Late Breaking News
The investigation into the Atlanta VA’s management of a mental health (MH) patient care contract began with an anonymous call to the OIG Hotline Division. The resulting audit uncovered extensive financial mismanagement of the contract with the DeKalb County, GA, Community Service Board (CSB) — and two deaths of mental health patients who “fell through the cracks.”
According to the IG audits, the initial death occurred as a result of an overdose. A suicidal patient with history of substance abuse, left unmonitored at an ophthalmology appointment for several hours, took alprazolam brought in by a visitor. When asked for a urine sample for a drug screen, he provided one, which tested negative. After his death, another patient admitted to providing the urine for the screen.
One of the two additional deaths reported in the audit occurred as the result of a drug overdose, while the other was ruled a suicide. Here are the details:
● A patient with a history of suicidal behavior called the Veterans Crisis Line with suicidal ideation and was referred for an evaluation. Ten days later, he had a complete mental health intake evaluation by a psychiatrist, during which time he expressed no intent to harm himself. He was instructed to contact DeKalb CSB and continue taking medications prescribed by a private psychiatrist. His CSB appointment, initially scheduled for Day 93, shifted to Day 107 at the patient’s request. He failed to show for the appointment. Day 206 he reported feeling depressed to his primary care provider. Two weeks later, he died of a drug overdose.
● Another patient with an extensive history of mental health issues and suicidal behavior was prescribed medication for depression and referred to the DeKalb CSB for consultation. Three weeks later, he told the Healthcare for Homeless Veterans that he still had no appointment with the CSB and felt depressed and suicidal. Healthcare for Homeless Veterans’ psychiatrist was unable to see the patient and directed staff to send him to the Emergency Department via public transportation. He did not go to the ED. The following day, he committed suicide.
As for the November death not included in the IG report, other media have reported that Petit, who suffered from chronic pain and documented mental health issues, took a van to the VA and presented to the veterans hospital emergency department, saying he was hearing voices and was afraid he would hurt his mother. ED staff sent him to his regular psychiatrist and the patient was released later that day. His body was discovered in a staff bathroom in his wheelchair with a bag over his head the following morning.
The VA IG’s office, which noted it had no inspectors on site at the time but sent staff to interview first responders and VA medical personnel, said an autopsy concluded Petit died from suicide.
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