Deficiencies in Mental Health Care Coordination and Administrative Processes for a Patient Who Died by Suicide, Ralph H. Johnson VA Medical Center, Charleston, South Carolina

The VA Office of Inspector General (OIG) reviewed allegations referred by Chairman Mark Takano, House Committee on Veterans’ Affairs, regarding deficiencies in the mental health care provided at the Ralph H. Johnson VA Medical Center (facility) to a high risk for suicide patient who died by suicide. The OIG did not substantiate that service agreement procedures resulted in inadequate psychiatric monitoring or delayed psychiatric care or that facility staff delayed placement of the patient’s high risk for suicide patient record flag. The OIG found that staff did not adequately evaluate the patient’s condition when reviewing the patient’s high-risk status. Facility staff did not assign a Mental Health Treatment Coordinator (MHTC) prior to discharge or establish a facility MHTC policy, as required. The Recovery Engagement and Coordination for Health – Veterans Enhanced Treatment (REACH VET) provider did not outreach the patient, as required. Facility staff did not comply with Veterans Health Administration suicide risk assessment procedures and did not notify facility leaders or suicide prevention staff of the patient’s death by suicide. The OIG made five recommendations to the Facility Director related to high risk for suicide patient record flag reviews, MHTC assignment, REACH VET program requirements, suicide risk assessment, and staff notification of patients’ death by suicide.