Missteps by Staff at the St. Louis VA Faulted in Veteran's In-Hospital Suicide

Inaction by staff at the St. Louis VA Medical Center contributed to the suicide of a 61-year-old veteran in the hospital's emergency room -- systemic failures that must be addressed to improve patient care and safety at the facility, the Veterans Affairs Office of Inspector General said Thursday.

A VA's internal watchdog published an investigation that found the staff did not properly assess the veteran's suicide risk, even though he expressly raised the topic of death, telling the triage nurse that he didn't "want to die" and that he was depressed. He was placed in a room to await evaluation by a physician but was forgotten.

When staff finally checked on him more than two hours later, the veteran, who was not identified in the VA OIG report but who was identified by St. Louis-area media at the time as Kenneth Hagans, had killed himself when alone in the room.

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"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," Dr. John Daigh, assistant inspector general for healthcare inspections, wrote in the report.

Hagans, who had a history of substance use and suicide attempts, post-traumatic stress disorder, depression and an enlarged prostate, went to the St. Louis VA at 5:14 a.m. on Sept. 29, 2021, where he complained of an inability to urinate and general depression.

Although he had been previously admitted to the facility for suicidal thoughts and attempts, the triage nurse determined that he was not at risk for suicide and placed him in an exam room.

Fifteen minutes later, the emergency department physician was notified of the patient's arrival, and a bladder scan was ordered.

But the physician, who was taking a nap in another exam room following a 14-hour shift, was "slow to move" -- fatigue he attributed to having recently received a vaccine -- and didn't actually rise to see patients until 6:48 a.m., when the chief of the Emergency Department arrived for work and told him to attend to patients.

He saw two other patients first and sent a hospital tech to find Hagans. By then, 7:38 a.m., Hagans had killed himself. He could not be resuscitated.

The VA OIG not only determined that the emergency room staff failed the patient, but hospital administrators made several errors following the death, including a delay in notifying the family in what is called an "institutional disclosure" to inform them of the incident, their rights and recourse. The VA recommends that this call come within 72 hours of an adverse event; the staff took two weeks.

Hospital administration also did not report the triage nurse to the licensing boards of three states in which she is licensed to practice. The nurse resigned from the VA in 2022.

A 2020 Government Accountability Office report noted that 55 suicides occurred from 2018 to 2019 on Veterans Affairs campuses, but the statistic is questionable because the system VA uses to track such deaths lacked the capability to weed out duplications or undercounts.

The system was so riddled with errors, according to GAO, that a living veteran was counted as dead.

The number of veterans dying by suicide has declined by 9.7% since 2018, falling to 6,146 veterans in 2020, the most recent available data.

The VA OIG made six recommendations to the St. Louis Health Care system to improve its emergency room and response to similar events, to include reviewing the conduct of the ER's chief, standardizing the suicide risk screening process, establishing a policy on monitoring patients, and following guidelines for institutional disclosures and reporting providers to their state licensing board as required.

VA officials concurred with the recommendations.

"We are deeply saddened by the passing of this Veteran and our sympathies go out to the Veteran's family and loved ones. There is nothing more important to us at VA than preventing Veteran suicide, and we are utilizing this review to strengthen processes for improved suicide prevention at our facility through the recommendations provided in this report," wrote St. Louis Health Care System Medical Director Candace Ifabiyi in the VA's response.

Attempts by Military.com to reach Hagan's family were unsuccessful.

Service members and veterans facing a mental health crisis can call the VA Crisis Line at 988, press 1. Help also is available by texting 838255 or chatting online.

-- Patricia Kime can be reached at Patricia.Kime@Military.com. Follow her on Twitter @patriciakime

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