Healthcare Inspection Suicide After Hospitalization At a Veterans Health Facility

The VA Office of Inspector General, Office of Healthcare Inspections, received a Congressional request to evaluate the care of a veteran who committed suicide 5 days after discharge from a VA medical facility. The patient was hospitalized for treatment of depression and anxiety. Throughout his hospitalization, he denied any suicidal ideations. Clinicians made reasonable decisions and made acceptable discharge plans based on what they knew about the patient’s home safety situation. At the time of discharge, the patient was competent to make decisions and did not voice suicide ideations. We found that the patient received appropriate care. The Veterans Integrated Service Network and medical center Directors agreed with the report. We made no recommendations.