A VA inspector general report has found that a New Jersey clinic's neglect drove one of its patients to commit suicide. Charles Ingram, a Gulf War veteran, had a history of mental health issues. He was supposed to get a series of therapy sessions at the Northfield, N.J., clinic but they never came. The clinic was also supposed to contact him because agency policy mandated they reach out to any patient who had not reached out in a year. They never did.
The IG report is more damning as it goes on. The Northfield staff canceled an appointment Ingram had in fall 2015 because a provider was unavailable, didn’t follow up to reschedule. When he walked into the clinic to ask for an appointment, he had to wait another three months.
After being repeatedly denied an appointment, a desperate Ingram doused himself in gasoline in front of the clinic in March 2016.
“(S)taff failed to follow up on no-shows, clinic cancellations, termination of services, and Non-VA Care Coordination consults as required,” the inspector general wrote in a report released Wednesday. “This led to a lack of ordered (mental health) therapy and necessary medications… and may have contributed to his distress.”
The Northfield clinic is now taking steps to address what led to the tragedy. The staff is getting more training and new supervisors and managers.
VA Secretary David Shulkin, although currently under fire for an expensive trip to Europe with his wife, says he is dedicated to reforming and modernizing the agency. So far, the Trump administration has signed five key pieces of legislation into law that show they are committed to those goals. These are: The Veterans Choice Program Extension and Improvement Act, the VA Accountability and Whistleblower Protection Act, The VA Choice and Quality Employment Act, The Veterans Appeals Improvement and Modernization Act of 2017, and The Harry W. Colmery Veterans Educational Assistance Act of 2017.