A Minneapolis Veterans Affairs hospital has been cited for a preventable patient suicide that occurred in 2018, the second in recent years, according to an Office of Inspector General report released Jan. 7.
In spring 2018, a veteran visited Minneapolis VA Health Care System's emergency room for opioid and benzodiazepine withdrawal symptoms. The veteran was admitted after expressing thoughts of suicide and homicide.
Over the next few days, the veteran told a dietitian, chaplain and medical resident, "I want to die." In a phone call overheard by a nurse, the veteran gave away property and expressed feelings of impending death. Two hours after the call, the hospital could not find the veteran. The VA was later informed that the patient had died by suicide and was pronounced dead at an off-site ER.
The OIG faulted the dietitian, chaplain and nurse for failing to involve a physician as they were trained to. The VA also failed to notify its suicide prevention coordinator about a suicidal patient, as required by policy, and the medical resident did not properly review notes about the veteran's suicidal thoughts.
The hospital now has a suicide program manager and provides additional related training for staff, Patrick Kelly, the hospital director, wrote in a response to the inspector general, according to Stars and Stripes. Mr. Kelly wrote that suicide prevention is the VA's first clinical priority.
In September 2018, the OIG cited the hospital's mental health unit for violating VA policies in February 2018, when staff discharged an Iraq War veteran who immediately shot himself in the facility's parking lot.