As you may recall, in 2016, a veteran burned himself alive outside a Veterans Affairs office to protest their refusal to provide him mental health support. The investigation that this shocking act sparked, has finally vindicated the veteran – beyond the shadow of a doubt.
Charles Ingram, a 51-year-old Gulf War veteran, went on for nearly a year without a therapy session or appointment with the psychiatrist. The doctor prescribed him medication for Obsessive Compulsive Disorder, prior to his suicide, the VA inspector found in the investigation.
Dan Caldwell, the executive director of Concerned Veterans for America, said that while the VA has since implemented many reforms to improve the access for veterans, problems still remain in the system.
“It’s an absolutely tragic situation,” he said in a statement. “No veteran should have to wait three months for an appointment—that is completely unacceptable. It’s important to note this case is from March 2016, but some of the issues that created this problem still exist today, especially in getting veterans access to care in a timely manner.”
The delays to Ingram’s mental health treatment began in Fall of 2015 when a New Jersey veterans’ clinic cancelled an appointment for Ingram because a provider was unavailable, then failed to follow up to reschedule the appointment.
When Ingram walked into the clinic a few months later to request an appointment with his psychologist again, the VA staff didn’t schedule a visit until more than three months later. He lost his job and was facing a divorce, and was desperate for a therapy session.
Shortly before the date of his rescheduled appointment, Ingram drenched himself in gasoline and lit himself on fire in front of the facility. A firefighter who had responded to the incident told the news sources that his body was “100 percent burned.”
The investigation determined the VA facility failed to provide Ingram with all the proper supervision that was required, and scheduling oversight in the 11 months led to Ingram’s suicide.
The inspector general said that it couldn’t determine whether an earlier appointment would have changed Ingram’s decision to commit suicide, but said the staff’s failure to follow up on the no-shows, clinic cancellations, termination of services, and other medical care outside of the VA “led to a lack of ordered therapy and necessary medications” and “may have contributed to his distress.”
In response to the suicide, the New Jersey facility had hired additional staff and reinforced its own capacity to provide proper psychiatric and psychological services for the veterans who are suffering from mental health issues, the report said.
VA spokesman David Cowgill said that the investigation’s findings “highlight unacceptable problems” and that the agency has moved to remedy the situation through several reforms, including the removal of the facility’s medical center director, assigning the regional officials to take over the management, establishing the same-day mental health services for urgent cases, and prioritizing suicide prevention efforts.