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VA inspector general exposes breakdown at D.C. hospital that led to veteran’s suicide

Lisa Rein

A veteran, suffering in pain and out of medication, turned last year to the Veterans Affairs’ hospital in D.C. for help. Instead of receiving aid, a new report says, a cascade of failures by the medical staff resulted in him being forcibly expelled. The veteran shot and killed himself six days later.


A VA inspector general’s report released Tuesday revealed not only poor communication and poor judgment by multiple mental health and emergency room staff, but it exposed an insensitive call by the emergency department’s attending physician: “[The patient] can go shoot [themself]. I do not care,” the physician was heard shouting, dismissing the veteran’s symptoms.


The physician called hospital police to expel the veteran after deciding that he was “malingering” and “ranting,” said the report.


Of the incident, which occurred early in 2019, Inspector General Michael Missal’s office found that “despite the patient’s withdrawal risk, Emergency Department staff discharged the patient without a thorough understanding of the patient’s withdrawal management needs.”


Neither the patient nor the doctor — who was affiliated with George Washington University and had a history of “verbal misconduct” — were named in the report, which outlines a series of failings by the medical staff at a hospital that in recent years has been under fire for poor patient care and mismanagement and just two years ago had a leadership shake-up.


The report comes as the Trump administration tries to tout its efforts to fight the persistent problem of veteran suicides, which have been stuck for years at about 20 a day, a far greater number than suicides among the population that did not serve in the military.


VA Secretary Robert Wilkie, as part of an effort to put a spotlight on his tenure as Trump runs for reelection, claimed to the conservative media site OAN this month that “President Trump is the first president since the 1890s who recognized the scourge of veteran suicide.”


Wilkie’s comment drew widespread criticism, as similar efforts have previously been made.

Wilkie has touted a public health campaign Trump and VA launched in June that calls for improved research, community partnerships and other measures to fight veteran suicide, but those efforts were criticized by some veterans advocates and lawmakers for not being ambitious enough.


The veteran whose case came under investigation who was in his 60s and had a history of anxiety and addiction to painkillers. He had injuries stemming in part from a serious motorcycle accident years ago.


From his first call to the hospital’s medical advice line, complaining of low back pain and running out of his prescribed medication, to his visit to the emergency room with a bag of clothes hoping to be admitted and then his discharge, the veteran was in contact with seven medical providers over twelve hours, investigators found. Each failed to help him.


“The providers’ lack of systematic assessments, of either the patient’s risk factors for moderate to severe withdrawal or the patient’s expressed suicidal thoughts related to withdrawal symptoms, contributed to a failure to properly assess the patient’s risk for significant harm, including death by suicide and [drug] withdrawal,” wrote John Daigh Jr., the assistant inspector general for health-care inspections.


Daigh’s report describes a breakdown in communication among the hospital’s emergency room and mental health staffs, a “compromised understanding” of the patient’s treatment needs and a failure to follow the recommendations of a psychiatrist who evaluated him and recommended that he be admitted to the hospital.


The veteran described pain from drug withdrawal and said he could not sleep. He asked to be admitted to get help detoxifying from drug addiction. But after the psychiatrist assessed him as being at “moderate risk for suicide,” he was sent back to the emergency room, where a series of sloppy handoffs among doctors and physician assistants failed him, investigators found.

A consulting psychiatry resident instead recommended outpatient care and said he should be sent home, but the patient refused to leave, the report said. That’s when the attending physician got involved. At least three colleagues witnessed her outburst, investigators found.


Officials at the hospital agreed with the report’s multiple criticisms and said in the report that since the veteran’s suicide, they have made changes that include giving doctors better training in recognizing patients at risk for killing themselves and improved communication. The attending physician was dismissed — nine months after the incident.


“The Washington DC VAMC grieves for the loss of this Veteran and extends our deepest condolences to their loved ones,” hospital director Mike Heimall said in a statement. The attending physician’s conduct “is unacceptable and does not represent the dedication and compassion our employees exhibit daily. This person was never a VA employee, only worked on a contract basis and is no longer welcome at the facility.”


“While this isolated incident does not represent the quality health care tens of thousands of DC-area Veterans have come to expect from our facilities, it has prompted a number of improvements that will strengthen our continuity of care and prevent similar issues from happening in the future.”


Rep. Gerald E. Connolly (D-Va.), who leads the House Oversight and Reform Committee’s panel on government operations, called Tuesday’s report a “very troubling” example of a “culture of indifference and callousness to patients experiencing mental health issues.”

The attending physician’s outburst “is disgusting and this individual should have been terminated immediately,” Connolly said in a statement.


The DC VA Medical Center has found itself in an unwelcome spotlight in recent years. In 2018, then-VA secretary David Shulkin announced an overhaul of its senior leadership after the inspector general found multiple safety and management issues.


Last year a senior Capitol Hill aide said she was assaulted by a man who turned out to be a hospital vendor while she was there. The incident, and Wilkie’s involvement in its aftermath, are the subject of an ongoing investigation by Missal’s office.

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