A government watchdog has found that a Department of Veterans Affairs clinic in New Jersey repeatedly failed to provide mental health care for a Gulf War veteran in the months before he committed suicide by setting himself on fire in front of the clinic.
The VA clinic in Northfield, New Jersey, canceled a counseling appointment for Navy veteran Charles Ingram, 51, in 2015 because no therapist was available. The agency didn’t reschedule a new appointment until Mr. Ingram came back to the clinic, then gave him an appointment for three months later, the department’s office of Inspector General found.
Before his next counseling session, on a Saturday in March 2016, Ingram walked nine miles from his home to the clinic, doused himself in gasoline and set himself on fire on a grassy area next to the parking lot.
The clinic was closed at the time; a bystander tried to put out the fire with a blanket. A medical helicopter flew Ingram to a hospital in Philadelphia, where he died that night.
The inspector general’s investigation found “a series of … staff failures prevented the patient from receiving requested [mental health] care during the 11 months prior to his death, including deficiencies in the [clinic’s] management of walk-in patients, no-shows, clinic cancellations, termination of services.”
“These failures led to a lack of follow-up and therapy for this patient who denied suicidal ideation yet, according to a family member, was in distress,” the report said. “The patient was very upset with VA and the [clinic] because he believed staff did not return calls and were rude, and he experienced problems scheduling appointments.”
Each day, an average of 22 veterans commit suicide, a VA report concluded in 2016. Mr. Ingram had undergone a divorce, and then lost his job about a month before he killed himself.
The veteran had received mental health treatment at the clinic since 2011, but often was required to wait more than a month for appointments.
In the year before his death, Ingram hadn’t seen a therapist. VA policy requires reaching out to such veterans, but the IG concluded, “we found no attempts to follow this process.”
The investigation, released Wednesday, said the clinic’s failures with Ingram’s treatment may have worsened his condition, although there’s no way to be certain.
Clinic staff “failed to follow up on no-shows, clinic cancellations, termination of services, and non-VA Care Coordination consults as required,” the inspector general wrote. “This led to a lack of ordered [mental health] therapy and necessary medications … and may have contributed to his distress.”
After the death, VA Secretary David Shulkin devoted more resources to the clinic, removed the hospital director in charge of the facility and ordered new management for the clinic.
The regional VA office said it agreed with the report’s findings and is instituting other managerial improvements to be completed by March 2018.
VA officials said schedulers at the clinic have received more training.
• Dave Boyer can be reached at dboyer@washingtontimes.com.
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