Mismanaged Mental Health Care for a Patient Who Died by Suicide and Review of Administrative Actions at the VA Tuscaloosa Healthcare System in Alabama

The OIG evaluated allegations related to the care of a patient who died by suicide six days after a mental health appointment at the VA Tuscaloosa Healthcare System (facility). Concerns regarding appointment scheduling, supervision of a posttraumatic stress disorder (PTSD) clinic social worker (social worker), and leaders’ administrative actions were reviewed.The OIG substantiated that a mental health nurse practitioner failed to inform the patient of a mirtazapine-related suicide risk, complete required suicide screening, and closely monitor the patient after initiating mirtazapine. Administrative staff did not attempt to schedule the patient’s medication management follow-up appointment within two business days, as required.The OIG substantiated that the social worker failed to sufficiently assess suicide risk, conduct lethal means safety counseling, and seek consultation. Facility staff did not arrange the patient’s PTSD treatment and the social worker received inadequate supervision.The OIG substantiated that staff did not submit a consult for required traumatic brain injury evaluation.Staff did not inform leaders about closing an incomplete root cause analysis action item. The peer review committee failed to address two identified system issues. Further, a suicide prevention coordinator failed to complete required Behavioral Health Autopsy Program (BHAP) documentation.VHA leaders did not provide guidance to suicide prevention staff on when not to contact family to offer a BHAP interview, and facility leaders did not conduct an institutional disclosure due to an erroneous understanding of requirements.The OIG made one recommendation to the Under Secretary for Health to consider establishing written guidance regarding the BHAP family interview process, and 13 recommendations to the Facility Director related to reviewing the patient’s care; boxed warning education; suicide risk screenings; appointment scheduling; lethal means safety counseling; PTSD clinic processes; traumatic brain injury evaluation; and root cause analysis, peer review, BHAP, and institutional disclosure processes.