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HAMPTON, Va. (AP) — A Hampton VA Medical Center patient twice reported his attempted suicide but the staff never notified the hospital's suicide prevention coordinator, according to an inspector general's report released Monday.
The incident involving the man who had a history of depression and insomnia occurred more than three years ago and was investigated at the request of Republican Sen. Richard Burr of North Carolina.
According to report, the staff noted the attempted suicide in the patient's record, but never filed a report to alert the suicide prevention coordinator for further monitoring and review.
Providers are required to complete a suicide behavior report when they become aware of suicide attempts under VA policy. A suicide prevention coordinator would then assess the patient's risk, ensure they're evaluated at least weekly for the next month at a minimum, as well as follow up on missed appointments.
Media outlets report that the unidentified young man later died of accidental causes six weeks after visiting an area outpatient clinic.
The report "reveals the upsetting reality that VA personnel did not do everything they could in this case to help a troubled veteran," Burr said. "The findings highlight the necessity for administrators and medical personnel to approach the difficult nature of suicide with compassion and fully train all personnel to follow procedures in these situations."
Hampton VA Medical Center officials said they agree with the report and its recommendations. Providers who work there under contract are now trained in managing suicide risk. The medical center also is randomly auditing 70 medical records per month in three departments to ensure the staff is taking steps to evaluate at-risk patients.
"There were things that could have been done differently," said Dr. Priscilla Hankins, chief of mental health at the Hampton VA. "The documentation is one of them."
Hankins also noted that while the VA's expanding services are helping many veterans, there are some that are beyond help.
"Are there some who do not get better? Yes, unfortunately, that is the reality," she said. "There are some who we cannot assist. That is the unfortunate, sad outcome."
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