteran suicide rate, about 20 per day, has largely stagnated or worsened in recent years despite additional money and programs aimed at helping each year.
Read the full report: