Deficiencies in Inpatient Mental Health Care Coordination and Processes Prior to a Patient’s Death by Suicide, Harry S. Truman Memorial Veterans’ Hospital in Columbia, Missouri

The VA Office of Inspector General (OIG) conducted a healthcare inspection to determine the validity of an allegation regarding a patient’s mental health care at the Harry S. Truman Memorial Veterans’ Hospital (facility) in Columbia, Missouri, prior to death by suicide. The OIG reviewed the patient’s mental health care coordination, discharge planning, suicide risk screening and evaluation, administrative actions, and Mental Health Treatment Coordinator (MHTC) assignment. The OIG substantiated that the patient died by suicide within three days of discharge from the facility’s Inpatient Mental Health Unit. The OIG also substantiated that an inpatient psychiatry resident initiated antidepressant medication, and a registered nurse provided discharge instructions that included suicide prevention materials, consistent with Veterans Health Administration (VHA) guidance. Inpatient staff did not include Columbia Vet Center staff in discharge planning and failed to complete the VHA-required comprehensive suicide risk evaluation prior to the patient’s discharge, which may have contributed to missed information to adequately establish acute and chronic suicide risk factors and a risk mitigation plan. Facility leaders did not establish an MHTC policy and staff did not assign the patient’s MHTC while awaiting transfer to another level of care. Staff failed to comprehensively report a positive suicide risk screening result in an issue brief related to the patient’s death, and facility leaders, in part based on the issue brief, did not make an institutional disclosure to the patient’s next of kin. Veterans Integrated Service Network and National Center for Patient Safety leaders did not have knowledge of a memorandum of understanding that required Vet Center representation for shared patients during VHA root cause analyses. The OIG made one recommendation to the Under Secretary for Health and six recommendations to the Facility Director. Key words: Inpatient Mental Health, Suicide Risk, Mental Health Treatment Coordinator, Vet Center