Review of Mental Health Care Provided Prior to a Veteran’s Death by Suicide, Minneapolis VA Health Care System, Minnesota

In response to a request from Representative Tim Walz, the VA Office of Inspector General (OIG) reviewed the care of a patient who died from a self-inflicted gunshot wound less than 24 hours after discharge from the inpatient mental health unit of the Minneapolis VA Health Care System. The OIG determined that an inpatient interdisciplinary treatment team failed to include the outpatient treatment team in discharge planning, did not manage medication follow-up, and did not educate the patient on limiting access to firearms. The inspection also revealed inadequate documentation of clinicians’ assessments of the patient’s access to unsecured firearms, as well as efforts to contact the family to secure weapons, engage in treatment or discharge planning, or to confirm the discharge plan that included release to the parents’ home. The System Suicide Prevention Coordinator did not collaborate with the inpatient interdisciplinary treatment team during admission, determine the need for a Patient Record Flag indicating a high risk for suicide before discharge, or provide required Suicide Behavior Report training to System clinical staff. Beyond the case findings, the OIG found the Suicide Prevention Coordinator failed to complete 22 percent of a sample of 2017 and 2018 Behavioral Health Autopsies within the required timeframe. System staff also failed to follow policy for conducting a root cause analysis. The OIG was unable to determine that identified deficits, alone or in combination, were a causal factor in the patient’s death. However, the OIG made seven recommendations related to interdisciplinary team collaboration, determination of Patient Record Flag status, accuracy of mental health clinical documentation, Suicide Behavior Report training, timely completion of Behavioral Health Autopsies, documentation of Suicide Prevention Awareness Committee activities, and the root cause analysis process.