Whistle-blowers: VA still endangering suicidal vets

PHOENIX — During the past eight months, roughly 1,000 military veterans with mental health problems have shown up in the emergency room at Carl T. Hayden VA Medical Center in Phoenix, sometimes intoxicated and potentially suicidal.

They were seeking treatment after closing time at the VA mental-health clinic and, according to hospital officials, most of them received suicide evaluations.

How those after-hours patients are handled has emerged as a new controversy at the scandal-plagued hospital. Two whistle-blowers claim patients and staff are being endangered. VA administrators insist they are doing what they can to ensure safety and security.

There is no dispute that, while awaiting care, some of the at-risk veterans simply decide to leave the ER and are able to walk out without evaluation or treatment.

One medical-center employee, who asked not to be identified for fear of reprisal, said staff concerns about the so-called "elopements" peaked during a Jan. 23 meeting of VA social workers.

The employee, who filed a complaint with the VA Office of Special Counsel and secured whistle-blower status, said Chief of Social Work David Jacobson acknowledged during the meeting several instances where troubled veterans fled the hospital, saying, "We have been really lucky that nothing bad has happened in these instances ... It was sheer luck that nothing (tragic) happened."

The whistle-blower quoted an emergency-room staffer's response to Jacobson: "It has been a high number, like five in the last week (who fled without care). I just wanted to make sure we are addressing security."

As the meeting continued, an ER staffer purportedly asked if "sitters" could at least distract troubled patients while they waited for a mental-health professional. The whistle-blower said that question generated laughter when the employee added, "Like a deck of cards? Not just sitting and staring into space, but the sitter can say, 'Hey, how 'bout a card game?' Is that appropriate?"

Brandon Coleman, a VA substance-abuse specialist, said disclosures from the meeting of social workers corroborate his separate whistle-blower complaint last month to the Office of Inspector General and Office of Special Counsel. He asserted in those letters that the hospital mishandles suicides, fails to properly serve at-risk patients and provides little or no care for employees traumatized by patient suicides. He warned that veterans in distress may harm themselves, other patients or staffers.

"This proves everything is still wrong. It's a huge systems breakdown," Coleman said.

In a Feb. 6 letter to VA headquarters on behalf of Coleman, Sen. John McCain, R-Ariz., urged Secretary Robert McDonald to "address this situation immediately."

Phoenix VA officials confirmed the social workers' discussion of elopements. During a meeting with The Arizona Republic, they also acknowledged the ER sometimes gets overloaded with at-risk patients who may be seated in an area divided by curtains, where others can eavesdrop or interject comments.

But they said only two patients fled in days leading up to the meeting of social workers, and hospital staff convinced both to return. They stressed that all employees assigned as sitters have completed a class on prevention and management of disruptive behavior. Hospital officials said only nurses or nurse's aides oversee potentially suicidal patients, though whistle-blowers contend that untrained volunteers sometimes are assigned to the task.

Jacobson also said his comments about being lucky were misconstrued. The intended message: "We're always fortunate if we do a rescue instead of having a suicide."

Dr. Darren Deering, chief of staff, said the VA hospital is doing its best for troubled vets, but faces challenges when patients choose to leave before a mental-health evaluation can be completed.

"When we're in the process of trying to petition someone (for involuntary commitment)," Deering said, "we can't tie them down. We can't prevent the person from getting up and bolting."

Deering noted that employees might be charged criminally if they detain or confine veterans without following legal procedures. "If patients are determined to elope, they're almost impossible to stop without violating their rights," he added.

Struggle to fill jobs

The Republic investigated Phoenix VA mental-health and suicide services in August based on similar complaints. At the time, Jacobson acknowledged a recent history of shortcomings but claimed mental-health services had "improved phenomenally."

Jacobson told the paper the Phoenix VA had hired a dozen additional psychiatrists, plus other mental health specialists. The enlarged Suicide Prevention Team was about to hire a coordinator. The ER, which previously had no mental-health specialists, was given round-the-clock social workers and on-call psychiatrists.

But Coleman and others said veterans still are not getting the care they deserve, in part because of a leadership void.

Jacobson recently confirmed that the Suicide Prevention Team went at least eight months without a coordinator, in part because two candidates for the job bailed after being selected. He said an acting boss has been installed, but the VA is struggling to fill other mental-health positions.

In a Jan. 2 complaint, Coleman said troubled veterans are not getting timely evaluations or proper monitoring. The problem is most glaring with substance abusers who are in denial, he said. Such patients are referred to a non-VA program miles away, and offered a ride without monitoring.

"Unfortunately, when a vet presents (in the ER) under the influence of drugs and/or alcohol, and they deny being possibly homicidal or suicidal, they are for the most part on their own," Coleman said. "Substance abuse and being under the influence are huge risk factors to a vet committing suicide or accidentally hurting themselves by walking into traffic or leaving to be raped, robbed or murdered."

Coleman said after he became a whistle-blower he was placed on leave and notified of allegations that he had threatened another employee. He denied threatening anyone and said the suspension violates VA policies protecting employees who speak out against unsafe conditions.

McCain, in his letter to McDonald, referred to that issue. "I have heard from an increasing number of current and former VA employees who have shared similar fears of retaliation," he wrote. "Those facts suggest that the Department of Veterans Affairs (VA) continues to face a systemic problem in its handling of whistle-blower complaints, as well as a culture that breeds retaliation and reprisal."

Glen Grippen, acting director of the Phoenix VA Health Care System, said he cannot comment on employee-discipline issues. But he confirmed meeting with Coleman recently, and said complaints are being reviewed to determine whether they are valid and require reforms. He also said he respects the rights of whistle-blowers.

"Any staff that says we can do better, we're going to take that seriously," added Deering. "One suicide is too many. I think we all feel that way."

New measures OK'd

About 22 U.S. veterans commit suicide each day, according to VA data. That's roughly 100,000 since the 9/11 terrorist attacks — more than 14 times the total of American troops killed in action during the same period in Iraq and Afghanistan.

The devastating numbers prompted Congress to recently pass the Clay Hunt Suicide Prevention for American Veterans Act. It calls for the VA to issue annual reports and hire more psychiatrists in veterans hospitals. The bill was signed into law Thursday by President Barack Obama.

In Phoenix, suicide-prevention services first emerged as a major issue in late 2013 when Dr. Katherine Mitchell complained of overwhelmed and untrained staff. Mitchell had been the hospital's ER supervisor and, after that, was medical director for transition services to veterans from Iraq and Afghanistan.

After new whistle-blowers came forward, Mitchell said she was shocked to learn that suicide-prevention efforts may remain problematic. "If you're not trained on how to deal with potentially suicidal patients, you could exacerbate the situation, and escalate things," she said.

Coleman, a disabled Marine Corps veteran, said he tried to address issues through the chain of command, but was threatened with termination. After turning to the media, he said, a hospital employee unlawfully opened and altered his electronic medical records.

Coleman said he empathizes with patients because he attempted to take his own life years ago. He also said he loves the VA, was accepted in a leadership program, and helped develop an outpatient program for veterans with criminal convictions.

Coleman said comments made during the social workers' meeting verified his own concerns. After losing six patients to suicide in three years, he said he could not remain silent about flawed care and counseling.

"It's like being punched in the gut over and over again," he said. "It is so sad. There is no current protocol or guidance for us as employees on how to work through a suicide. We are not given any help."

New law could help

President Barack Obama on Thursday signed bipartisan legislation intended to reduce the high rate of veteran suicides.

The Clay Hunt Suicide Prevention for American Veterans Act requires the VA every year to seek independent evaluations of mental-health care and suicide-prevention programs, and to work with non-profit mental-health agencies on collaborative mental-health programs.

The legislation also requires the VA to centralize resources and information about mental health in a manner easily accessible to veterans who need help transitioning from combat duty to civilian life.

The bill also allows the VA to offer financial incentives to lure more mental-health professionals, a provision intended to ease the shortage of qualified applicants for those positions.

Dennis Wagner also reports for The Arizona Republic.