Deficiencies in Care and Administrative Processes for a Patient Who Died by Suicide, Phoenix VA Health Care System, Arizona

The VA Office of Inspector General (OIG) conducted an inspection to review concerns related to the mental health care provided at the Phoenix VA Health Care System (facility) to a patient who died by suicide in 2019. The patient initially established mental health care at the facility in 2017. Upon the patient’s request to reestablish mental health care in 2019, a social worker referred the patient for non-VA psychological diagnostic testing. The OIG found that, while the patient awaited the testing, facility staff failed to offer mental health treatment. The social worker did not complete a suicide risk assessment and relied on another social worker’s suicide risk assessment completed eight months prior. A family member called and left a voicemail message for the social worker. However, the social worker’s documentation did not include essential information, specifically, that the patient died by suicide. Upon learning of the patient’s death by suicide, a Suicide Prevention Coordinator failed to complete timely documentation of outreach to the patient’s family. The OIG found that the mental health delegate did not approve the community care psychology consult within three business days, as required by VHA, and the third-party administrator scheduled the patient for therapy rather than psychodiagnostics testing. Additionally, the OIG found that facility scheduling staff did not complete required outreach efforts when the patient missed a primary care appointment one day prior to the patient’s death by suicide, and the Suicide Prevention Coordinator did not complete the patient’s behavioral health autopsy within 30 days, as required. The OIG made seven recommendations related to consideration of administrative action related to the patient’s care, suicide risk assessment, electronic health record documentation, timely community care authorization, missed appointment procedures, community care scheduling accuracy, and timely completion of behavioral health autopsies.