Healthcare Inspection – Alleged Poor Mental Health Care Resulting in a Patient Death, VA Central Iowa Health Care System, Des Moines, Iowa

OIG conducted an inspection at the request of Senator Joni Ernst to review allegations regarding poor mental health care resulting in a patient’s death at the VA Central Iowa Health Care System (VACIHCS), Des Moines, IA. We did not substantiate the allegation that the patient had been denied long term mental health services at the time of a winter 2015 Emergency Department visit. We found no documentation that the patient had requested these services or that his clinical condition would have warranted admission at that time. We did not substantiate that the patient received poor quality of care through the Emergency Department but concluded that VACIHCS did not comply with Veterans Health Administration policy regarding case management services. We reviewed mental health programs at VACIHCS from the perspective of how they interfaced to provide care for this patient. The facility appeared to be substantially in compliance with its policy regarding time frames for consult completion. The patient did not experience a delay in obtaining mental health services, as he had not requested these services in the 2 years prior to his winter 2015 Emergency Department visit. We determined that the patient was not contacted by the local recovery coordinator because his name did not appear on the list of seriously mentally ill patients; for purposes of recovery coordinator activities, seriously mentally ill patients are considered to be those patients with a diagnosis of schizophrenia, bipolar disorder, or psychoses. This patient had anxiety, depression, and post-traumatic stress disorder but had never been diagnosed with schizophrenia, bipolar disorder, or a psychoses that would have triggered contact from the local recovery coordinator. We made two recommendations. The Interim Under Secretary for Health and the Acting Veterans Integrated Service Network and Acting Facility Directors concurred with the recommendations and provided an acceptable action plan.