Indiana Vet's Suicide Followed Multiple Care Lapses - OIG Report

By Walter F. Roche Jr.

A critical report on the 2013 suicide of an Indiana veteran concludes that Veterans Affairs health care providers missed multiple opportunities to provide needed care and even failed to read his entire electronic medical record, which contained multiple indications he was a suicide risk.
The 33-page report issued Monday concludes that while the final outcome might not have changed actions and in-actions by VA staffers "compromised the patient's mental health."
The review, which was requested by U.S. Rep. Jackie Walorski, notes that physicians continued the unnamed veteran on a high dose regimen of a steroid, prednisone, despite warnings that there was evidence that it was causing severe mood swings.
Side effects of that drug with prolonged use range from mild depression to mania and delirium, the report states.
The veteran, who lived in Marion, had multiple diagnoses indicating he was a suicide risk including bipolar disorder and post traumatic stress syndrome. He died of a self inflicted gunshot wound.
In addition both the patient and his wife had stated verbally that he was contemplating suicide due to excessive pain.
Shortly before his death, the wife of the veteran, told his health care providers that her husband was in so much pain he was "ready to blow his brains out."
In addition a rheumatologist who treated the patient had noted in the VA record that the patient "did not require steroid therapy."
"Although the outcome may have been the same for this patient, there were several missed opportunities where the patient's care and effectiveness could have been improved," the IG's report states.
Citing communications breakdowns and "failure to review information available in the patient's electronic health record," the report concludes that the patient's mental health was compromised."
The VA, in response to the report, agreed to more than a dozen recommendations aimed at avoiding a recurrence.
According to the report the veteran committed suicide in December of 2013 after he had sought care at at least three VA facilities and an unnamed private health care agency.