Sheridan VA provided flawed care to veteran patient prior to suicide, report concludes

The Sheridan VA Medical Center mishandled the treatment of a veteran last year before the individual killed themself at the facility. That’s according to a federal Office of Inspector General report released July 25, which outlines what went wrong in the 40-year-old veteran’s death last summer.

The Sheridan VA admitted the veteran for treatment for suicidal ideation and alcohol withdrawal last summer. The patient died four days later in the facility. Investigators found a number of instances where staff at the hospital failed to follow policies and procedures including allowing the patient to keep belongings that were later used in the death. At one point, the patient was also taken off continuous monitoring without a required re-evaluation.

The federal report found there was a “drift” from staff adhering to policies at the Sheridan facility, putting inpatient veterans at risk.

“The OIG concluded that the deviations from policies or [standard operating procedure]s outlined in this report ultimately placed the patient at greater risk for suicide,” the report states.

In response to the incident and federal recommendations laid out in the report, the Sheridan VA outlined in the document some of its plans to increase training, create more checklists and bolster monitoring. Beyond that, it also looked at why this happened in the first place.

“On the same day of the tragic event, the Sheridan VA medical center director initiated a root cause analysis, which is a comprehensive investigation to review health care adverse events and close calls. The goal of each RCA is to find out what happened, why it happened, and what must be done to prevent it from happening again,” VA Press Secretary Terrence Hayes said in an email.

When The Sheridan Press and WyoFile requested this root cause analysis, Sheridan VA staff said it was unable to share the document, citing federal laws regarding the confidentiality of medical quality-assurance records.

Sheridan VA Health Care System Director Pam Crowell said in an email the agency could not speculate on why this happened. But instead, she said, what’s important is “taking steps to stop this in the future.”

To combat future drift, she said the office must review policies often, provide training and ensure policy compliance. Training compliance is now being reviewed monthly at board meetings, she stated in the same email.

Staff declined interviews outside of emails.

Recommendations

As part of its investigation, the Office of Inspector General made specific recommendations based on its findings, Hayes said.

“The OIG made four recommendations to the facility director related to clinical screenings and evaluations, communication between staff, reassessment of patients before removing them from one-to-one observation status, timely documentation, and removing personal belongings and environmental risks for suicidal patients,” Hayes said.

The timeline stated in the report to enact these changes is later this year and early next year.

“A tragic event of this nature is never acceptable. Despite striving to provide high-quality, Veteran-centered care, the care provided to this Veteran was flawed,” Crowell stated in the memo. “We at Sheridan VA Medical Center have reflected upon this tragedy and have implemented changes to ensure to the best of our ability that an event of this nature does not happen again.”

But there was another suicide at the facility this year, according to the Sheridan County Coroner’s Office. The Sheridan VA said it wasn’t aware of any further Office of Inspector General reviews related to patients deaths at the facility. While numbers vary, there are between three and seven veterans staying at the facility on any given day for inpatient suicidality or mental health treatment, Crowell said in an email to The Sheridan Press and WyoFile.

“This incident resulted in the tragic loss of life of a veteran under our care and we have taken actions based on internal and external reviews to ensure better outcomes moving forward,” Hayes said about the 2023 death. “There have not been recommendations for any staff removals.”

Vexing issue

Suicide rates among veterans , Sheridan County residents and Wyomingites are all significantly above average — the state rate is second in the nation .

There were 32 Wyoming veterans who died by suicide in 2021, alone, according to the U.S. Department of Veterans Affairs. That’s compared to 190 suicides in the state overall that year.

“Ending veteran suicide is our number one clinical priority and my staff is working to proactively prevent suicide,” Crowell said. She also explained how the community and partnerships engage with various veteran communities across the state developing coalitions to combat suicide.

According to a report from the county coroner’s office, there were six total suicides in the county in 2023, and another seven thus far in 2024. One in each year occurred at the Sheridan VA, the coroner confirmed in a letter to The Sheridan Press and WyoFile.

There have been broad efforts by state policy makers, nonprofits and advocacy groups to prevent them in recent years.

“Our heartfelt condolences go out to the Veteran’s family and all who knew them,” Crowell said in a June 6 memo to the VA Rocky Mountain Network. “We are deeply committed to doing everything within our ability to strengthen and improve our processes involved with suicide prevention.”

The report

Widely accepted journalistic guidelines recommend not providing the details of a death by suicide. This story includes only the elements that are critical for understanding the Sheridan VA’s handling of this incident.

The unnamed veteran was admitted to the Sheridan VA under dire circumstances, with diagnoses of “posttraumatic stress disorder, substance abuse, alcohol dependence, anxiety disorder, bipolar disorder, and chronic pain.”

Health records further indicated “that the patient had ongoing family issues, unemployment, and homelessness,” the federal report stated.

The alcohol was intended to numb the physical pain, but induced suicidality, the veteran told health care providers.

The individual had a history of self-harm, and police first brought the veteran to the hospital after a community member called with concerns. The veteran had been suicidal for a month, they later said.

At the veteran’s request, the ER transferred them to the Sheridan VA for treatment for suicidality and alcohol withdrawal.

One of the first deviations from protocol was a nursing assistant allowing the veteran to keep items on their person, including one later used to end their life.

“Despite clear guidance in facility policy, [the nurse] reported being less concerned about removing belongings because the patient was on 1:1,” or continuous monitoring, the report found.

Not all environmental risks were removed from the patient’s room, the report also found, with nurses again citing the continuous monitoring being done at that time.

A nurse also failed to provide the required “warm handoff” of the individual to an independent practitioner to complete a suicide risk evaluation after an initial test reflected the veteran’s suicidality. The nurse wasn’t aware of the requirement, according to the federal report.

A psychiatrist didn’t document the completion of a suicide risk evaluation, the report found. However, the psychiatrist did address all the elements of one during a telehealth evaluation the next day, the doctor told investigators. The psychiatrist also found the patient was at a low short-term risk for suicide, but failed to sign that note for 25 hours, federal officials said.

After the note was signed the next day, and without required re-evaluation, the patient was allowed to be taken off of continuous monitoring, switching to 15-minute checks. Staff found the veteran hanging at 2:45 a.m. on the fourth day of their stay and began CPR. At 3:21 a.m. the veteran was pronounced dead.

Federal recommendations

The report offered four recommendations, which director Crowell concurred with. Those include:

• Ensuring warm handoffs and suicide risk evaluations within 24 hours for patients on the medical unit that screen positive on the Columbia Suicide Severity Rating Scale.
• Ensuring that psychiatry or medical officer of the day staff reassess suicidal patients prior to changing a one-to-one observation status order.
• Ensuring inpatient notes are completed and authenticated by providers as soon as possible, but always within 24 hours.
• Ensuring staff follow facility policies for removing belongings and environmental risks for suicidal patients on one-to-one observation status on the medical unit.

The Sheridan VA stated in the federal report that it’s already completed training and made some changes to avoid similar incidents in the future. However, federal officials haven’t verified that they’ve met all four recommendations yet, and the Sheridan VA’s written target dates for completing them are late this year and early next year.

“We will continue to work alongside the OIG until all recommendations have been implemented,” Crowell said.

If you or someone you know is having suicidal thoughts, you can call or text the Suicide and Crisis Lifeline at 988.

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