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Veteran set himself on fire, committed suicide in front of VA after neglect, says new report

(U.S. Marine Corps photo by Cpl. Russel Midori)
November 16, 2017

A veteran set himself on fire and committed suicide in front of a New Jersey VA clinic after the VA repeatedly pushed off his mental health appointments and delayed getting him adequate care, an investigative report by USA Today recently found.

Gulf War veteran Charles Ingram, 51, had received treatment at the Northfield, New Jersey, VA clinic since 2011, and repeatedly had to wait more than a month for appointments, the USA Today report found. And, in the fall of 2015, the VA cancelled one of his appointments because a provider wasn’t available. But VA staff never followed up to see if Ingram received proper mental health care following the cancellation.

Ingram then went to the clinic in person to request an appointment – it wasn’t scheduled until three months later, the VA inspector general (IG) discovered, USA Today reported.

While Ingram had been approved to get treatment at a non-VA facility, no one at the VA told him or scheduled the appointment, USA Today said.

Then, in March 2016, shortly before his rescheduled VA appointment, Ingram “went to the clinic in Northfield, N.J., doused himself in gasoline and lit himself on fire,” USA Today reported, adding that the clinic was closed at the time.

“[Staff] failed to follow up on no-shows, clinic cancellations, termination of services, and Non-VA Care Coordination consults as required,” the IG wrote in a report released Wednesday, USA Today said. “This led to a lack of ordered (mental health) therapy and necessary medications… and may have contributed to his distress.”

Ingram had not seen a therapist in the year prior to his death, USA Today reported.

The VA IG said that no attempts had been made to follow policy regarding when patients go a year without seeing anyone – policy states that mental health providers must reach out to the patient.

“We found no attempts to follow this process,” the inspector general said, USA Today reported.

USA Today also reported:

After the death, VA Secretary David Shulkin allocated more clinical resources to the clinic, removed the hospital director overseeing the facility and directed regional officials to take over clinic management. He also instituted same-day mental health services for urgent cases.

But the report provides a tragic glimpse of how appointment-scheduling failures, which have plagued VA facilities across the country for years, can leave veterans desperate and without treatment. […]

In early 2015, Ingram’s VA psychologist asked that he be approved to get outside treatment for neurological impairment. VA administrators approved several therapy sessions. He never got them.

In response to the report, VA officials said schedulers at the Northfield clinic have received more training and new supervisors and managers have been hired. They said regional and local officials also are reorganizing non-VA care coordination.

“The new structure…ensures high-quality and timely care,” wrote Robert Boucher, acting director of the Wilmington VA Medical Center.