A unidentified whistleblower at the Albuquerque Veterans Affairs hospital claimed in 2016 that the suicide prevention coordinator “regularly failed to fulfill her assigned duties according to VA regulations, resulting in unsatisfactory care for suicidal veterans,” according to a letter from Henry J. Kerner of the OSC to the president sent on Nov. 30.
Among other allegations, the whistleblower claimed the coordinator failed to manage the hospital’s “high risk for suicide” list by not flagging patient records as high risk in a timely manner.
The flagging system was put into place in 2012 and required VA medical centers to create a list of those at high risk for suicide and a system for flagging patients’ records. The flag would then be visible to VA staff accessing the patient’s records, either at a local or national level.
There was no deadline for flagging in place at the VA.
Kerner noted that “a lack of requirements leads to delays and delays lead to veteran deaths,” and the OSC recommended the VA change policy to include a deadline for the flagging process.
The VA agreed and is revising the directive to require that high-risk patients’ files be flagged within 24 hours.
The investigation revealed that the coordinator did not perform required 90-day evaluations for some veterans placed on the high-risk list. The investigation also found instances of delayed responses to calls to the Veterans Crisis Line. In one case, a referral to the hospital from the crisis line was not responded to for eight days.
“OSC found the agency’s contention that (redacted) succeeded in carrying out her duties related to responding to calls from the Veterans Crisis Line surprising, as it simultaneously noted that (redacted) had delayed responses to multiple calls from suicidal veterans,” Kerner wrote.
Sonja Brown, associate director of the Albuquerque hospital, said the coordinator remains in her position.
The report also said staffing at the hospital was a concern and recommended that the hospital ensure the coordinator’s position is adequately supported.
Brown said that there are currently a psychologist, social worker and administrative assistant staffing the suicide prevention office, and that a second social worker is expected to join the staff in a month.
Two additional social worker positions have been approved, Brown said, and the facility director has approved staff to work overtime if needed.
Six veterans receiving care at the Albuquerque facility committed suicide in the 2014 fiscal year, followed by 10 in 2015 and five from October 2015 to March 2016, according to the report.
VA spokesman Curtis Cashour said in an email that the agency appreciates the work of the OSC.
“VA believes every veteran suicide is a tragedy, that’s why Secretary Shulkin has made suicide prevention the department’s number one clinical priority,” Cashour said.