VA Mishandled Dead Vet's Discharge

By Walter F. Roche Jr.

Multiple failures at a Veterans Administration facility may well have contributed to the 2017 death of a veteran who died just eight days after his release from an agency hospital.
The details of the veteran's case, including a major medication error, were spelled out in a 50-page report from the VA Inspector General issued this week.
The name of the victim and the facility where he was under treatment were not disclosed but the report states that the VA facility was in the VA's VISN 4, a region which includes the state of Pennsylvania and parts of Delaware and New Jersey.
The IG did report that the original anonymous tip -that the veteran committed suicide two days after his discharge- was not correct.
According to the report, the veteran was released from the VA hospital only to be taken into custody at a federal detention facility where he was to face federal charges for an incident with a VA employee. He died from hypertensive and atherosclerotic cardiovascular disease, the report states.
Both before and after the discharge, the report states, officials at the facility failed to properly handle the case and provided false information about the patient's drug regimen, completely omitting one key drug, benzodiazepine. The dosage for another key drug the patient was getting from the VA was listed at only one fifth of the amount actually prescribed.
Citing the veteran's underlying cardiac condition, the report concludes that the misinformation about the drug dosages would likely have caused withdrawal symptoms leading to increased blood pressure which "may have contributed to the patient's hypertension related death."
In addition to the false drug information, the IG found that the VA facility failed to communicate with the receiving federal facility or the patient's family. (The only federal correctional facility in the region is located in Philadelphia).
The report also found that facility officials did not inform the veteran or his family of his rights to appeal the decision to discharge him to federal custody. The veteran had requested to be returned to a VA community living center where he had previously resided.
The facility "failed to engage in proper discharge planning" and "failed to engage in proper treatment planning," the report concludes.
David Cowgill, a VISN 4 spokesman, said the recommendations included in the audit report already were being implemented and completion is expected early next year.
"Additionally, the facility has assigned Veterans Justice Outreach Coordinators to serve as liaisons between the staff at the medical center and staff at the correctional facility in the event that any other veteran is incarcerated following discharge," Cowgill wrote in an email response to questions.
According to the IG's report the veteran was schizophrenic and had a long history of involvement in the VA's health system including lengthy stays in agency facilities. He was described as being in his fifties.
Citing "multiple failures of communication," the report says facility officials failed to follow agency rules on voluntary and involuntary commitments and at one point allowed the veteran to voluntarily commit himself even though there were literally dozens of notations in his record indicating he was not competent.
"The patient's cardiac condition warranted close monitoring," the report states, "and there was no evidence that the facility staff provided this information" to the staff at the federal correctional facility.
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