Inquiry: Unknown if Iowa City VA ‘shortcomings’ led to suicide

An inspector general's investigation, requested by several members of Congress in the wake of a veteran's suicide shortly after he was denied admittance to the Iowa City VA hospital, found 'shortcomings” at the facility but could not conclude if any of them led to the death.

'The ability to address the patient's problems was complicated by the fact that the patient's (mental health) team was not made aware of all the psychosocial struggles the patient was experiencing, which if known to (Veterans Health Administration) providers may have altered the course of care,” found the report, which was released Thursday.

The investigation follows the suicide last year of Sgt. Brandon Ketchum, 33, of Davenport, who had served in both the Marines and Army and done tours of duty in Afghanistan and Iraq.

On July 7, 2016, Ketchum visited the Iowa City VA, saying previous mental health issues had resurfaced and asking a psychiatrist if he could be admitted to an inpatient treatment center.

According to a later post on Facebook, Ketchum wrote he sought help with his post-traumatic stress disorder only to be told to go home and take his medication. His girlfriend, Kristine Nichols, found him dead the next day.

Five members of Congress - including Iowa Sens. Chuck Grassley and Joni Ernst and Rep. Dave Loebsack - requested the Inspector General's Office of the Department of Veterans Affairs look into it.

'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,” a joint statement Thursday from the elected officials said. '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 investigation, which does not refer to Ketchum by name, found that the psychiatrist had told him the inpatient unit was full that night and that he would 'probably not” be admitted, although his treatment could start on an outpatient basis.

Ketchum quickly left, the report said, but the 'psychiatrist followed him to his car and subsequently made attempts to call him by phone but was unable to further interact with the patient.”

The report called it a 'good faith effort” that followed 'appropriate medical decision-making practices based on the information available to him at the time.”

The inquiry found that the VA had created four treatment plans for Ketchum between 2012 and 2015, 'however, these plans were not updated following a number of significant events.”

The investigation found Ketchum had tried to kill himself at least three times during that period. And later, closer to his death, he did not show up for about a third of his appointments.

The investigation found that staff called and left messages for him after the no-shows, but on at least some occasions didn't reach him.

'An opportunity to assess and treat a patient is lost when he or she misses an appointment,” the report said.

The inspector made four recommendations:

l That the facility staff 'conduct thorough post-suicide reviews to include all information that provides valuable context and details related to the event;”

l That the 'no-show” for mental health appointments policy is in keeping with guidelines and is monitored;

l That clinicians update mental health treatment plans as warranted;

l And that the mental health treatment coordinator - or principal provider - program complies with VA rules and is monitored.

In a statement, Director of the Iowa City VA Health Care System Judy Johnson-Mekota said she is committed to the report's recommendations.

'I want to express my sympathy and condolences for the family of Mr. Ketchum,” she said in a statement. 'My thoughts are with the them today. I am committed to always strengthening our suicide prevention program, and recommendations such as this OIG report only help us to improve in those efforts.”

l Comments: (319) 368-8516; makayla.tendall@thegazette.com