This is something we unfortunately know all too well. It was known by the VA that Dane was suffering from suicidal thoughts and he was even placed in a "suicide prevention program". The two emergency contacts written down on his prevention program were never contacted when he canceled psychiatric appointments without reason. That definitely is considered a "red flag" for someone who is suicidal. Read the following article for more details about how this is happening more and more frequently across the country.
By MARK BRUNSWICK, STAR TRIBUNE
January 05, 2015 - 5:38 PM
Despite heightened awareness of military suicides, the Department of Veterans Affairs is incorrectly reporting suicide data and does a poor job of tracking and caring for vets at risk who are prescribed antidepressants, according to a report by the U.S. Government Accountability Office.
The VA’s protocols for treating veterans diagnosed with depression were broken, and patient and suicide data were flawed, inconsistent and incomplete, the GAO report found.
Ten percent of veterans who received VA health care in the past five years were diagnosed with major depressive disorder, and 94 percent of those were prescribed antidepressants.
Because of problems that may permeate its record-keeping, the VA may understate the prevalence of major depressive disorders among veterans being treated at the VA.
Investigators reviewed 30 medical files for veterans prescribed antidepressants following a major depression diagnosis at VA medical centers in Phoenix; Philadelphia; Canandaigua, N.Y.; Gainesville, Fla.; Iowa City, Iowa; and Reno, Nev., from 2009 through 2013.
Twenty-six of those veterans weren’t assessed after four to six weeks, the time specified in the VA’s clinical practice guidelines, and 10 veterans did not receive follow-up care within the time frame recommended, the audit found.
The accuracy of veteran suicide data used for prevention work also was cited as “not always complete, accurate, or consistent,” the report found.
Forty out of 63 Behavioral Health Autopsy Program reports had incomplete data, six had incorrect dates of death and nine reported an incorrect number of outpatient mental health visits in the last 30 days.
The errors were attributed to varying interpretations of the guidance given for filling out forms, which also were not generally reviewed at any level in the VA.
In response to the report, the VA said it will review its diagnostic patterns looking at depression and said it will ask for additional reviews of any suicide data it submits to ensure it is complete and current.