Review of Care Provided to a Patient Who Died by Suicide, Marion VA Health Care System in Illinois

Report Information

Issue Date
Report Number
24-02987-27
VISN
State
Illinois
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Report Topic
Care Coordination
Community Care
Suicide Prevention
Major Management Challenges
Healthcare Services
Leadership and Governance
Recommendations
13
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

The VA Office of Inspector General (OIG) evaluated allegations about the care of a patient at the Marion VA Health Care System (facility) who died by suicide. The OIG reviewed concerns that the patient’s traumatic brain injury (TBI), pain, and mental health needs were not addressed. The OIG identified additional concerns regarding the management of the patient’s repeated falls, TBI care coordination, suicide prevention efforts, and the absence of an institutional disclosure.

The OIG substantiated that the neurologist did not provide TBI treatment following the patient’s TBI diagnosis and the primary care provider (PCP) did not facilitate recommended follow-up care. Further, facility staff did not ensure timely coordination of community care records highlighting the patient’s TBI treatment needs. The OIG also found the PCP did not coordinate with community providers regarding the patient’s pain management. The OIG did not substantiate that facility staff failed to provide the patient with appropriate mental health treatment. 

Facility staff did not address the patient’s multiple reports of falls with strikes to the head. Suicide prevention staff did not notify the patient of high-risk flag activation status, routinely complete safety plan reviews, or accommodate the patient’s communication preferences. Facility leaders also did not consider an institutional disclosure related to the patient’s care due to the lack of identifying any concerns. 

Inadequate management of the patient’s TBI and pain care needs, repeated falls, and insufficient suicide prevention efforts may have limited the treatment options available to the patient. 

In response to the OIG’s findings and recommendations, the Facility Director shared plans to update procedures on fall prevention, care coordination, and management of high risk for suicide flags. The Facility Director also planned to ensure compliance with community care coordination and scheduling practices. 
 

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/8/2026

The Marion VA Health Care System Director ensures a review is conducted of the care provided to the patient by the primary care provider and the neurologist, consults with Human Resources and General Counsel Offices, and takes action as warranted. 

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Marion VA Health Care System Director ensures primary care nursing staff’s adherence to facility fall prevention policy and monitors compliance.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Marion VA Health Care System Director evaluates the facility fall prevention policy to consider expectations for mental health staff’s role in responding to patient reports of falls at home. 

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/8/2026

The Marion VA Health Care System Director reviews processes to ensure primary care and specialty care staff are appropriately educated and trained on making referrals to and the services available through the facility’s Traumatic Brain Injury Polytrauma Clinic.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Marion VA Health Care System Director ensures compliance with the primary care program facility policy concerning specialty consultation staff’s communication with a patient’s primary care provider regarding patient concerns.

No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Marion VA Health Care System Director ensures compliance with the facility patient problem list standard operating procedure. 

No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Marion VA Health Care System Director strengthens processes to ensure compliance with Veterans Health Administration timeliness standards for obtaining and scanning community care records.

No. 8
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Marion VA Health Care System Director reviews facility care coordination practices between primary care providers and community care providers, identifies barriers to sharing patient treatment information to inform clinical decision-making, and takes action as warranted. 

No. 9
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Marion VA Health Care System Director ensures community care staff adhere to requirements regarding completion of community care-care coordination plan notes and monitors compliance.

No. 10
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Marion VA Health Care System Director conducts a review of the facility primary care scheduling processes to ensure compliance with Veterans Health Administration and facility policy on care coordination within Patient Aligned Care Teams. 

No. 11
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Marion VA Health Care System Director ensures suicide prevention staff document high-risk flag inactivation within patients’ electronic health records and notify patients when a high-risk flag is activated or inactivated as required by the Veterans Health Administration, and monitors compliance.

No. 12
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Marion VA Health Care System Director ensures mental health staff adhere to Veterans Health Administration requirements on safety planning during high risk for suicide patient record flag patient contacts.

No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/8/2026

The Marion VA Health Care System Director evaluates the care provided to the patient, determines if an institutional disclosure is warranted, and takes action as indicated.