Multiple failings by VA staff could have contributed to veteran suicide death, report shows

Photo credit Department of Veterans Affairs

A veteran died by suicide at a Minneapolis VA hospital after multiple failings by Department of Veterans Affairs staff, a new watchdog report shows.

At least three VA staff members -- a nurse, a chaplain and a dietician -- heard the veteran express suicidal thoughts and didn't tell doctors, as they were all trained to do.

A veteran in their 60s arrived at a VA emergency department asking for help with withdrawal symptoms in spring 2018. He or she told ER staff they were having thoughts of suicide and homicide and said they had a gun at home. The veteran was not identified in the report.

The veteran had previously been receiving care at another VA facility for more than 10 years and had been diagnosed with major depression and a history of substance abuse that was in remission.

The veteran was admitted to the hospital for observation and treatment of their depression, suicidal thoughts, withdrawal symptoms and because they lived alone and had “ample access” to a means of suicide, according to a report from the VA Office of the Inspector General.

Due to a lack of available psychiatric beds, the veteran was moved to a medical unit. The psychiatrist said the veteran did not require “continuous monitoring,” noting that they had a “heightened, but not imminent risk, for suicide,” investigators found. 

Later that same day, two VA staff members -- a dietician and a chaplain -- documented that the veteran had suicidal thoughts. The psychiatrist noted the veteran was depressed and confused, but the veteran denied suicidal thoughts and said he or she did not want to die, the investigators’ report shows. 

The veteran would later go missing from the medical unit. About two hours before the veteran was discovered missing, a nurse overheard them on a phone call “giving away property and expressing feelings of impending death.” 

The nurse did not document or report the conversation to the veterans’ treatment team. 

VA police later received a call that the veteran had died by suicide. 

Investigators found multiple failings in communication by VA, including failure to notify the hospital’s suicide prevention coordinator of a veteran with suicidal thoughts. 

Several staff members did not tell doctors when the veteran was having suicidal thoughts and displaying other warning signs, which goes against the training they had completed.

Though some staff did document the veteran’s suicidal thoughts and warning signs, investigators did not find any indication that those warnings were heeded.

“These care coordination deficiencies may have resulted in a failure to provide adequate mental health assessment and monitoring of the patient,” investigators said in their report. 

Hospital leaders did not provide an “institutional disclosure” to the veteran’s family, investigators found. An institutional disclosure is a formal process at VA for leaders and doctors to tell a patient or their family that an “adverse event occurred” and includes specific information about a patient’s rights and recourse. 

Investigators made multiple recommendations in light of their findings, including consulting Human Resources and attorneys to determine whether “personnel actions are warranted.” 

The VA facility director said in the report that staff was reviewed, but "no personnel actions are warranted" and "no personnel actions were taken."

Leaders of the VA facility involved agreed with OIG’s recommendations and provided an action plan.

"Our deepest condolences go out to the veteran's family and friends," VA spokesman Brad Doboszenski told Connecting Vets in a statement. 

Since the veteran's death "nearly 20 months ago," Doboszenski said the Minneapolis VA Health Care System has implemented multiple changes "to help prevent similar tragic acts in the future," including:

  • Installing perimeter fencing around the top floor of the veteran parking ramp;
  • Hiring a facility-wide suicide prevention program manager;
  • Better reporting and communication;
  • Additional training on documenting and responding to veterans with suicidal thoughts or behaviors;
  • Improving inpatient processes so veterans with suicidal thoughts are under closer supervision.

Doboszenski said suicide prevention continues to be "VA's highest clinical priority." 


If you or someone you know needs help, contact the Veteran Crisis Line 24/7 at 1-800-273-8255 (select option 1 for a VA staff member). Veterans, service members or their families also can text 838255 or go to
Reach Abbie Bennett: or @AbbieRBennett.
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