In the end, his call for help was answered by a fire extinguisher, a robot from the bomb squad and a ridiculous statement from the very agency he was trying to change. With burns consuming 85-90% of his VA-neglected mind and body, Air Force veteran 58-year-old John Michael Watts passed away in a Georgia hospital. A sad irony considering the fact that the only way he could get the help he needed was to kill himself first.
Mr. Watts and his family had to endure the following statement from a spokeswoman for the Department of Veterans Affairs:
“While we can’t comment on the specifics of this veteran’s case due to patient privacy laws, the department is ensuring he receives the VA care that he needs.”
WHAT? What kind of upside-down world are we living in when this kind of official statement is issued? I also want to know who paid for his burial? Did the family receive any death benefits? Any counseling after the fact? How are they doing now?
Mr. Watts fits the profile of those who commit veteran suicide: he was white, over 50 and he was homeless. His family was under the impression that he was fine and was getting the medical help he needed. He clearly was not.
There’s no easy answer when asked to turn around the dead weight that is the VA. You can’t staff fast enough or use enough technology to fill in the missing pieces. There’s no mystery to why these veterans and their families are suffering. There are missing pieces to the puzzle and it seems that no administration can make the right fit.
NOT THE FIRST OR THE LAST
As the details come to light about the failures of the Veteran’s Administration, we can expect more bad news. Looking back at another veteran suicide by fire on March 2016, nothing has changed since Charles Ingram lit himself on fire in front of a Veteran’s Administration building in New Jersey.
As for the list of failures that led to Mr. Ingram’s suicide, here is Benjamin Krause’s tally of the noteworthy failures from the IG summary from this post on his site:
- failure to provide timely appointment
- failure to follow overbooking instructions
- failure to follow up after clinic cancels appointments
- failure to follow up on patient no-shows
- failure to provide follow-up appointments
- failure to refill prescribed medications
- failure to document lack of appointments
- failure to acknowledge lack of appointments
- failure to provide outreach to a veteran in distress
- failure to schedule community care
- failure to supervise clinic processes
READ THE IG’S FULL REPORT BELOW
INSPECTOR GENERAL’S REPORT – CHARLES INGRAM SUICIDE BY FIRE
The patient was in his fifties when he completed suicide in 2016. He had been receiving VHA care for a variety of medical conditions, including obsessive-compulsive disorder (OCD) and a particular neurodevelopmental disorder (NDD). The patient received medical care intermittently at several VA hospitals since 1997. In 1997, the patient indicated he had been treated for depression in the past. His first VHA MH treatment began with management of OCD in 2000. At that time, the patient reported to the psychiatrist that he had been treated for the past 2 years by a non-VA therapist and a non-VA psychiatrist and had been taking fluvoxamine (Luvox®).
The patient continued on Luvox® and remained in psychiatric treatment. In 2005, he indicated that he was doing well and performing better at work with reduced compulsiveness. He attributed this improvement to the medication Luvox®. During the visit in 2005, the psychiatrist continued treatment for OCD with Luvox®. At his next psychiatry visit in February 2008, he indicated he had run out of his medication and was experiencing increased OCD symptoms that were contributing to problems at work. For the remainder of 2008, the patient reported adherence in taking his medication and fewer symptoms.
In mid-2011, after a period of stressful life events, he had a MH Initial Assessment Consult with the Licensed Clinical Social Worker (LCSW) and began psychotherapy. During the initial session, the patient denied active thoughts of suicidal ideation. However, he stated that he had experienced suicidal ideation in the past with no history of a suicide attempt. He continued with ongoing individual therapy sessions until early 2013.
In 2012, according to the LCSW’s clinical notes, the patient exhibited negative thought patterns that he attributed to his OCD. This created difficulty for him in maintaining personal relationships and employment. The LCSW also noted “Pt’s mood and affect remains dysphoric [a mood of unhappiness]. He denies SI/HI [suicidal ideations/homicidal ideations], however, he admits to feeling hopeless at times. Thoughts were tangential but he responded to redirection, which was reinforced. Insight and judgment is limited.” The patient attended several individual psychotherapy visits with the LCSW in 2012, then a final visit with the LCSW in early 2013.
A psychiatrist’s note shows he started the patient on sertraline (Zoloft®) in early 2013, at which time his compliance with Luvox® was in question. In late 2013, the patient reported he was seeking care from a non-VA “therapist, and she is helping with ocd [sic].” He did not provide records for these visits. He noted that he wanted to keep his medications the same as his obsessive symptoms were reduced; he was sleeping better, and was calmer. He reported he felt his OCD was worse after stopping his medication and that he felt better after restarting it. In mid-2014, the patient provided a written outline of work history (dates, employers, and reasons for being terminated) to his psychiatrist. According to the psychiatrist, this large number of different types of jobs demonstrated “…a long extensive pattern of severe work impairment that is caused directly by his obsessive compulsive disorder [OCD] despite being [on] multiple medications and [seeing a] therapist… referring to a new therapist.”
One month later, a VA psychologist assessed the patient for psychotherapy. She noted “DIAGNOSIS: OCD, will add new diagnosis of [neurodevelopmental disorder (NDD)]…Diagnosis of NDD due to patient’s report of difficulties in social situations and rigid thinking patterns.”
Two months later, the psychologist requested individual psychological testing to clarify the patient’s diagnoses “between OCD and [NDD] or both. As well as treatment recommendations.” While the psychology providers agreed his diagnosis was [a particular NDD], the psychiatrist disagreed and noted, “…this is classic ocd [sic]” and “… consistent with a diagnosis of obsessive-compulsive disorder [OCD], in my opinion.”
In early 2015, the psychologist saw the patient three times. During each of these 50-minute individual therapy visits for both of his diagnoses of a particular NDD and OCD, the patient denied suicidal and homicidal thoughts, plans, or ideation. He reported stress and frustration about financial and employment issues. According to the psychologist in early 2015, the patient’s “thought process was goal oriented with no evidence of thought disorder noted.” He denied auditory or visual hallucinations, unusual experiences, special powers, etc. No contrary evidence was elicited during this interview.” Orientation and memory “appeared intact for both long term and short term memory recall. He demonstrated fair insight and judgment.” His prognoses during two of these three visits were documented as fair; his prognosis the following month was documented as guarded.
A specialist in the particular NDD was not available at the facility. In early 2015, the psychologist requested and received authorization for the patient to have several outpatient non-VA visits for his NDD. The non-VA provider, who had been contacted by the psychologist, told us the patient had not been seen despite the non-VA provider’s attempts to schedule an appointment with the patient and telephone calls to the facility on more than one occasion.
Also in early 2015, at the request of the treating psychologist, the patient and his wife attended a 50-minute marital therapy appointment at the MH clinic with a marriage and family therapist. No other MH visits occurred in 2015 or 2016. However, the patient did seek medical and surgical care unrelated to his MH issues from other VA outpatient clinics during 2015 and early 2016. In late 2015, the patient walked in to the MH clinic to request an appointment with his therapist and, after speaking with the therapist briefly, was directed to a scheduling clerk who scheduled an appointment months later. The patient completed suicide before this scheduled appointment in 2016.
Source found here.
