Environmental Suicide Hazards at the VA Boston Healthcare System in Brockton, Massachusetts

The VA Office of Inspector General (OIG) issued this preliminary result advisory memorandum to report significant suicide hazards identified during an on-site inspection of inpatient mental health units at the VA Boston Healthcare System in Brockton, Massachusetts, conducted November 18–19, 2025. The inspection revealed multiple environmental risks that pose a serious threat to patient safety, particularly the presence of anchor points and other objects that could facilitate self-harm.

The OIG observed several high-risk features inconsistent with the safety standards outlined in VHA Directive 1167 and the Mental Health Environment of Care Checklist. These included:
     •    toilets not securely mounted to both floor and wall, with removable seats creating potential anchor points;
     •    exposed plumbing that could be used for hanging or other forms of self-harm;
     •    sink faucets and handles lacking required tapered or rounded designs, increasing risk of ligature use;
     •    cabinet door handles with protrusions that could serve as anchor points; and
     •    unsecured medical equipment and cords, which were long enough to pose strangulation hazards.

These deficiencies were identified across four inpatient mental health units housing 111 authorized beds. The presence of such hazards represents a critical vulnerability in the facility’s suicide prevention infrastructure.

Following immediate notification to facility leaders between November 18–20, 2025, interim mitigation measures were implemented. These included removal of select hazardous items, initiation of 15-minute patient safety checks, staff education on environmental risks, and enhanced observation protocols. Facility staff conducted a formal risk assessment to guide long-term corrective actions.

The OIG continues to oversee the facility’s response and will provide a full analysis in the final inspection report. Given the seriousness of the issue and similar concerns identified at other facilities, these findings are being shared broadly to prompt proactive hazard mitigation across other VHA facilities.