gettyimages 588167294 VA clinic disorganization culminates in veterans suicide

American flags stand on the National Mall Thursday, March 27, 2014 in Washington D.C. The flags represent each of the 1,892 veterans and servicemembers who has died by suicide this year. (Photo by Ken Cedeno/Corbis via Getty Images)

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By Jonathan Kaupanger

The Department of Veterans Affairs failed Charles Richard Ingram, III, a Navy veteran.

On March 19, 2016, Ingram walked nine miles from his home until he got within 75 feet of the Atlantic County Community Based Outpatient Clinic (CBOC) in Northfield, New Jersey. He then soaked is body with gasoline and set himself on fire.  Ingram died later that evening.

At the time it was reported that he killed himself in order to bring attention to problems in the VA system. According to family members interviewed by the VA’s inspector General (IG), Ingram was in distress prior to his suicide.  He had lost his job and was on the brink of divorce.  Family members also told the IG that Ingram was upset with the VA and the CBOC because he believed that some staff members at the VA were rude, they didn’t return his phone calls and he had difficulties scheduling appointments.

Ingram had been a patient at the CBOC for several years and had been receiving care for Obsessive Compulsive Disorder until 2014. The last two years of his life, he had been diagnosed with a neurodevelopmental disorder, but was waiting for therapy for this at the time of his death.

Late in 2015, Ingram walked into the CBOC and requested an appointment with his psychologist. The psychologist assessed Ingram in the waiting room and determined that he appeared to not be under stress. Ingram was then directed to the appointment scheduler who was told to make the appointment and to overbook if needed.    He was given an appointment for three months later, which was early 2016.  It was noted in the schedule that the appointment was Ingram’s desired date.

The IG found that the Northfield CBOC had failed with many of its procedures that prevented Ingram from getting the proper mental health care 11 months before his suicide. It was discovered that many if Ingram’s clinic appointments weren’t scheduled within 30 days of the indicated date. In fact, 54 percent of his wait times were out of the 30-day wait time allowed by VA policy.

Communication between the clinical and scheduling staff was found lacking also. Overbooking an appointment means to add the appointment after normal working hours.  It was discovered that the scheduler would sometimes ignore the overbook instructions as a way to protect medical staff’s personal time.  It was also uncovered that the appointment given to Ingram was 2 – 3 weeks later than the date he requested.

VA’s own policy was found to be at fault at this point. VHA requires staff to deal with walk-in patients by having a well-defined plan for these patients.  The CBOC had a policy that did address management of new, walk-in patients, but did not have anything planned out as a way to help already established patients who walk in without appointments.

Another fault of the VA was lack of follow-up for canceled appointments. Just between 2014 and 2016, Ingram canceled three mental health appointments.  The CBOC canceled an additional three and Ingram was a no show for one appointment.  There was no evidence that the CBOC reached out to Ingram after the cancelations and no show.  And worse still, the IG was not able to determine if CBOC staff evaluated Ingram’s patient records for care needs or even made any attempts to contact him as required. VA requires staff to reach out to no-show patients at least three times, and document these efforts in the patients’ electronic medical records.

To make matters worse, lack of communication between psychiatry and psychology staff led to unclear treatment plans and goals for Ingram. It was found that there was a lack of consensus on his diagnosis prognosis and treatment as well.

After his final therapy session, the communication – or lack of communication to be more precise continued.   The psychologist wrote in the health records that Ingram was to return in one month.  He was a no-show for that appointment.  The appointment was rescheduled for three months later, but that appointment was canceled by staff and was never rescheduled.

This was just about one year prior to his suicide.

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