VA Whistleblowers Credited With Preventing Patient Suicides

Two counselors at the Phoenix, Ariz., veterans hospital who blew the whistle on lapsed suicide-prevention procedures prompted changes that are saving lives, the Office of Special Counsel said on Monday.

In letters to the White House and Congress, the independent investigative agency said it verified disclosures from Brandon Coleman and Jared Kinnaman that the staff’s monitoring of veterans with mental health and substance abuse problems was not being done in compliance with a VA directive requiring that at least one qualified hospital employee observe each potentially suicidal patient at all times. 

“The Emergency Department lacked safeguards preventing elopement, a situation where a patient is not permitted to leave, because they pose a danger to themselves or others, but intentionally does so,” the whistleblower protection agency said in a statement. “As a result of these deficiencies, Mr. Coleman and Mr. Kinnaman reported to OSC that 10 suicidal patients deemed 'high risk for suicide' eloped from the Emergency Department from October 2014 and February 2015. 

“Although these issues had been recognized by Phoenix VA leadership prior to the investigation, only after Mr. Coleman made his disclosures to OSC and went public in the press did the hospital come into compliance with the VA’s directive and move the rooms for these patients farther from the exit door,” OSC added. The facility also installed a delayed release on the door. 

Since these changes were implemented, the VA has reported no further cases of elopement from the Emergency Department. But a later report confirmed the whistleblower’s accounts that since February 2015, some potentially suicidal veterans treated elsewhere in the hospital have left the premises, as have veterans with substance abuse issues in the Emergency Department.

The VA hospital has since improved interdepartmental communication and training in suicide prevention, OSC said. 

In a related matter, OSC this spring facilitated resolution of a claim of whistleblower retaliation filed by Coleman through an Alternative Dispute Resolution program, moving him to a new position as an addiction therapist at nearby clinic.

“Mr. Coleman and Mr. Kinnaman likely saved lives by speaking up for the veterans in the Phoenix VA’s care,” said Special Counsel Carolyn Lerner. “They prompted long-overdue changes to better protect veterans who are seeking help for their mental health and substance abuse issues. However, based on recent reports suggesting continuing problems, I urge the Phoenix VA to keep working with whistleblowers to improve veterans’ care.”