Healthcare Inspection – Suicide Risk and Alleged Medical Management Issues, Hampton VA Medical Center, Hampton, Virginia

OIG conducted an inspection at the request of Senator Richard Burr to assess the merit of allegations received from a complainant concerning the clinical management of a veteran who reported a recent suicide attempt and failure to diagnose a cardiac condition at the Hampton VA Medical Center (facility), Hampton, VA. The veteran died several weeks after the reported suicide attempt. The medical examiner who performed an autopsy stated that “The manner of death is accident” and recorded the cause of death as the combined toxic effects of two medications, a narcotic pain reliever and an anti-anxiety medication, with severe disease of one coronary artery (a blood vessel that supplies the heart muscle) contributing to the death. We substantiated that the veteran’s reported attempt to commit suicide was not managed as required by Veterans Health Administration (VHA) policy. We found that although all but one of the clinical staff members in the facility’s Emergency Department and Mental Health clinics had completed suicide risk management training, they did not identify his suicide risk factors and did not report the veteran’s recent suicidal behavior as required by VHA. We substantiated the allegation that the veteran suffered from undiagnosed heart disease. However, his complaints of chest pain and shortness of breath had been evaluated on several occasions. We found that his physical exam, laboratory studies, and four electrocardiograms were within normal limits and did not support a need for a further, more invasive evaluation. We found that contracted providers were not required to undergo suicide risk management training. We made two recommendations. The Veterans Integrated Service Network and Facility Directors concurred with our recommendations and provided an acceptable action plan.