Minneapolis VA cited in patient suicide
The Minneapolis Veterans health care system has been cited by the VA Inspector General, after a patient died from suicide in the facility's parking lot.
In February, the veteran who served at least one deployment in Iraq, called the VA crisis hotline.
The patient reported having suicidal thoughts and "immediate access to firearms," according to a review by the office of the Inspector General of the U.S. Department of Veterans Affairs released Tuesday.
Much of the patient's personal information has not been released, including age and gender.
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The crisis worker talked the patient into going to the mental health unit of the Minneapolis VA.
After three days of treatment and observation, the patient was ruled at low risk of suicide, and was discharged, reportedly telling nurses, "it sounds corny but yeah, [I'm feeling] hopeful."
Less than 24 hours later, the patient was dead from a self-inflicted gunshot wound, in the parking lot of the medical center.
The Inspector General's review points to a number of issues largely stemming from a lack of communication within the Minneapolis VA system.
According to the review, medical staff didn't effectively coordinate outpatient treatment plans, and didn't schedule a follow-up appointment to manage the patient's medication.
They also failed to address "inconsistent and contradictory documentation regarding the patient's access to firearms or other lethal means."
Over four days, nine medical workers at different times asked the patient about gun access, and documented the response. Three workers wrote that the patient had access to guns. Three said the patient didn't, and three others said it wasn't clear.
Just before being discharged, the patient reportedly denied having a gun, but acknowledged having the ability to get one.
In a statement, the Minneapolis VA said, "we strive to be a high reliability organization [and have] begun implementing each of the [Office of Inspector General's] recommendations, which are expected to be completed by January 2019."
The Minneapolis VA system will also perform its own review of communication practices, and examine its process for determining suicide risk.