The Center Square [By Vivian Jones] –
A veteran seeking care at the Memphis VA Medical Center died by suicide one day after experiencing “deficiencies in care, care coordination, and facility response,” a VA investigation found.
The Veterans Affairs Office of the Inspector General disclosed the 2019 death of an unidentified veteran in an inspection report released Thursday that detailed how the Memphis VA Medical Center failed to provide adequate treatment.
The veteran, whose identity and gender are not included in the report, was in his or her 30s and sought treatment at the Memphis VA Medical Center in summer 2019. The veteran had been diagnosed with post-traumatic stress disorder, was suffering from insomnia, and had run out of prescribed psychiatric medication.
An emergency room doctor discharged the veteran and directed him or her to visit the facility’s outpatient mental health clinic. According to the report, the patient’s family member accompanied the veteran to the mental health clinic. After waiting for an hour to speak with a staff member, the family member recalled being told that the next available appointment was in one month. The veteran was able to get a 10-day refill of one of three needed prescriptions at the facility pharmacy.
The next day, the veteran died of a self-inflicted gunshot wound.
Investigators identified a number of failures by the Memphis VA Medical Center, including lack of coordination between departments, inadequate facility oversight, medication reconciliation deficiencies, and “vulnerabilities” with the on-site Mental Health Clinic check-in process. While the report did not assume responsibility for the veteran’s death, the investigation found the veteran “did not receive the care needed.”
The report outlined 16 recommendations to address failures.
“My staff is in touch with Facility Director David Dunning, and I will be tracking action on the VAOIG recommendations closely,” Tennessee U.S. Sen. Marsha Blackburn said in a statement to The Center Square. “Our men and women in uniform should not have to wait until they become veterans to address their health challenges.”
Blackburn has co-sponsored legislation that would update VA mental health and telehealth care, expand eligibility for VA hospital care for recently discharged veterans, require the VA to take specific actions to prevent veteran suicide, expand VA telehealth services and expand the VA’s direct hiring authority for mental health workforce.
The bill would also require the VA to conduct various studies and establish measurable goals for suicide prevention and mental health outreach.
Tennessee U.S. Rep. Phil Roe, who serves as ranking member of the House Veterans Affairs Committee, is working to get the bill passed in the House.
“That bill includes a provision named after Parker Gordon Fox – a Tennessee veteran who recently died by suicide – that will facilitate better coordination between VA and community providers in hopes of preventing another tragedy like the one in Memphis from ever happening again,” Roe told The Center Square in a statement.
The bill passed the Senate last month. Roe hopes to see the bill become law by the end of this year.
“My thoughts and prayers are with the family members and loved ones of the veteran whose tragic death was detailed in a report by the VA Inspector General last week,” Roe said.
The Memphis VA Medical Center consistently has ranked at the bottom among VA hospitals around the country. In 2019, Memphis VA Medical Center was one of nine VA hospitals to receive a one-star rating – the lowest possible. The VA abolished the star ranking system in January, but according to the VA’s new comparative analysis of health centers in the Memphis area, the Memphis VA Medical Center ranks 20th out of 24 total available hospital facilities. The current estimated wait time to be seen at the facility is 10 days.
Last year, WalletHub ranked Memphis 97th out of the 100 largest cities in the U.S. for veterans to live.