Review of Two Mental Health Patients Who Died by Suicide, William S. Middleton Memorial Veterans Hospital Madison, Wisconsin

At the request of Senators Tammy Baldwin and Ron Johnson, the VA Office of Inspector General (OIG) conducted a healthcare inspection regarding the care and management of a patient who committed suicide less than 48 hours after discharge from William S. Middleton Memorial Veterans Hospital (Facility), Madison, Wisconsin. A second patient was also identified and reviewed. The OIG found that Facility managers correctly classified the patient’s death as a sentinel event and completed Veterans Health Administration and Joint Commission reporting requirements; however, the Facility’s root cause analysis process was deficient. A 72-hour hold was not required for the patient although it was considered by the provider. The OIG identified ethical concerns regarding the patient’s enrollment in a research study; a failure by staff to inform a community monitoring agency of the patient’s court settlement agreement violations, deficiencies in discharge planning; and inadequate post discharge follow-up. The OIG also identified deficiencies in psychiatric clinical pharmacists’ outpatient Mental Health (MH) care in the 15 months prior to the patient’s death and similar MH care deficiencies by a psychiatric clinical pharmacist in the care of another patient that died by suicide 13 months prior to the first patient’s death. The OIG made 11 recommendations related to institutional disclosures for both patients, an ethics review of the first patient’s participation in a research study, an expanded evaluation of the first patient’s death, court settlement agreements, revision of the MH unit policy, prescribing practices including adherence to black box warnings, the use of collaborative agreements and assignment of prescribers for patients with complex MH needs, and strengthening psychiatric clinical pharmacists’ supervision processes.