Report finds flaws in mental health care at St. Louis VA

ST. LOUIS -- St. Louis Veterans Administration health-care officials insufficiently investigated the death of a mental-health patient who killed himself, according to a report from the VA Office of Inspector General.

The OIG launched an investigation in 2014 after concerns were raised by Dr. Jose Mathews, the St. Louis VA's former chief of psychiatry.

Mathews alleged in a federal whistleblower complaint veterans often waited a month or more for mental-health treatment because psychiatrists and other staff members were so lax in their work.

The investigation report released Tuesday found new patients wait about 17 days for appointments -- only about three days above the national average for all VA centers.

Investigators also denied Mathews' claims staff psychiatrists were unproductive; in fact, the report said the St. Louis psychiatrists ranked high in productivity.

VA St. Louis spokeswoman Marcena Gunter said Wednesday several recommendations suggested by the report have been implemented, and others are in the works.

She said the St. Louis facility now is in the top 20 percent of all VA medical centers in providing access to mental-health services.

Perhaps the most alarming finding concerned the VA's response to the suicide of a 69-year-old schizophrenic.

The report said the veteran had tried to kill himself at least once before when, in 2014, he told VA medical staff he heard voices urging him to shoot himself. The man even asked for information about a suicide prevention hotline.

Nearly three months after the initial visit, unable to reach the veteran by phone, VA officials sent a letter advising him medical tests showed his kidney function was deteriorating and a prostate test result was "abnormal," especially alarming since the man had prostate cancer.

The man shot himself fatally two weeks after receiving the letter.

Soon after the death, a leadership team review member at the VA requested an internal management review, calling the case "a pretty serious miss."

But the OIG report said among other errors, a formal review of the psychiatrist or nurse was not requested until OIG investigators were on site nearly four months later.

Corrective action didn't occur until eight months after the man's death, the report said.

The report also found "no evidence of any administrative follow-up" of another death, a mental-health patient in his mid-20s who died in a car wreck three days after hospitalization amid suicide concerns. The death was ruled accidental, but the report said suicide could not be ruled out.

The investigation also found the VA failed to provide timely treatment for a woman who complained of being sexually assaulted in the military and for a patient suffering from post-traumatic stress disorder.

The St. Louis VA has had other problems in recent years.

In 2010, faulty sterilization in the dental clinic could have exposed 1,812 veterans to hepatitis and HIV.

Testing found no link to either disease in any of the patients.

In 2011, operating rooms at the medical center were shut down after rust stains were found on surgical equipment. Surgeries resumed months later after the faulty equipment was cleaned or replaced.

The VA opened a new $7 million sterile processing lab in May 2012.