Deficiencies in Emergency Department Care for a Patient Who Died by Suicide at the John Cochran Division of the VA St. Louis Health Care System in Missouri

The VA Office of Inspector General (OIG) conducted an inspection to evaluate the care provided to a patient who died by suicide in the Emergency Department and assessed leadership failures related to the event at the John Cochran Division of the VA St. Louis Health Care System (facility) in Missouri. The OIG determined that deficiencies in the quality of Emergency Department care provided to the patient resulted in a delay of care and may have contributed to the patient’s death. The OIG found that an Emergency Department nurse may not have properly administered a suicide risk screen and did not monitor the patient after triage. The OIG determined that an Emergency Department physician did not evaluate the patient due to the nurse’s failure to communicate that the patient was awaiting evaluation. Over two hours and twenty minutes elapsed from the time the patient arrived in the Emergency Department to the time the patient was found unresponsive. The OIG found deficiencies related to the root cause analysis process and determined that facility leaders did not complete a timely institutional disclosure or comply with Veterans Health Administration requirements in reporting to state licensing boards. The OIG also identified a concern related to the chief of the Emergency Department’s conduct, specifically their attempt to direct staff responses during the OIG inspection. The OIG made six recommendations to the Facility Director related to the chief of the Emergency Department’s conduct; standardized administration of the suicide risk screen; monitoring Emergency Department patients; completion of root cause analyses and administrative investigations on the same event; completion of institutional disclosures within required time frames; and state licensing board reporting.