Again and again, teams at the Department of Veterans Affairs' San Diego Health Care System reached out to and helped a troubled veteran battling suicidal thoughts and substance abuse who frequently missed appointments or broke off contact.
The efforts were not enough. The veteran was found dead in July 2018; the San Diego Medical Examiner's Office ruled the death a suicide by asphyxiation.
Prompted by charges from an anonymous caller, the VA's Office of Inspector General (OIG) investigated the circumstances of the death and issued a report earlier this month titled: "Alleged Deficiencies in Mental Health Care Prior to a Death by Suicide at the VA San Diego Healthcare System, California."
The anonymous caller who claimed that the veteran was "turned away" by the VA could not be reached by the IG's office to back up the accusations.
"The OIG inspection team attempted to contact the complainant by telephone, certified mail, and electronic mail; however, the complainant did not respond," the report states.
The 27-page IG report found procedural "deficits" in how the San Diego VA dealt with the veteran, but stopped short of leveling blame.
The IG's detailed report offered penetrating insight into a case that is emblematic of the challenges faced by the VA health care system. As VA staff serve nine million veterans each year, they must contend with what officials have described as an "epidemic" of suicides among veterans.
The challenges become even more acute, the IG report shows, when the veteran misses appointments, rejects treatment plans or sporadically ignores attempts at outreach.
The investigation was conducted to assess whether the VA failed to provide mental health care to a patient who subsequently died by suicide. Ultimately, investigators did not substantiate claims that the VA failed to provide mental health care when the patient sought help, according to the report.
"The OIG found that the suicide risk assessment of the patient was adequate" and complied with the standards of the Veterans Health Administration and the San Diego system's requirements, the report states.
Still, there were serious shortcomings. Investigators identified the move to deactivate the patient’s flag in medical records noting a high risk for suicide as a concern. The suicide prevention coordinator at the hospital removed the veteran from the high-risk list "without contacting the patient" or "consulting the patient's treatment team," the report states.
The veteran remained off the list even after failing to show up for mental health services for more than two months.
Patients are supposed to be added to the high-risk list so VA staff members can track those veterans closely, making efforts to reach them when they miss or cancel appointments, agency guidelines state.
The IG made two recommendations for improving procedures and documentation at the San Diego VA based on a case that could serve as a valuable example for systemic improvements.
Investigations of such deaths often center on what the VA did, or didn't do, to assist the veteran, although statistics show that about 14 of the 20 veterans who die daily by suicide never have any contact with the department.
"It seems like the VA did a lot of things correctly" based on the IG report, said Navy Reserve Cmdr. Jeremy Butler, CEO of Iraq and Afghanistan Veterans of America. "But it's not a totally clean bill of health."
Butler called the issue of veteran suicide "a national emergency."
"We realize the VA can't do everything," he said, but he questioned the removal of the veteran in the San Diego case from the high-risk list.
Butler said the San Diego suicide case underlined the need for the VA to engage in more outreach to veterans, either by the department itself or through local and state partners when veterans become difficult to contact.
VA Secretary Robert Wilkie has repeatedly cited curbing the veteran suicide rate as the "top clinical priority" for the system's 170 hospitals and more than 1,100 clinics nationwide.
In March, President Donald Trump signed an executive order creating a cabinet-level task force that he pledged would "mobilize every level of American society" to address the crisis of suicides among veterans.
The death of the veteran in San Diego, and the report of the IG on the circumstances, illustrate how difficult the task will be.
Early Warning Signs
The veteran in this case, who was identified only as the "patient" due to privacy rules, was younger than 30 at the time of death.
The veteran's gender and military branch were not disclosed, but investigators found the individual "first experienced depressive symptoms including insomnia and thoughts of suicide during high school but did not seek treatment at that time."
Just a month after joining the military in 2013, the patient met with a counselor and was "feeling really depressed," the report states, but chose not to start medication until the summer of 2014 for fear that it might interfere with training.
The patient was then prescribed two antidepressant medications and a sleep aid. The patient's first contact with the VA came in the spring of 2017, after leaving the military.
"During that visit, the patient complained of periodic thoughts of self-harm," the report adds. "The patient asked to restart psychiatric medications, and the primary-care provider prescribed an antidepressant."
The investigation goes on to detail several contacts and visits to the VA by the patient, though it notes the veteran's follow-up on advice or treatment suggestions was sporadic.
In the initial visit to the VA, the patient described "chronic passive suicidal ideation" and recounted an attempt while in the military. The patient ultimately stopped the attempt and called a suicide hotline, the report states.
A VA social worker drew up a risk assessment in which the patient reported researching methods of suicide on the internet. The social worker estimated the patient's risk of suicide to be "moderate/ambivalent," but the patient did not think a safety plan would be useful and declined to complete one.
Then followed meetings with a VA psychiatrist and psychologist in which the patient would ask for changes in medication and admit to substance abuse while refusing treatment for it. The patient also met with a private psychologist under the VA's "Choice" program for private-care options.
In the summer of 2017, after the patient rescheduled appointments multiple times, the VA psychiatrist called the patient.
"The patient reported intrusive thoughts of suicide" and spoke of planning to discuss them with the VA Choice provider, but also "denied active suicidal ideation, intent, or plans," the report states.
The psychiatrist called the patient's Choice provider less than a week later. They agreed that, although the patient did not meet criteria for inpatient psychiatric admission, the patient was at long-term elevated risk for self-harm, according to the report.
"During a follow-up psychiatric visit four days later, the patient admitted to a suicide attempt in mid-summer of 2017," the report continues.
This attempt was also stopped by the patient after about a minute, the report states.
There was more back and forth between the VA and the patient on recommendations for treatment and medication, many of which the patient ignored, according to the report.
In early 2018, the VA psychiatrist reached out to the patient following a missed appointment. The patient said that two weeks prior while at an airport, they sent a photo to a friend showing an apparent self-strangulation attempt, and then turned the phone off, the report states.
The friend contacted the patient's family, who called airport security.
"The patient said that the police spoke with the patient upon landing but did not detain the patient," according to the report.
Three days after the phone call, it adds, the patient agreed to an intensive outpatient program referral, but declined the psychiatrist's offers for substance abuse treatment or restarting psychiatric medication.
"After the patient missed the next appointment, the psychiatrist contacted the system emergency department social worker, who called police and requested a health and welfare check," it continues.
"During the health and welfare check, the patient expressed passive thoughts of death but did not meet criteria for inpatient admission," the report states. "The patient agreed to follow up with the outpatient providers the following week but did not."
After multiple calls to the patient without a response, the VA psychiatrist called the patient's mother and left a voice message. The patient's mother called back and said that she was speaking with the patient twice a week and was appreciative of staff concern, the report states.
Suicide Risk Flag Deactivated
In late winter 2017, a VA suicide prevention coordinator, or SPC, contacted the patient, who reported "decreased depression, and decreased frequency and intensity of suicidal thoughts."
"The SPC changed the patient's suicide risk assessment to moderate/ambivalent," and after additional calls, the patient's suicide risk flag was deactivated in late spring of 2018, the report states.
However, in the summer of 2018, the patient went to the VA emergency room with thoughts of suicide, according to the report.
The patient was evaluated by a second-year psychiatry resident, who "described the patient as 'pleasant, engaging, and jovial at times,' despite the patient's self-report of feeling suicidal for the prior two days after a fight with a friend," the report states.
The patient denied symptoms consistent with major depressive disorder, investigators found, including changes in appetite, energy or concentration, but admitted having fleeting thoughts of suicide most days of the week.
"The resident offered the patient voluntary psychiatric admission for stabilization, but the patient declined," the report states. "The patient stated that the conversation with the resident had improved the patient's mood and the patient now felt safe to return home with a roommate."
The resident decided that the patient did not meet the criteria for involuntary admission or "warrant psychiatric inpatient admission at that time," according to the report.
"The resident assessed the patient's short-term risk of suicide as low," but "acknowledged that the patient's long-term risk of suicide was elevated given the patient's history of chronic suicidality and other mental health conditions," the report adds.
The staff psychiatrist at the hospital co-signed the resident's consultation note about four hours after the patient left, the report states, and the resident added the outpatient psychiatrist, outpatient psychologist and lead suicide prevention coordinator to the note.
Several days later, the outpatient psychiatrist attempted to contact the patient by phone and left a voice message asking the patient to return to care. A psychiatry medical support assistant later attempted to phone the patient but was unsuccessful, according to the report.
The medical support assistant then sent a letter to the patient "that encouraged the patient to call to schedule an appointment and noted that there would be no further attempts to schedule an appointment," the report adds.
"The patient expired two days after the medical support assistant sent the letter," the report states. "The Deputy Medical Examiner reported the patient's cause of death as asphyxia [suffocation] and manner of death as suicide."
In response to questions from Military.com, the IG office said that the detailed analysis of an individual case could point the way to improvements in suicide prevention.
"It is hoped that the identification of failures in a specific case will lead to lessons learned across the VA system of care," the office said in a statement.
In its response, the VA's San Diego Health Care System thanked the IG for the "thorough review of the circumstances involving this tragic veteran suicide which occurred in July 2018," but did not refer to any "failures."
"We appreciate their confirmation that there were no deficiencies in the care of the veteran provided by our mental health providers or our emergency department, or in the supervision of the resident physician staff who also participated in the veteran's care," Cynthia Butler, public affairs director for the San Diego VA, said in a statement.
On the subject of red flags for high-risk patients, Butler said, "We are also working with the VA Office of Mental Health and Suicide Prevention to assure that consistent processes are developed and implemented for the management of flags alerting staff to the presence of veterans who may be at higher risk for suicide."
-- Richard Sisk can be reached at Richard.Sisk@Military.com.