Veterans Affairs Office of Inspector General report on the death of Charles Ingram and the failures that caused it

Source for the article is the VA OIG report.

I know the formatting is horrible, it is better on the PDF at the link. I included it here for those who do not want to go to a link. They have a lot of extra spaces which makes it so erratic.

The VA Office of Inspector General conducted a healthcare inspection at the request of
Senator Cory Booker, Senator Robert Menendez, and Congressman Frank LoBiondo,
to assess concerns that a patient’s insufficient access to timely mental health (MH) care
may have contributed to the patient’s suicide, and that general access to MH care was
limited at the Atlantic County Community Based Outpatient Clinic (CBOC),
Northfield, NJ. Prior to our review of these concerns, Senators Booker and Menendez,
and Congressman LoBiondo communicated other issues surrounding the CBOC to the
Deputy Under Secretary for Health for Operations and Management, which led to
Veterans Integrated Service Network 4 assuming supervision of the CBOC in
May 2016.

The patient at the center of this review received routine MH care for Obsessive
Compulsive Disorder (OCD) at the CBOC for several years, up until 2014. In the last
2 years of his life, clinicians added a diagnosis of a particular neurodevelopmental
disorder (NDD) and he was awaiting therapy for it in the community.

In late 2015, the patient walked into the CBOC MH clinic seeking an appointment with
his psychologist. The psychologist assessed the patient in the waiting room,
determined he appeared to be in no distress, and sent him to the front desk with
instructions for the scheduler to make an appointment and to overbook if needed. The
scheduler told us that he did not remember this patient or these instructions. The
scheduler set the appointment for a date over 3 months later, and recorded the
appointment as the patient’s desired/preferred date. The Veterans Health
Administration (VHA) requires appointments to be scheduled based on providers’
clinically indicated dates and if no such dates are specified, then appointments should
be scheduled based on patients’ desired/preferred dates. We could not determine if the
patient told the scheduler about the instructions to overbook and we could not
determine the patient’s actual preferred date to understand why the appointment was
scheduled for a date over 3 months after the request to see the psychologist.

In early 2016, shortly before his scheduled appointment, the patient completed suicide.
The people we interviewed told us that between late 2015 and the scheduled
appointment in early 2016, the patient was in distress as he was facing serious life
stressors including a divorce and the loss of his job. CBOC clinicians had not seen him
during this time frame nor did we find evidence that he attempted to contact CBOC staff
for an earlier appointment. We also did not find records of him contacting the Veterans
Crisis Line to report suicidal thoughts. We could not determine if an earlier appointment
with MH would have made a difference in the outcome.

Family members reported they had no warning signs that the patient might try to take
his own life and no suicide note was found. Family members also told us he was upset
with VA and the CBOC because he believed some staff members were rude, staff did
not return his telephone calls, and he had problems scheduling appointments. We were
unable to substantiate these concerns.

At the time of his death, it had been about a year since his last therapy session and
over a year since he had seen the psychiatrist who prescribed his medications for OCD.
He had been waiting for an appointment for therapy in the community to address his
particular NDD for over a year. Clinicians in primary care, orthopedics, and
gastroenterology saw him prior to his death, but none of them documented any
indications of MH issues or the life stressors mentioned above.

From 2011 to 2014, the patient met with a CBOC licensed clinical social worker for
therapy centered on his diagnosis of OCD, missing only 2 of the 29 regularly scheduled
appointments. During his subsequent therapy (2014—2015) with a psychologist, he
maintained an irregular schedule for appointments with occasional cancellations and
no-shows. During these visits, it was noted he denied suicidal thoughts or ideas.

We found several of the patient’s clinic appointments were scheduled beyond 30 days
from the clinically indicated date. We reviewed 23 MH appointments from 2014 through
2016. For 11 of the 23 appointments, providers had specified a clinically indicated date,
and for 6 of these, (54 percent), the wait time exceeded the 30 days allowed by VHA
policy. We noted that the patient’s desired/preferred dates for these appointments were
recorded as within 30 days of the actual appointments.

We found that in addition to the lack of timely appointments, staff failed to follow up on
no-shows, clinic cancellations, termination of services, and Non-VA Care Coordination
(NVCC) consults as required. This led to a lack of ordered MH therapy and necessary
medications for the patient’s OCD, and may have contributed to his distress.

In addition, MH providers failed to address the patient’s lack of participation in active
care appointments for over a year. Facility policy on patient termination requires MH
providers to contact patients in an attempt to re-engage them after 12 months without
active treatment. We found no attempts to follow this process.

CBOC schedulers canceled an appointment scheduled for the fall of 2015 because the
provider was not available. We did not find documentation that CBOC schedulers
attempted to contact the patient to reschedule the appointment or to renew medications,
if needed, as required by VHA.

In early 2015, a psychologist requested the patient’s referral to a community provider for
treatment of his particular NDD. NVCC staff approved the request for several therapy
sessions. We found no evidence that NVCC staff contacted the patient or made
appointments for this therapy. The non-VA provider, who had been contacted by the
psychologist, told us she did not see the patient and was unable to make contact with
the patient or NVCC staff, despite making several attempts. This failure of the NVCC
staff led to non-delivery of ordered care that might have benefited this patient.
We found an overall lack of communication between psychiatry and psychology
services led to unclear treatment goals for this patient, including his diagnoses,
prognosis, and treatment. We were told of a disagreement between MH providers
regarding the diagnosis of the NDD that created a lack of clarity in the care and services

Regarding general MH access, we found the CBOC had several positive processes in
place, including appropriate automated phone greetings, extended operating hours,
sufficient MH staffing (with plans to increase staffing), and appropriate use of telehealth.
We noted that CBOC patients reported overall higher satisfaction scores for access
than VHA patients nationally.

CBOC staff generally scheduled MH appointments within 30 calendar days of patients’
documented desired/preferred dates. However, the CBOC’s wait times for new and
established patients were higher than national averages by 7 days for new patients and
1.5 days for established patients.

We found a lack of scheduling practices oversight by CBOC managers and/or the
Acting Chief of Health Administration Service. This led to noncompliance in patient
follow-up care and clinic management. Specifically, processes for management of
walk-in patients, no-shows, clinic cancellations, termination of services, and NVCC did
not comply with VHA and facility policies. The facility did not complete audits of CBOC
scheduling practices and provided no onsite management oversight of appointment

We made six recommendations. We recommended that the Veterans Integrated
Service Network Director ensure:

Atlantic County CBOC schedulers determine and document appointment dates
using clinically indicated and preferred dates and facility managers monitor

Atlantic County CBOC managers implement a process for management of
established MH patients seeking an unscheduled appointment that includes
communication between patients and clinical and administrative staff.

Atlantic County CBOC managers implement a process including a definition of
supervisor responsibilities for oversight and auditing of no-shows and CBOC
scheduling practices, and facility managers monitor compliance.

Atlantic County CBOC managers implement a process to manage patients who still
need care when CBOC staff have cancelled appointments, and facility managers
monitor compliance.

Atlantic County CBOC managers implement the CBOC MH services termination
process as outlined in local policy and monitor for compliance.

The Facility Director implements oversight processes that ensure NVCC staff
follow up on all consults in a timely manner and facility managers monitor