Alleged Deficiencies in Mental Health Care Prior to a Death by Suicide at the VA San Diego Healthcare System, California

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations that staff at the San Diego VA Healthcare System, California, failed to provide mental health care to a patient who subsequently died by suicide. The OIG did not substantiate that the system failed to provide mental health care when the patient sought help. The OIG found that the suicide risk assessment of the patient was adequate. The system complied with both Veterans Health Administration (VHA) and system requirements related to the risk assessment and resident supervision, supervision documentation, and monitoring of resident supervision documentation. The OIG identified deficits in the decision-making process to deactivate the patient’s High Risk for Suicide Patient Record Flag. The assigned Suicide Prevention Coordinator deactivated the High Risk for Suicide Patient Record Flag without contacting the patient, consulting the patient’s treatment team, the patient having scheduled future appointments, and despite the patient having not been engaged in mental health services for more than two months. VHA does not have clearly delineated requirements for the decision-making process to deactivate the High Risk for Suicide Patient Record Flag; however, the Executive Director, Suicide Prevention Program, told the OIG that the suicide prevention coordinator is expected to consult with the patient’s treatment team, provide evidence of decreased risk and reduced suicide risk factors, and document rationale for clinical judgment about mental health conditions and behaviors. Further, the OIG identified deficits in the medication reconciliation process and documentation. The OIG made one recommendation to the Under Secretary for Health related to management of High Risk for Suicide Patient Record Flags and one recommendation to the System Director related to the medication reconciliation process and documentation.