Healthcare Inspection - Service Delivery and Follow-up After a Patient’s Suicide Attempt, Minneapolis VA Health Care System, Minneapolis, Minnesota

The VA Office of Inspector General Office of Healthcare Inspections conducted a review at the request of Congressman Tim Walz regarding alleged improper medication management and discharge planning practices at the Minneapolis VA Health Care System. We did not substantiate those allegations; however, we found that suicide prevention activities were not completed as required, and as a result, the patient did not receive the prescribed level of monitoring and follow-up. The facility’s review of the patient’s death did not address the overall suicide risk management issues, identified systems issues had not been adequately followed up, and facility policy lacked several important provisions for managing patients at high risk for suicide. Further, some staff were unaware of administrative requirements related to managing these high-risk patients.