Deficient Care of a Patient Who Died by Suicide and Facility Leaders’ Response at the Charlie Norwood VA Medical Center in Augusta, Georgia

The VA Office of Inspector General (OIG) conducted an inspection to review allegations that providers at the Charlie Norwood VA Medical Center in Augusta, Georgia, delayed care and failed to “provide services,” for a patient who died by suicide on the grounds of the Aiken Community Based Outpatient Clinic and the facility director “. . . covered it up.” The OIG also reviewed leaders’ responses to these allegations. The OIG substantiated the patient received deficient clinical care, which hindered referrals for mental health and pain management services. The deficiencies included (1) a primary care provider’s failure to follow up on positive mental health screenings, (2) a primary care provider’s failure to follow up on a discontinued mental health consult and order testing, (3) facility staff failures to ensure a timely pain management appointment, (4) pain management clinic providers’ failure to perform required mental health screenings, (5) a nurse’s failure to communicate a Veterans Crisis Line (VCL) referral prior to the Emergency Department encounter, and (6) suicide prevention staff failures to act after the VCL referral. The OIG did not substantiate that facility leaders “covered up” the patient’s death by suicide and could not determine the basis for this allegation due to the complainant being anonymous. Facility leaders immediately responded per Veterans Health Administration guidance; however, they failed to initiate a timely investigation of the death as a sentinel event. The OIG also identified completion of an inaccurate Behavioral Health Autopsy, failure to complete a Family Interview Tool Contact, delayed peer reviews, and a clinical review that did not identify and address deficiencies in care. The OIG made nine recommendations regarding mental health screenings, consult management, community care referral, suicide risk assessments, communication and closure of a VCL referral, completed suicides on VA campuses, and accurate completion of quality management reviews.