WASHINGTON – The Office of Inspector General at the U.S. Department of Veterans Affairs (VA OIG) today released the results of its review of the circumstances of veteran Brandon Ketchum’s suicide and whether Ketchum received adequate mental health treatment at the Iowa City VA Health Care System. Ketchum was a native of Wisconsin Dells, Wis. Sens. Ron Johnson, Chuck Grassley and Joni Ernst, sought the review in August 2016. The senators made the following comment:
“This case is a tragic example of why we must do better for our veterans. It also illustrates the importance of having independent watchdogs at federal agencies. Inspectors general review agency work and point out problems that need to be fixed and ensure that policies and procedures in place are adequate. In this case, the inspector general report made four recommendations to improve mental health treatment for veterans going forward, but could not determine if these shortcomings impacted Brandon’s care. With an average of 20 veterans committing suicide a day, the VA must do everything in its power to extend help before it is too late. When it comes to caring for these brave men and women, there is no room for error. We expect the VA to implement the recommendations thoroughly and carefully, and we intend to make sure the VA does so. The VA should go beyond the recommendations if necessary. We all have to work as hard as possible to make sure all veterans receive the care they need and deserve.”
The VA OIG’s four recommendations include:
· The OIG recommends that the Acting Under Secretary for Health ensure that facility staff conduct thorough post suicide reviews to include all information that provides valuable context and details related to the event.
· The OIG recommends that the System Director ensure that the system No-Show policy and practice for mental health patients is in alignment with the expectations of the Office of Mental Health Operations and that system leaders monitor compliance.
· The OIG recommends that the System Director ensure that clinicians update outpatient mental health treatment plans according to applicable requirements and guidance and that system leaders monitor compliance.
· The OIG recommends that the System Director ensure that the Mental Health Treatment Coordinator program complies with the Veterans Health Administration requirements and guidance, and that system leaders monitor compliance.
The inspector general report is available here.
Sens. Johnson, Grassley, and Ernst sent a letter to the VA Inspector General in August of 2016 seeking an investigation in Brandon Ketchum’s death.