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

Excerpt:  The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate the care provided to a patient who died by suicide in the Emergency Department at the John Cochran Division of the VA St. Louis Health Care System (facility) in Missouri. The patient was in their 60s with a history of an enlarged prostate, substance use, depression, posttraumatic stress disorder, and suicide attempts. Since 2001, the patient had been receiving health care at the facility and had multiple admissions for suicidal thoughts and substance use. … 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.” (footnotes omitted)