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Here is what you need to know about the newest IG Report after one veteran committed suicide at Minneapolis VA after making obvious suicidal comments to VA staff.
I live near the Minneapolis VA and have sought care from them a few times.
Some of the folks at the Minneapolis VA are great. Some are not. Dr. Michael Dieperink should be completely embarrassed after the IG Report calling out his inability to properly train staff to prevent suicide.
Sporting a 1-star rating, reviews on Healthgrades.com called Dr. Dieperink “a total quack” and “Dr. Michael Dieperink is a horrible person: arrogant and condescending. He has little interest in the wellbeing of his patients and offers nothing to the field of psychiatry.”
Head of the facility, Dr. Dieperink’s boss, Patrick Kelly wrote, “Suicide prevention is the VA’s number one clinical priority, and this tragic event has greatly impacted the family and the staff at the Minneapolis VA Health Care System.”
Really?
Veteran came into the ER suffering from withdrawal symptoms from opioids and benzodiazepines. How many veterans meet this description?
VA gets you addicted to a substance. They then cut you off.
The veteran tells staff he has thoughts of suicide and homicide. While an inpatient, he told a dietitian, chaplain, and medical resident, “I came here to die,” “I want to die” and, “I wish that someone could give me a dose of morphine so I could die.”
Nurses, doctors, and anyone with ears knew the guy was suicidal.
Two hours later, the veteran completed his suicide after disappearing from the hospital.
So, why was he not in 72-hour hold?
Distain For Veterans?
My friend and attorney Brian Lewis has some ideas that I wanted to share with readers curious about what’s going on within the Minneapolis VA mental health department in reference to the Stars and Stripes article about the IG Report.
Full disclaimer behind the sign above. Brian and I were part of the push to publish that billboard at three locations surrounding Minneapolis VA back in 2015. It cost $15k for three billboards for one month. Worth every penny.
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Many VA employees complained to Patrick Kelly about the sign and even asked him to make us stop. He literally had to write an internal memo to those employees complaining to remind them that veterans enjoy the 1st Amendment just like every other American who did not fight to protect it.
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Here is what Brian Lewis had to say about the “apparent disdain” of the head of mental health that led to the malaise leading up to the suicide:
OK, so here’s a point of view from someone who uses the failure called the Minneapolis VA Health Care System. It wouldn’t have mattered one bit had God and everyone took the proper actions. The Mental Health Services Department at this supposed medical facility falls beneath even the Veterans Health Administration (VHA) – U.S. Department of Veterans Affairs’s usual standards of malpractice care. When the rest of the hospital sees that the Mental Health Services Department is in disarray, disengaged, and disinterested in their patients, why even bother to send a consult over?
I believe Dr. Michael Dieperink, the Mental Health Services Department Head, has virtually zero interest in patients. His apparent disdain for patients radiates down through the chain of command and has infected professionals throughout the department. The staff appears to be overall more concerned with numbers and metrics than actually providing patient care that aligns with patient goals. Even inside the #PTSD Clinical Team, the staff appears to be more concerned with evidence-based practice, avoidance of alternative therapies, and ensuring patient desires for their care are ignored. Thus, I find it hard to believe the veteran in question actually received mental health care that was appropriate to needs.
When the new Director of VISN 23, Mr. Robert McDivitt, first came aboard, I asked him at the VA Town Hall if he had any plans of conducting independent oversight of the Minneapolis VA. He hemmed and hawed around the question for a good minute, but the answer was no. CAPT Pat Kelly has proven over the course of several years and at least two separate deaths that he is unfit to lead a patrol to the latrine, much less a major medical center to a course correction it badly needs. Isn’t it time to dump a zero, U.S. Department of Veterans Affairs? The #veterans you serve deserve better.
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Shocking IG Report Summary
Hold what Brian had to say in your back pocket for a second and compare that to what the agency summarized in the IG report:
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.
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Is Patrick Kelly Being Honest?
Digging a little deeper, the lack of consideration and failure to adhere to standard suicide protocol make me think Patrick Kelly is either totally ignorant about his staffs’ disposition toward suicidal veterans or lying.
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Here is what IG said from the brief patient summary buried within the report:
The patient was in their sixties at the time of death by suicide in spring 2018. The patient used a central nervous stimulant for more than 30 years. Starting in 2006, the patient received mental health treatment at another VA medical center’s community based outpatient clinic (CBOC). The patient established sobriety and mood stability for over 10 years through treatment including a combination of an antidepressant and an antipsychotic medication. In 2017, the patient transferred care to one of the facility’s CBOCs. The primary care provider diagnosed the patient with major depression and history of substance use in remission. For additional patient case summary details related to pre-spring 2018, see appendix A.
On a day in spring 2018 (day 1), the patient’s public health nurse informed the facility CBOC team that the patient had been taking leftover medication (benzodiazepine 1) and had run out. The nurse described the patient as “a little unsteady” and reported that the patient had “a rough weekend.” The CBOC nurse called the patient who denied suicidal ideations although reported feeling more depressed. The patient agreed to come in the following day. On day 2, the patient presented to the CBOC. The primary care physician documented that the patient abruptly discontinued benzodiazepine 1 one week prior and had been trying to decrease use of opioid medication 1. The patient described dizziness, nausea, vomiting, and visual hallucinations but denied seizure activity. The patient verbalized a desire to stop taking all narcotic medications. The physician urged the patient to go directly to the facility’s Emergency Department, but the patient declined and chose to go to a non-VA Emergency Department instead. The non-VA Emergency Department provided intravenous fluids and discharged the patient home. On day 3, following a fall, an ambulance transported the patient to a non-VA Emergency Department where the patient was treated with opioid medication and intravenous fluids, and discharged to home. The patient called the CBOC on day 4 requesting help with opiate and benzodiazepine withdrawal symptoms. The patient agreed to go to the facility Emergency Department and the CBOC nurse called ahead to provide communication regarding the transfer of care.
When the patient arrived in the Emergency Department on day 4, the triage nurse described the patient as disoriented and reported that the patient denied thoughts of self-harm or harming others. However, the patient told the Emergency Department staff nurse about thoughts of suicide and homicide, and acknowledged having a gun at home. The patient told the Emergency Department evaluating psychiatrist that the patient would “definitely end it,” if “discharged home tonight and go into opiate WD [withdrawal].” The patient reported having a loaded gun and “a suitcase” filled with “old medications” at home. The evaluating psychiatrist recommended inpatient admission for observation and treatment of depressive symptoms, suicidal ideation, living alone with ample access to means of suicide, mild cognitive impairment, and withdrawal symptoms. Due to a lack of available facility or community psychiatric beds, the psychiatrist recommended admission to a medical unit and stated, “[n]o need for 1:1 sitter,” because the patient professed being able to remain safe on a medical unit and agreed to alert staff to any thoughts of suicide or self-harm.
On day 5, the patient was admitted to an inpatient medical unit. The inpatient medicine resident noted that the patient was intermittently agitated and stated, “I want to die.” The resident prescribed a medication for agitation and anxiety. Later that morning, the patient told the dietician, “I wish that someone could give me a dose of morphine so I could die.” The patient also told the chaplain about the wish for morphine to die, as well as feelings of guilt and being “unforgiveable.” The following morning, the resident documented that the patient “feels much better” but continued to express suicidal thoughts. Later that day, a nurse documented that the patient endorsed feeling depressed but denied suicidal ideation.
On day 7, the psychiatrist noted the patient’s depression and confusion, but the patient denied suicidal ideation and verbalized not wanting to die. The patient was found to have “significant” cognitive impairment, and the patient expressed a desire to go to a nursing home at discharge. The psychiatrist assessed the patient as being at heightened, but not imminent, risk for suicide, and did “not see need” for the patient’s transfer to an inpatient psychiatric unit but would reassess once discharge options were determined. The psychiatrist deferred completion of a safety plan until the patient was ready for discharge. That evening, the chaplain documented that the patient thought “[the patient] may die soon.”
On day 8, the occupational therapist assessed the patient as having mild to moderate cognitive decline and recommended an assisted living facility placement at discharge. Mid-morning, an inpatient nurse overheard the patient on the phone telling someone that the patient was going to die in the hospital and “I want you to have the seven acres for all the help you have given me.” The patient was not in the hospital room approximately two hours later. and the nurse did not find the patient during a search of the unit. The nurse had the patient paged overhead, but the patient did not return. Forty-five minutes later, the nurse contacted the Assistant Nurse Manager, who then informed the VA police that the patient was missing. Approximately 30 minutes later, the VA police received a call that a patient attempted suicide. Emergency responders provided cardiopulmonary resuscitation before the patient was taken to a non-VA Emergency Department, where the patient was pronounced dead.
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Brain Tumor And More
If you are still reading, you are my kind of advocate. Here is the final bit that jumped out at me that most folks will not appreciate. The veteran recently had a meningioma tumor:
The patient was in their sixties at the time of death by suicide. After military discharge, the patient used a central nervous system stimulant for more than 30 years and established abstinence in 2006. The patient reported mood stability on a combination of an antidepressant and an antipsychotic medication for more than 10 years. In 2006, the patient established care with the VA after receiving non-VA mental health and substance use disorder treatment and was diagnosed with major depressive disorder, recurrent, severe, and substance use remission. The patient completed a one-month VA domiciliary admission in 2007 and continued mental health treatment at a VA medical center CBOC.
In summer 2017, the patient transferred care to one of the facility’s CBOCs. The primary care provider diagnosed the patient with major depression, and history of substance abuse, in remission. The psychiatrist continued the patient’s six active medications for treatment of anxiety, insomnia, chronic pain, depression, and stabilization of mood. Prior to this episode of care, the patient was prescribed medication for anxiety and insomnia, but that prescription was discontinued because the patient was also taking medication for sleep.
In fall 2017, the patient presented to a non-VA hospital Emergency Department with a complaint of new onset headaches for three days. Brain imaging revealed a 4-centimeter brain mass consistent with a neoplasm and the patient was directly admitted to the facility. During the admission medication reconciliation, the patient reported having “extra bottles” of benzodiazepine 1 and taking the medication at bedtime for anxiety and sleep despite having been told not to by a provider. The patient was discharged three days later, with a plan to return for tumor removal surgery approximately a month later.
Prior to the scheduled surgery, the patient’s public health nurse contacted the CBOC primary care nurse with concerns about the patient’s nonadherence with the prescribed medication regimen.40 The public health nurse reported that the patient was not taking medication as prescribed and that the patient “is very calm in the mornings, but by evening, [the patient] is agitated; tells nurse and family that [the patient] sees bugs in [the] house again.” The primary care nurse recommended that the public health nurse contact the neurosurgery team.
Ten days later, the patient was admitted for a craniotomy and meningioma resection. The pathology report confirmed a meningioma diagnosis. During recovery, the patient exhibited impairments in balance, mobility, and completion of activities of daily living. The patient was admitted to acute inpatient rehabilitation four days after surgery. Approximately two weeks later, the interdisciplinary treatment team met with the patient’s family members. The interdisciplinary treatment team described improvement in the patient’s activities of daily living and ability to walk, and recommended 24-hour supervision, cessation of driving, and a family member to stay with the patient for a week to help with home equipment set-up and development of routines after discharge. The physician recommended that pain medications continue to be tapered on an outpatient basis. The patient repeatedly refused to stay with family members or to discharge to a supervised facility. The patient was discharged to home six days later, with instructions to follow up with primary care, the traumatic brain injury clinic, radiation oncology, neurosurgery, mental health, and with the home public health nurse.
The patient met with a psychiatrist for an intake evaluation a month later. During that visit, the patient described a “pretty good” mood and denied current suicidal ideation, though the patient continued to report insomnia and memory problems. The psychiatrist diagnosed the patient with mild neurocognitive disorder; major depression; recurrent, moderate, delusional disorder; and substance use disorder in sustained remission. The patient reluctantly agreed to discontinue benzodiazepine 2, increase the sleep medication, and continue the other medications, including sustained-release antidepressant 1 daily. At the patient’s follow-up visit the patient admitted to continuing benzodiazepine 2 despite instructions to stop taking it, due to fears of worsening insomnia. The psychiatrist repeated the rationale for discontinuation and told the patient the benzodiazepine 2 would not be refilled. The patient again described a good mood and denied suicidal ideation. The psychiatrist planned to increase the sleep medication dosage, discontinue benzodiazepine 2, and continue other medications at prior doses. The last prescription for antidepressant 1 was a three-month supply ordered in late 2017, but it was discontinued by pharmacy 21 days later. Approximately a month later, neither the mental health nurse’s progress note nor the medication reconciliation note included antidepressant 1. The patient did not attend the scheduled psychiatric follow-up in spring 2018.
