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Deficient Care of a Patient Who Died by Suicide and Facility Leaders' Response at the Charlie Norwood VA Medical Center in Augusta, Georgia.
July 5, 2023
Washington DC: Department of Veterans Affairs, Office of Inspector General; May 10, 2023. Report no. 22-01116-110.
Death of a patient by suicide is a sentinel event. This report examined one incident and identified care deficiencies associated with lack of mental health referrals and pain management follow-up. In addition, post-event process gaps occurred, impacting learning and resolution such as a delay in the inquiry launch, peer review, and clinical review of the incident. Claims that the facility purposely sought to hide information that the suicide happened were unsubstantiated.
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