For the second time in 16 months, a federal watchdog agency has cited the Minneapolis VA Health Care Center for failures connected to a Minnesota veteran's suicide.
"I want to die," the veteran said after he was admitted to the medical center in the spring of 2018. Three days later, a nurse overheard the man talking on the telephone, saying he was going to die in the hospital. "I want you to have the seven acres for all the help you have given me," the vet told the other person on the line.
Hours later, police responded to a report that a patient had attempted suicide on VA property. Despite CPR, the vet died.
It was the second time within weeks that a veteran had taken his own life at the medical center.
In February 2018, a 33-year-old Lino Lakes man killed himself in the medical center's parking lot, less than 24 hours after he was discharged from its mental health unit. Tim Walz, now Minnesota governor but at that time a ranking member of the U.S. House Committee on Veterans Affairs, asked that the case be reviewed. Months later, the VA Office of Inspector General cited the Minneapolis hospital for numerous failures, including not documenting the patient's access to firearms.
A month later, Walz asked for a review of the second suicide. A 27-page report released this week cited a number of failures such as deficiencies in care coordination, including the failure of the emergency department's staff to follow requirements that they report the patient's suicidal ideation to the medical center's suicide prevention coordinator.
In a written statement Thursday, VA officials noted that the report focuses on events that happened 20 months ago.
Since then, they said, they've made improvements to address the failures. The report doesn't identify the veteran, who was in his 60s.
Alissa Harrington of St. Paul, whose brother, Justin Miller, killed himself at the hospital in February 2018, said she takes comfort in the fact that local VA officials are trying to fix the problems.
Still, it was traumatic for her to read the latest report.
"When someone dies by suicide, there are all kinds of questions about why, and one of the things you learn to tell yourself is that it's no one's fault," she said. "But having a government report in black and white in front of you that says no, actually these things did go wrong in the care of that person, blows that out of the water. It's devastating to know that someone could have done something that would have given your loved one a better chance at survival."
Just months apart, the two Minnesota veterans went to the VA hospital in search of help, Harrington said.
"They were suicidal and they needed assistance," she said. "The care coordination wasn't there to make sure they received the level of care they needed to prevent their deaths by suicide."
The VA is a complicated system, Harrington said. "It has to be. It's doing a lot of things," she said. "People need to be talking and communicating with each other."
That hasn't always happened, she said.
According to the inspector general's review, a dietitian, chaplain and a registered nurse failed to communicate the man's suicidal thoughts to others on the treatment team. That resulted in "missed opportunities" in care that might have prevented his death, the report said.
"In the case of this veteran," Harrington said, "he was telling people, not necessarily the doctors, that he was there to die, and they didn't coordinate."
After the man's death, the inspector general's report said VA officials didn't conduct an "effective fact-finding to determine root causes and corrective actions sufficiently."
Minnesota VA officials were working on corrective actions before this week's report.
Suicide prevention is the VA's highest clinical priority, officials said in a statement that listed a number of improvements made to prevent similar tragedies.
Among the changes, the VA has integrated reports on suicidal behavior and overdoses into emergency department processes, taken steps to make sure veterans with suicidal ideation or behaviors are under closer supervision and hired a suicide prevention program manager who works across all service areas to coordinate prevention efforts.
Such improvements are a good first step, Harrington said.
"They're finally recognizing that doing the same things over and over again is not working," she said. "There needs to be large systematic change, and I recognize that takes time."
She'll be watching. "I know that large systems don't change unless you keep pushing them to do so," Harrington said.
Her voice trailed off as emotion overcame her. "I think both [men] would have had a chance to survive had they received better care from the VA," she said. "It breaks my heart."
