VA Report: MN Vet Did Not Warn of Suicide

From the Minneapolis-St. Paul Star Tribune:

An internal investigation by the Veterans Administration into the suicide of Marine veteran Jonathan Schulze found that the VA record is "diametrically opposed" to his family's contentions that he was denied psychiatric care just days before he killed himself.

The report [pdf], from the VA's Office of the Medical Inspector, said no evidence exists that Schulze twice told staff at the VA hospital in St. Cloud that he was suicidal. But the report, released Friday, also reveals that doctors at the VA hospital in Minneapolis, where Schulze made at least 40 medical visits, had diagnosed him with post-traumatic stress disorder in the wake of combat in Iraq.

Five mental health workers interviewed at the St. Cloud hospital told investigators that had Schulze mentioned suicide they were certain that "appropriate actions would have been taken. All staff, including the janitors, knows to take the mention of suicide very seriously." That conclusion contradicts statements by Jim and Marianne Schulze, Schulze's father and stepmother, who told VA investigators that they witnessed their son telling the nurse he was suicidal.

Click on 'Article Link' below tags for selections from the report...

Selections from the VA Inspector General's report [pdf]:

Introduction
On January 16, 2007, a veteran of the United States Marine Corps (USMC) and Operation Iraqi Freedom (OIF) committed suicide in a friend’s home. This patient had received extensive health care over the previous 20 months from the VA Medical Center (VAMC) in Minneapolis, Minnesota. He received general medical care there, primarily for infectious conditions and musculoskeletal injuries, and he was also the recipient of psychiatric care at the Minneapolis VAMC, predominantly for post-traumatic stress disorder (PTSD).

Although a patient of the Minneapolis VAMC, the patient visited the St. Cloud VAMC, 75 miles to the northwest of Minneapolis, for the first time 5 days before his death. At that time, he was accompanying his father who was a veteran patient of that facility, and who had a prescheduled January 11, 2007, doctor’s appointment. While at the St. Cloud VAMC with both his father and his stepmother, the patient started the process to be admitted to a St. Cloud VAMC elective residential treatment program. This program is a non-emergency program described by the Veterans Health Administration (VHA) as “appropriate for veterans…who require additional structure and support to address multiple and severe psychosocial deficits, including homelessness and unemployment.”

Two processes were to occur before elective residential treatment program admittance could be arranged. The first was a pre-screening evaluation in which patients spplying for the program are asked if there are legal or medical issues that would prevent program completion. The second is for prospective program participants to answer a more detailed screen administered by a nurse or social worker. These steps occurred on January 11 and 12 respectively, and the patient was advised by the screening social worker that he had been accepted for the program.

Four days later, the patient committed suicide. In the aftermath of the patient’s suicide the patient’s father and stepmother claimed that at the time of both screenings, the patient had told St. Cloud VAMC staff—an intake nurse on January 11 and the screening social worker on January 12—that he was suicidal. This declaration, if true, should have prompted a far more thorough evaluation than simply the residential treatment program admission screens that had been administered.

At the request of VA’s Secretary and members of Congress, VA’s Office of Inspector General (OIG), Office of Healthcare Inspections (OHI) performed a comprehensive inspection of the Minneapolis and St. Cloud VAMCs’ health care provided to the patient. This included the 2 days in question, as well as in the 20 months prior; OHI also examined the circumstances of the patient’s death. Both the prior VA health care and circumstances of death were critical in order to understand the patient’s mental state and actions after his January 12 screening telephone call with the St. Cloud VAMC social worker, and to reconstruct and understand what transpired on January 11–12.

Additionally, in the aftermath of the above allegations, others arose. One was that much of VA’s medical care for the patient was inadequate, the thrust of these allegations being that VA displayed an overall indifference to, and lack of understanding of, the patient’s needs, including, in particular, his PTSD. Another was that the reason the patient was not admitted emergently to the St. Cloud VAMC on January 11–12 was that a bed was unavailable. Still another appeared to be that VA should have recognized the patient’s suicidality in time to prevent it. These allegations, too, are addressed in this report.

Results
OHI found that the patient received extensive quality medical care at the Minneapolis VAMC, consisting of intensive treatment for infections as well as somewhat more routine care for orthopedic conditions. He was hospitalized on May 9, 2005, 1 month after discharge from the USMC, due to lip swelling and inflammation of his superficial abdominal wall, both caused by soft tissue infections. He required intravenous antibiotic therapy and surgical debridement and was ultimately discharged in stable condition 11 days later on May 20. He was hospitalized again from June 12–16, 2005, with abscess-like infections in his groin, buttocks region, and lower extremities, and again required intravenous antibiotic therapy and surgical intervention. The patient’s failure to fight infection well was both troubling and perplexing in an apparently healthy 25-year-old. An immune system evaluation was performed, which found no abnormalities.

During the patient’s May 9–20, 2005, Minneapolis VAMC admission, his attending physician elicited the history that the patient had been diagnosed by his family physician with PTSD. Arrangements were made for a Minneapolis VAMC evaluation. On May 13, the patient was seen by a Minneapolis VAMC social worker to whom he told that he suffered anxiety symptoms associated with combat exposure including panic attacks, nightmares, flashbacks, and hypervigilance. A more detailed evaluation was performed a week later by a Minneapolis VAMC nurse clinician and a Minneapolis VAMC psychiatrist. A PTSD treatment plan was formulated with the patient’s approval consisting of prescription medications, counseling, and group therapy. However, in the following weeks and months, these measures could not be implemented successfully because the patient frequently did not keep follow-up appointments. The patient’s mental health treatment was further complicated by the patient’s reluctance to fully disclose the extent of his problems with alcohol. Overall, we found that his medical and psychiatric treatment were often impeded by not providing a complete and accurate medical history or complying with follow-up recommendations.

In the face of missed appointments, Minneapolis VAMC caregivers called the patient, offered care after daytime work hours, and when he “no-showed,” reviewed his medical chart and assessed his risk for suicidality and homicidality. These assessments were negative. Despite the patient’s clear underlying illness, however, he was not delusional or an imminent risk to himself or others such that he could be committed under Minnesota law.

In the latter part of 2006, when legal problems related to a Driving While Intoxicated (DWI) conviction were an issue for the patient, the Minneapolis VAMC formulated a care plan. The patient was scheduled for March 2007 entry into a Minneapolis VAMC program, which is an elective, non-emergent program.

In January 2007, the patient considered other VA program options that met his needs, including pending legal requirements. On or about January 4, a friend telephoned the Minneapolis VAMC because the patient was in distress. The staff there advised to bring him to the VAMC, and a friend offered to take him, but the patient declined. On January 11, he accompanied his father and stepmother to the St. Cloud VAMC because his father had an appointment there with his own doctor. At the St. Cloud VAMC, the patient began the application process for an elective non-emergent residential program. OHI could not substantiate the allegation that the patient stated he was suicidal at the St. Cloud VAMC that day or in a telephone screening interview the next day. We did not find evidence of attempts made to seek help at a non-VA facility, or to contact other sources of help such as the police or 911 in reaction to a purported statement of suicidality. Further, OHI found that the patient did not express suicidal ideation from January 13–15. On January 16, the day he committed suicide, evidence indicates that the patient had heavy alcohol intake after a period of abstinence. Either deliberately or inadvertently, the patient fatally asphyxiated himself, and the Regional Medical Examiner ruled the patient’s death a suicide by hanging.

OHI found that this patient’s VA medical care met or exceeded community standards. The patient’s medical record contemporaneously documents care provided for PTSD. However, although extensive PTSD care was offered, it was never fully engaged in. The patient was also offered care for other disclosed mental health issues. The St. Cloud VAMC had inpatient psychiatric beds available on January 11–12, 2007, to hospitalize a patient, if acutely suicidal. The patient was not turned away from the St. Cloud VAMC due to lack of an acute psychiatry bed. He was placed on a waiting list for elective residential care, the program for which he had been screened. During his VAMC care, he was repeatedly assessed for suicidality and these evaluations were always negative.

Recommendations
OHI’s recommendations concern the screening process for the St. Cloud VAMC’s elective residential program. Because patients diagnosed with PTSD and co-morbid conditions have an elevated risk for self-destructive behaviors, we believe that screening for entry into VA mental health programs, even non-emergent elective programs such as in this case, should entail a more comprehensive and detailed assessment process. We recommended that the St. Cloud VAMC screening questionnaire be reviewed and that a multidisciplinary process be considered. As discussed in the body of this report, we found that the patient was asked to contact the St. Cloud VAMC regarding follow-up, both for evaluation and information. We believe that it would be a superior approach for a VAMC to initiate the contact with patients and provide updates as required instead of placing this onus on patients.

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