Despite claims of increased accountability at the department in recent years, Veterans Affairs officials took nine months to sever ties with a physician who told a suicidal patient she did not care if he shot himself, according to a report released by the VA Inspector General this week.
The veteran died of a self-inflicted gunshot wound less than a week later.
The episode — which took place at the Washington DC VA medical center, just a few miles away from the White House — stands in contrast to President Donald Trump’s frequent stump speech claims that “anyone who mistreats or abuses our great veterans can be promptly fired” thanks to legislation he signed into law in 2017.
And it also calls into question the efficacy of VA officials’ recent efforts to emphasize all staffers’ role in suicide prevention, an issue that claims the lives of about 20 veterans and military members each day, even after years of intense focus on the issue.
The move comes as part of a slate of suicide prevention and department reform measures from House Veterans' Affairs Committee members.
In a statement after the report release, DC Medical Center Director Mike Heimall said the conduct of the doctor involved in the case “is unacceptable and does not represent the dedication and compassion our employees exhibit daily.”
The doctor was not named in the report.
Investigators could not determine whether the veteran heard the comment by the physician — “(the patient) can go shoot (himself), I do not care” — during a medical discharge from the hospital in early 2019.
The veteran, a patient in his 60s with a history of panic attacks and opioid withdrawal seizures, had been previously assessed as a moderate suicide risk. But when a team of physicians recommended his discharge with follow-up mental health consultation, the patient refused, prompting the physician to call campus police and shout the offensive comments.
The patient died by suicide a few days later. Investigators could not say whether the patient ever heard the doctor’s comments, or whether they were a factor in the death.
But the IG report says at least three other employees heard the comment and reported it to superiors. Despite that, the doctor continued to see and treat VA patients for another nine months, before her contract was terminated for additional abusive language towards other employees.
DC hospital officials emphasized that “this person was never a VA employee, only worked on a contract basis and is no longer welcome at the facility.”
However, investigators found reports of “verbal misconduct” by the contract physician dating back to fall 2018, including incidents involving the chief of the hospital’s emergency department and facility police.
The report states that leadership at the facility opted not to cut ties with the problematic doctor earlier because they “believed that clinical reviews of the patient’s care were sufficient, and therefore did not pursue formal administrative reviews related to (the physician’s) pattern of verbal misconduct.”
Heimall acknowledged that the incident “does not represent the quality health care tens of thousands of DC-area veterans have come to expect from our facilities” but also labeled it an “isolated” event.
Officials at VA headquarters referred questions on the incident and the report to DC medical center staff and sidestepped questions about whether the event illustrates deeper problems within the department’s suicide prevention and accountability efforts.
A just-released White House campaign and upcoming congressional legislative push aim to reduce the 20 veterans lost each day to suicide.
Critics have repeatedly sparred with the White House over the value of the 2017 Accountability Act, which Trump has insisted has helped reform the entire agency by jettisoning more than 9,000 problematic bureaucrats and medical staff since its passage.
“People do a bad job for our vets, and they get fired,” Trump said in a July 19 online campaign speech to supporters. “It’s very simple … we had sadists in there, we had thieves in there, and you couldn’t do anything about it, whether it was for reasons of unions or civil service.”
But union leaders have argued the measure has largely allowed supervisors to target lower-ranking employees for quicker dismissal, rather than removing toxic leaders more responsible for systemic issues.
In the DC medical center case, contract issues appeared to supersede staff concerns. After the physician was finally removed, facility leaders pledged to report the problematic behavior to the National Practitioner Data Bank.
The inspector general report comes about a month after the White House announced its new veterans suicide prevention roadmap, the culmination of 15 months of work designed to refocus local communities and all federal agencies on the issue.
Among the initiatives emphasis is the idea that suicide is preventable if leaders and community members take the issue seriously and provide help to veterans.
Heimall said his facility has implemented additional suicide prevention measures since the 2019 incident, to include “weekly randomized audits of 20 percent of all suicide-related patient emergency room” to ensure that staff are providing appropriate care and “a comprehensive education program regarding employee misconduct and patient abuse.”
Veterans experiencing a mental health emergency can contact the Veteran Crisis Line at 1-800-273-8255 and select option 1 for a VA staffer. Veterans, troops or their family members can also text 838255 or visit VeteransCrisisLine.net for assistance.