A newly released government investigation has found that three Veterans Affairs health clinics “missed opportunities” to prevent a Vietnam veteran’s suicide, with failures ranging from “communication breakdowns” to completely ignoring his “multiple suicide risk factors.”
The unnamed sixty-something patient, who had previously attempted suicide in 1989, shot himself in the head in 2013. He’d been receiving treatment for chronic shoulder, neck and back pain; osteoarthritis, degenerative discs in his lower back, low bone density and a variety of nerve conditions exacerbating pain and weakness in his neck and back, and had had cervical spine surgery in the fall of 2012.
The patient bounced around from clinic to clinic beginning in 2011, when the VA reassigned him from his usual primary care clinic to one nearer his home. A year later he requested another transfer, and another six months after that.
He was also diagnosed with PTSD related to his service in Vietnam, depression, anxiety, “intermittent explosive disorder,” bipolar depression, steroid-induced mood disorder and alcohol abuse.
According to the investigation, “the patient was generally compliant and motivated for MH [mental health] treatment and medication management; he rarely cancelled an appointment.”
Yet by the winter of 2013, his condition had deteriorated significantly. His wife called a VA telephone triage during that time, telling them that her husband was in “excruciating pain,” even saying that he was “ready to blow his brains out.”
The telephone triage nurse sent a note to Suicide Prevention Staff about the call, but while they received it they did not contact her, the patient’s primary care provider or mental health care provider about his suicidal statements.
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