Posted on Aug 2, 2020
Investigation shows VA took nine months to dismiss physician who taunted suicidal patient
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Posted in these groups: 
Department of Veterans Affairs (VA)
Department of Veterans Affairs (VA)
Posted >1 y ago
Responses: 9
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Thank you my friend MAJ Dale E. Wilson, Ph.D. for posting the perspective from Leo Shane III who typically is mocking the POTUS "stands in contrast to President Donald Trump’s frequent stump speech claims that “anyone who mistreats or abuses our great veterans can be promptly fired” thanks to legislation he signed into law in 2017."
All of the Times from military through each service to Defense times was written by Leo Shane III who seems to be biased from some of his other articles.
It took a while to find an alternate and more reliable source my friend MAJ Dale E. Wilson, Ph.D.
By the way, I have been treated a couple times in the Washington, D.C VAMC. I don't like the drive through DC and the service at the entrance is much worse than at Martinsburg, WV VAMC which is my primary VAMC.
BLUF The OIG report reveals
1. it took nine months before an investigation was launched and the doctor in question was let go [relatively quickly].
Emergency Room Physician 2 [unidentified] "A second emergency department attending physician (physician 2) documented that the patient was 'clearly malingering' and 'ranting' and called VA police to escort the patient from the emergency department. After being escorted from the building, the patient wanted to return to the emergency department to address knee pain."
2. "facility’s Suicide Prevention Coordinator failed to complete the suicide behavior report following notification of the patient’s death by suicide, as required by VHA. The OIG further found that the facility’s Emergency Department failed to meet VHA’s requirements for a safe and secure evaluation area for patients seeking mental health services."
Background from a more informed and reliable source {[https://kutv.com/news/nation-world/report-va-doc-fired-9-mos-after-taunting-suicidal-vet-who-died-by-suicide-6-days-later]}
SALT LAKE CITY (KUTV) — It took nine months for the Department of Veteran Affairs (VA) to dismiss a doctor who shouted "[the patient] can go shoot [themself], I do not care" at a suicidal veteran who shot himself dead six days later, according to a new report from the VA's Office of Inspector General (OIG).
In 2019, a veteran in their 60s, accompanied with a family member, visited the emergency room at the Washington DC VA Medical Center to complain of withdrawals from alprazolam (Xanax) and oxycodone as well as insomnia.
The patient was hoping to be admitted to safely detoxify and get help, according to the report.
However, doctors scheduled the patient for a same-day outpatient evaluation.
The veteran and a family member then reported they were dissatisfied with the care, telling a veteran experience specialist the desire to be admitted. That specialist escorted the pair back to the emergency room and told staff of the patient's desire to be admitted.
The patient then went to the scheduled outpatient evaluation with a psychiatrist. That outpatient psychiatrist gave the patient a "moderate risk" for suicide and "recommended either an inpatient medicine admission for management of opioid and benzodiazepine withdrawal or an inpatient psychiatry admission for management of withdrawal, insomnia, and anxiety," the report says.
The outpatient psychiatrist then took the patient back to the emergency room and "reportedly provided a verbal hand-off directly and through an alert in the electronic health record to physician. The patient’s family member left the facility with the expectation that the patient was being admitted," the report states.
A physician's assistant made record that the patient was to be admitted to the hospital.
Despite all of that, the resident psychiatrist in the emergency room assessed the patient's suicidal risk as "mild," said the patient denied having suicidal ideations, a[n]d recommended he be discharged home.
The report documents what happened next:
When informed of the discharge plan, the patient refused to leave. "
A second emergency department attending physician (physician 2) documented that the patient was 'clearly malingering' and 'ranting' and called VA police to escort the patient from the emergency department. After being escorted from the building, the patient wanted to return to the emergency department to address knee pain."
Staff members reported that when informed of the patient’s plan to return, physician 2 dismissed the patient’s reported symptoms and shouted, '[the patient] can go shoot [themself]. I do not care.' While the OIG confirmed that at least three facility staff members heard the statement, the OIG could not confirm that the patient heard this statement (because the patient was dead at the time of the investigation, and therefore could not be asked if he heard it). The patient was picked up by the family member and left the facility."
The patient navigated two transitions between the Emergency Department and outpatient Mental Health Clinic and saw seven providers over the course of 12 hours. The lack of collaboration between Emergency Department and inpatient mental health providers, deficiencies in the handoff process, and the Emergency Department and inpatient mental health providers’ failure to read the outpatient psychiatrist’s notes led to a compromised understanding of the patient’s treatment needs and a failure to enact the outpatient psychiatrist’s recommended treatment plan.
While three staff members heard the disparaging comment and reported it to authorities, the report finds it took nine months before an investigation was launched and the doctor in question was let go. Hospital leaders are required by law to file a report when told about conduct issues with providers -- something that was not done, the report says.
The report also found "facility’s Suicide Prevention Coordinator failed to complete the suicide behavior report following notification of the patient’s death by suicide, as required by VHA. The OIG further found that the facility’s Emergency Department failed to meet VHA’s requirements for a safe and secure evaluation area for patients seeking mental health services."
FYI COL Mikel J. Burroughs SP5 Jim Curry SGT Robert Pryor SMSgt Lawrence McCarter LTC (Join to see) Maj Bill Smith, Ph.D. Maj William W. 'Bill' Price TSgt David L. PO2 (Join to see) PO1 H Gene Lawrence SPC Nancy Greene LTC John Shaw Lt Col John (Jack) Christensen Lt Col Charlie Brown MSgt Robert "Rock" Aldi SGT Steve McFarland 1SG Steven Imerman
All of the Times from military through each service to Defense times was written by Leo Shane III who seems to be biased from some of his other articles.
It took a while to find an alternate and more reliable source my friend MAJ Dale E. Wilson, Ph.D.
By the way, I have been treated a couple times in the Washington, D.C VAMC. I don't like the drive through DC and the service at the entrance is much worse than at Martinsburg, WV VAMC which is my primary VAMC.
BLUF The OIG report reveals
1. it took nine months before an investigation was launched and the doctor in question was let go [relatively quickly].
Emergency Room Physician 2 [unidentified] "A second emergency department attending physician (physician 2) documented that the patient was 'clearly malingering' and 'ranting' and called VA police to escort the patient from the emergency department. After being escorted from the building, the patient wanted to return to the emergency department to address knee pain."
2. "facility’s Suicide Prevention Coordinator failed to complete the suicide behavior report following notification of the patient’s death by suicide, as required by VHA. The OIG further found that the facility’s Emergency Department failed to meet VHA’s requirements for a safe and secure evaluation area for patients seeking mental health services."
Background from a more informed and reliable source {[https://kutv.com/news/nation-world/report-va-doc-fired-9-mos-after-taunting-suicidal-vet-who-died-by-suicide-6-days-later]}
SALT LAKE CITY (KUTV) — It took nine months for the Department of Veteran Affairs (VA) to dismiss a doctor who shouted "[the patient] can go shoot [themself], I do not care" at a suicidal veteran who shot himself dead six days later, according to a new report from the VA's Office of Inspector General (OIG).
In 2019, a veteran in their 60s, accompanied with a family member, visited the emergency room at the Washington DC VA Medical Center to complain of withdrawals from alprazolam (Xanax) and oxycodone as well as insomnia.
The patient was hoping to be admitted to safely detoxify and get help, according to the report.
However, doctors scheduled the patient for a same-day outpatient evaluation.
The veteran and a family member then reported they were dissatisfied with the care, telling a veteran experience specialist the desire to be admitted. That specialist escorted the pair back to the emergency room and told staff of the patient's desire to be admitted.
The patient then went to the scheduled outpatient evaluation with a psychiatrist. That outpatient psychiatrist gave the patient a "moderate risk" for suicide and "recommended either an inpatient medicine admission for management of opioid and benzodiazepine withdrawal or an inpatient psychiatry admission for management of withdrawal, insomnia, and anxiety," the report says.
The outpatient psychiatrist then took the patient back to the emergency room and "reportedly provided a verbal hand-off directly and through an alert in the electronic health record to physician. The patient’s family member left the facility with the expectation that the patient was being admitted," the report states.
A physician's assistant made record that the patient was to be admitted to the hospital.
Despite all of that, the resident psychiatrist in the emergency room assessed the patient's suicidal risk as "mild," said the patient denied having suicidal ideations, a[n]d recommended he be discharged home.
The report documents what happened next:
When informed of the discharge plan, the patient refused to leave. "
A second emergency department attending physician (physician 2) documented that the patient was 'clearly malingering' and 'ranting' and called VA police to escort the patient from the emergency department. After being escorted from the building, the patient wanted to return to the emergency department to address knee pain."
Staff members reported that when informed of the patient’s plan to return, physician 2 dismissed the patient’s reported symptoms and shouted, '[the patient] can go shoot [themself]. I do not care.' While the OIG confirmed that at least three facility staff members heard the statement, the OIG could not confirm that the patient heard this statement (because the patient was dead at the time of the investigation, and therefore could not be asked if he heard it). The patient was picked up by the family member and left the facility."
The patient navigated two transitions between the Emergency Department and outpatient Mental Health Clinic and saw seven providers over the course of 12 hours. The lack of collaboration between Emergency Department and inpatient mental health providers, deficiencies in the handoff process, and the Emergency Department and inpatient mental health providers’ failure to read the outpatient psychiatrist’s notes led to a compromised understanding of the patient’s treatment needs and a failure to enact the outpatient psychiatrist’s recommended treatment plan.
While three staff members heard the disparaging comment and reported it to authorities, the report finds it took nine months before an investigation was launched and the doctor in question was let go. Hospital leaders are required by law to file a report when told about conduct issues with providers -- something that was not done, the report says.
The report also found "facility’s Suicide Prevention Coordinator failed to complete the suicide behavior report following notification of the patient’s death by suicide, as required by VHA. The OIG further found that the facility’s Emergency Department failed to meet VHA’s requirements for a safe and secure evaluation area for patients seeking mental health services."
FYI COL Mikel J. Burroughs SP5 Jim Curry SGT Robert Pryor SMSgt Lawrence McCarter LTC (Join to see) Maj Bill Smith, Ph.D. Maj William W. 'Bill' Price TSgt David L. PO2 (Join to see) PO1 H Gene Lawrence SPC Nancy Greene LTC John Shaw Lt Col John (Jack) Christensen Lt Col Charlie Brown MSgt Robert "Rock" Aldi SGT Steve McFarland 1SG Steven Imerman
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Unfortunately, this doesn’t surprise me due to the fact the VAMC’s in NC have some of the most unprofessional doctors I’ve ever had the displeasure of interacting with
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