Deficiencies in Care Coordination and Facility Response to a Patient Suicide at the Minneapolis VA Health Care System, Minnesota

The VA Office of Inspector General (OIG) conducted a healthcare inspection to access care coordination for a patient who died by suicide while admitted to an inpatient medicine unit at the facility. The patient was assessed as heightened but not imminent risk for suicide. Facility Emergency Department staff failed to report the patient’s suicidal ideation to the facility's Suicide Prevention Coordinator. Two consulting staff members and an inpatient registered nurse completed required suicide prevention training but failed to involve clinicians when the patient verbalized suicidal thoughts and warning signs. Two of the three staff documented the patient’s suicidal thoughts and warning signs in consult results notes, but the OIG did not find documentation that the inpatient medicine resident reviewed or acted on the consult results. During an internal review, the facility’s root cause analysis team did not interview staff members involved in the patient’s care. The internal review team identified many lessons learned for which the Veterans Health Administration (VHA) does not require action items. VHA does not provide written guidance on the identification of lessons learned, related action expectations, and how to distinguish lessons learned from root causes. The absence of formal guidance may have contributed to the team’s failure to identify critical actions in the prevention of adverse patient events. Facility leaders did not make an institutional disclosure to the patient’s next of kin. The Patient Safety Committee and the Quality Management Council meeting minutes did not document deliberations and track actions to resolution. The OIG made a recommendation to the Under Secretary for Health related to written guidance for lessons learned, and six recommendations to the Facility Director related to Suicide Prevention Coordinator notification, a review of the patient’s care, consult results, institutional disclosure, the root cause analysis process, and documentation of meeting minutes.