More information has been released about the veteran whose death sparked a federal review of the Minneapolis Veterans health care system.
In a statement before the House Committee on Veterans' Affairs, U.S. Rep. Tim Walz laid out the details of the last four days of Justin Miller's life.
Miller, a 33-year-old Marine Corps veteran, called a veterans' crisis hotline on Feb. 20.
He was struggling with the symptoms of post-traumatic stress from his time in Iraq, and had recently been asked by his significant other to move out of his home.
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Miller told the crisis worker that he was hopeless, suicidal and had access to firearms. The crisis worker persuaded him to go the mental health unit of the Minneapolis VA.
From there, Walz said, the VA system began to fail Miller.
"When Justin arrived at the Minneapolis VA Medical Center, the help he needed never materialized," Walz said. "VA clinicians failed to utilize cutting-edge interventions that the facility has at their disposal."
The facility employs suicide prevention coordinators, who work with patients flagged as high-risk — pointing them toward other programs within the VA system and helping them identify support systems among their family and friends.
But Miller was never flagged as being at a high risk of suicide, so a prevention coordinator never met with him.
After three days of treatment and observation, Miller was discharged.
"Justin steps out of that hospital on that cold winter day in February," Walz said, "away from the nurses, the doctors and the medications that could have assisted in stabilizing him. He went to his car and tragically took his life. He was not found until the next day."
Earlier this week, the office of the Inspector General of the U.S. Department of Veterans Affairs released a review of Miller's case — citing the Minneapolis VA system for a number of issues largely stemming from a lack of communication.
According to the review, medical staff 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 Miller if he had access to guns, and documented the response. Three workers wrote that Miller had access to guns. Three said he didn't, and three others said it wasn't clear.
Just before being discharged, Miller reportedly denied having a gun, but acknowledged having the ability to get one.
Now it appears that Miller had a gun in his car, in the hospital parking lot.
In a statement, the Minneapolis VA said that it strives "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.