Healthcare Inspection Suicide After an Emergency Department Visit at the Dayton VA Medical Center, Dayton, Ohio

The VA Office of Inspector General Office of Healthcare Inspections received a Congressional request to evaluate the care of a patient who committed suicide on the grounds of the Dayton VA Medical Center (the medical center), in Dayton, Ohio, after leaving the emergency department (ED). We found that the ED staff made reasonable efforts to provide treatment to the patient in the hours preceding his suicide. In addition, we found that the patient received appropriate and ongoing primary care and mental health (MH) services prior to the event. We also found that providers made appropriate efforts to manage the patient’s pain and treat his MH conditions from August 2008 to April 2010. However, we found opportunities to improve communication and suicide risk management training. We recommended that the VISN Director ensure that the Medical Center Director requires providers to optimize appropriate “hand-off” and intra-staff communication and requires clinical staff to complete Veterans Health Administration’s mandatory suicide risk management training. The VISN and Medical Center Directors concurred with the recommendations and provided acceptable action plans.