Healthcare Inspection Quality of Care of Two Deceased West Virginia Veterans

The OIG reviewed the care of two West Virginia combat veterans who were being treated for severe post-traumatic stress disorder (PTSD) and who died in their sleep. Senator Rockefeller asked that the review take into account the medications prescribed and explore any pattern in these tragic deaths. The Chief Medical Examiner found that these patients died from combined drug intoxication involving prescribed and non-prescribed medications. VA’s Pharmacy Benefits Management program and its Center for Medication Safety conducted a nationwide data pull for the last 10 years of all-cause mortality for patients prescribed the combination of quetiapine, paroxetine, and clonazepam. Additional analyses examined other combinations of mental health medications, including an analysis by age of patients with and without PTSD. There was no apparent signal to indicate increased mortality for patients taking the combination of quetiapine, paroxetine, and clonazepam when compared with patients taking other similar combinations of psychotropic medications. We concluded that the clinical care provided for these patients at the Charleston community based outpatient clinic, and the VA facilities in Huntington and Cincinnati met community standards of care. The direct impact of non-prescribed medications in these patient deaths cannot be determined. VA mental health providers describe the use of non-prescription medications as growing area of concern in the treatment of young veterans. However, since returning war veterans may have multiple mental health conditions in addition to PTSD, we recommended that management evaluate exclusion criteria for admission related to medications for newly-diagnosed patients to the Residential PTSD Program.