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Updated: Oct 30, 2023

After the attacks on 9/11, the veteran joined the Army and served for 14 years, including three deployments to Iraq and Afghanistan. He was awarded the Bronze Star. After his discharge, he struggled with PTSD and the transition to civilian life.

In 2014, the veteran twice attempted to take his own life. In 2016, he tried again and was subsequently hospitalized at the Salem VA Medical Center in Salem, Virginia. In January 2017, he made another suicide attempt and was voluntarily hospitalized again at the Salem VAMC.

The veteran struggled to maintain employment and cultivate interpersonal relationships.

These issues resulted in multiple visits to VA providers for mental health counseling and suicide risk evaluation in the years prior to the veteran’s death.

On the afternoon of January 4, 2020, the veteran was seen speeding in a car back and forth on Jefferson Davis Highway in Chesterfield County, running red lights and ultimately hitting another vehicle, totaling his own car. Police responded and determined that he was uninjured but in psychological distress. Accordingly, the police transported the veteran to the McGuire VA Medical Center emergency department to be seen and evaluated.

McGuire VAMC records make no mention of the fact that the veteran was transported to its facility by police officers or of the motor vehicle accident which had just occurred. Three separate nurses who interacted with the veteran documented in his chart that he expressed suicidal thoughts and ideations.

A psychiatry consult was ordered by the ED attending physician. Remarkably, during the interview by the psychiatry resident, the resident noted that the patient denied having any suicidal ideations in more than a year. Even a cursory review of the McGuire VAMC psychiatry records, however, would have demonstrated his history of multiple suicide attempts and that he had missed his past two counseling appointments. Despite his earlier interactions with police, overall decline, deeply disturbed behavior, and the notes documented by three nurses, the resident discharged the veteran. Without personally evaluating the veteran, the attending psychiatrist signed off on the resident’s plan.

Within hours of his discharge from the McGuire VAMC and less than a mile away from the hospital, the veteran committed suicide by deliberately laying down on railroad tracks.

Due to the failures of VA providers to appropriately evaluate the condition and subsequently admit him for appropriate care and treatment, the veteran succumbed to his suicidal ideation.

The decedent left a wife and two children.


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