Report: VA doc fired 9 mos. after taunting suicidal vet who died by suicide 6 days later
by Adam Forgie
July 29th 2020
SALT LAKE CITY (KUTV) — It took nine months for the Department of Veteran Affairs (VA) to dismiss a doctor who shouted “[the patient] can go shoot [themself], I do not care” at a suicidal veteran who shot himself dead six days later, according to a new report from the VA’s Office of Inspector General (OIG).
In 2019, a veteran in their 60s, accompanied with a family member, visited the emergency room at the Washington DC VA Medical Center to complain of withdrawals from alprazolam (Xanax) and oxycodone as well as insomnia.
The patient was hoping to be admitted to safely detoxify and get help, according to the report.
However, doctors scheduled the patient for a same-day outpatient evaluation.
The veteran and a family member then reported they were dissatisfied with the care, telling a veteran experience specialist the desire to be admitted. That specialist escorted the pair back to the emergency room and told staff of the patient’s desire to be admitted.
The patient then went to the scheduled outpatient evaluation with a psychiatrist. That outpatient psychiatrist gave the patient a “moderate risk” for suicide and “recommended either an inpatient medicine admission for management of opioid and benzodiazepine withdrawal or an inpatient psychiatry admission for management of withdrawal, insomnia, and anxiety,” the report says.
The outpatient psychiatrist then took the patient back to the emergency room and “reportedly provided a verbal hand-off directly and through an alert in the electronic health record to physician. The patient’s family member left the facility with the expectation that the patient was being admitted,” the report states.
A physician’s assistant made record that the patient was to be admitted to the hospital.
Despite all of that, the resident psychiatrist in the emergency room assessed the patient’s suicidal risk as “mild,” said the patient denied having suicidal ideations, ad recommended he be discharged home.
The report documents what happened next:
“When informed of the discharge plan, the patient refused to leave. ”
“A second emergency department attending physician (physician 2) documented that the patient was ‘clearly malingering’ and ‘ranting’ and called VA police to escort the patient from the emergency department. After being escorted from the building, the patient wanted to return to the emergency department to address knee pain.”
“Staff members reported that when informed of the patient’s plan to return, physician 2 dismissed the patient’s reported symptoms and shouted, ‘[the patient] can go shoot [themself]. I do not care.’ While the OIG confirmed that at least three facility staff members heard the statement, the OIG could not confirm that the patient heard this statement (because the patient was dead at the time of the investigation, and therefore could not be asked if he heard it). The patient was picked up by the family member and left the facility.”
“The patient navigated two transitions between the Emergency Department and outpatient Mental Health Clinic and saw seven providers over the course of 12 hours. The lack of collaboration between Emergency Department and inpatient mental health providers, deficiencies in the handoff process, and the Emergency Department 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.”
While three staff members heard the disparaging comment and reported it to authorities, the report finds it took nine months before an investigation was launched and the doctor in question was let go. Hospital leaders are required by law to file a report when told about conduct issues with providers — something that was not done, the report says.
The report also found “facility’s Suicide Prevention Coordinator failed to complete the suicide behavior report following notification of the patient’s death by suicide, as required by VHA. The OIG further found that the facility’s Emergency Department failed to meet VHA’s requirements for a safe and secure evaluation area for patients seeking mental health services.”
On average, 22 veterans die by suicide every day in America.