A Patient’s Suicide Following Veterans Crisis Line Mismanagement and Deficient Follow-Up Actions by the Veterans Crisis Line and Audie L. Murphy Memorial Veterans Hospital in San Antonio, Texas

The OIG reviewed concerns that Veterans Crisis Line (VCL) staff mismanaged a patient’s contact prior to the patient’s death by suicide within the hour after VCL text contact. The OIG also evaluated Audie L. Murphy Memorial Veterans Hospital (facility) leaders’ and staff’s administrative actions following notification of the patient’s death. The OIG found that a VCL responder completed an inadequate assessment of the patient’s suicidal preparatory behavior and alcohol use and failed to establish an effective safety plan, confirm reduced access to lethal means, involve a family member in safety planning, consider a telephone transfer, and complete accurate documentation. It was also determined that VCL leaders provided inadequate oversight and quality assurance by failing to ensure sufficient silent monitor contacts and text message retention. The OIG further found inadequate and problematic leader and staff actions following the patient’s death. VCL leaders and staff failed to complete a root cause analysis and consider disclosure, potentially interfered in the OIG inspection, failed to alert facility staff of the patient’s death and address a family member’s complaint, and delayed discontinuation of caring letters. Facility leaders and staff failed to update the patient’s electronic health record and complete a behavioral health autopsy. The OIG made eleven recommendations to the VCL Director related to review of staff’s management of the patient’s contacts, suicide risk assessment classification guideline alignment, quality management oversight, text retention, issue brief accuracy, review of customers’ deaths by suicide and accidental overdose, institutional disclosure, notification of a customer’s death, review of leader and staff interactions during OIG inspection preparation, complaint submission, and caring letters discontinuation. The OIG made three recommendations to the Facility Director related to timely death notification processes, standard operating procedure adherence for actions following a death by suicide, and Behavioral Health Autopsy Program implementation.