VA IG: Suicidal Vets Cases Mishandled

By Walter F. Roche Jr.

A Pennsylvania veteran who should have been contacted for possible follow up mental health services on two separate occasions never was contacted and committed suicide about three months after being cut off from services, according to a report from the Veterans Administration's Inspector General.
The 19-page report on services provided at the Coatesville Veterans Administration Medical Center also found that in a more recent case another veteran also with a less than honorable discharge was improperly denied an extension of mental health services because a chief of staff failed to review the veteran's actual records.
The information on the veteran who committed suicide in 2018 surfaced in the course of investigating a complaint filed in the more recent case.
The suicidal veteran had sought assistance in the Fall of 2017 and was granted 90 days of emergent mental health services and subsequently received both in-patient and out-patient services.
The patient's eligibility expired on Dec. 27, 2017.
The veteran, however also qualified for a program called REACH VET and, as a result, should have been contacted for possible follow up services. The program was established to provide assistance to veterans judged to be at high risk for suicide. Though notices of qualification surfaced on two separate occasions, no contact was made because VA staffers assumed the patient was getting care in the private sector.
"The OIG was unable to determine whether outreach would have prevented the patient's death because of unknown factor's related to the patient's death," the IG reported.
In the more recent case a veteran with a history of mood anxiety and substance use disorders was granted 90 days of emergent mental health services and first received in-patient treatment at the Philadelphia VA Medical center.
Subsequently the patient was in an outpatient rehabilitation program under the Coatesville center.
Though the veteran had sought an extension, he wasn't told until two days before losing eligibility in May of 2019 that his request was denied.
The IG found that the chief of staff handling the extension request never looked at the veterans electronic health record and was unaware that the patient was eligible for extended services under the REACH VET program.
"The chief of staff was unaware of the patient's REACH VET status and acknowledged the REACH VET status would be an important factor to consider in the extension request decision," the report states.
The chief of staff also acknowledged giving a "less than careful" review of the veteran's record.
The report also was critical of the way the veteran was informed at the last minute that his extension request had been denied.
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