Report says methods used to identify victims ‘may be inadequate' 

The VA's Office of Medical Investigations discovered that from July 2007 through the first week of July 2008, at least 22 veterans in the Spokane VA service area killed themselves, and 15 of them had contact with the medical center.

Spokane VA had previously reported nine suicides and 34 attempted suicides in that time period. All of them had some contact with the medical center.

"The methods and sources routinely being utilized by the medical center to identify veterans who have committed suicide may be inadequate," a report by the VA medical inspectors said.

The suicides came amid heightened concern for the mental health of soldiers and veterans nationally. In response, VA facilities have strengthened protocols for identifying patients at risk of suicide.

The inspectors' report was released late last week by the Veterans Health Administration to Spokane resident Steve Senescall, after a year spent trying to find out more about the death of his son, Lucas Senescall. The young man's body was found hanging in his Spokane home a few hours after he sought psychiatric help at the Spokane VA.

Although the report was completed on Feb. 4, Senescall did not receive it until late Thursday, hours after The Spokesman-Review called VA headquarters and the office of U.S. Sen. Patty Murray with inquiries about the father's efforts to obtain the information.

On July 7, 2008, Steve Senescall accompanied his son - who had a history of mental illness, including a previous suicide attempt - to the medical center's psychiatric ward, where Lucas was seen by Dr. William L. Brown.

Rather than admit Lucas, Senescall said, the psychiatrist had the veteran make an appointment for an office visit in two weeks.

"I want to know why, when he was rocking back and forth in his chair with his hands over his mouth to keep from crying, he sent him home," Senescall said.

Senescall's suicide was the 15th in a little more than 12 months by a veteran who had at least some contact with the Spokane medical center.

The discrepancy between the nine deaths reported earlier by the Spokane VA and the 22 noted in the medical investigators' report came as a result of the medical center comparing death records from the Spokane County medical examiner with records from all three branches of the VA - the Veterans Health Administration, the Veteran Benefits Administration and the National Cemetery System.

Medical center officials had gathered the information to make it available to inspectors when they arrived for a two-day visit on July 23, 2008. "Up until this time we did not have a systematic way of determining all the veteran suicides that occurred in our catchment area," said Dr. Gregory Winter, head of behavioral health at Spokane VA.

The investigation found that other veterans who had not had contact with the medical center had killed themselves. The total number of veteran suicides likely would be much higher had the investigation checked all death records in the region served by the medical center, which provides care for 215,000 veterans from Wenatchee to Kalispell, Mont.

The heavily redacted report cited numerous exemptions under the federal Freedom of Information Act protecting the privacy of victims and their VA health care providers. It also cited an extraordinary exemption protecting the VA from disclosure of medical quality assurance review records.

The report was so redacted that it is difficult in most cases to determine the extent of an individual veteran's contact with Spokane VA, much less what action was taken to protect the veteran from himself. Medical center Director Sharon Helman said Friday some of them may have been enrolled as VA patients but failed to show up for health care.

The report identifies each veteran only by a number. Nevertheless, details provided in several cases closely match the circumstances of veterans who have previously been identified by The Spokesman-Review.

References to Veteran 1 match what is known about Senescall. The report concludes that VA staff should have attempted to interview him alone and should have offered him hospitalization.

"The medical center should peer review the care provided to Veteran 1 and appropriate actions should be taken based on the findings," the report said.

Helman declined to say whether any disciplinary action has been taken as a result of any of the suicides.

"Reviews were done and appropriate actions were taken," Helman said.

The description of Veteran 2 matches the case of Richard Kinsey Young, a 35-year-old Navy veteran who killed himself in April 2008 after a 16-month struggle with back pain and depression.

"This ... veteran did not appear to have a well-coordinated pain management plan to assist ... with intractable pain until a few days before death," the report states.

The report appears to conclude that several of the veterans who killed themselves were being treated for pain, which may have contributed to their suicides.

Statistics gathered at the Spokane VA in 2006 showed that nearly 70 percent of infantry soldiers returning from Iraq and Afghanistan sought treatment for musculoskeletal injuries related to carrying too much gear.

The most common complaint was lower back pain, reported by 54 percent of the soldiers, a previous Spokesman-Review investigation found. Two of the veterans who killed themselves were Iraq or Afghanistan veterans, including Spc. Timothy Juneman, a 25-year-old National Guardsman and former Stryker Brigade soldier who was injured in a roadside explosion in Iraq.

Juneman hanged himself at his home in Pullman, where he was taking classes at Washington State University after being released from inpatient suicide watch at the Spokane VA in January 2008. He apparently received no follow-up care by VA staff. Brown was the psychiatrist who released Juneman. In records obtained by Juneman before his death, Brown wrote that Juneman was apparently despondent over imminent redeployment to Iraq with the Guard, his family has said. Because of privacy laws, the VA was unable to notify the Department of Defense about the medical condition of "active veterans" such as Guard and Reserve members.

Among the recommendations of the medical inspectors was that the VA and Department of Defense "should determine under what circumstances patient safety should take priority over patient privacy, e.g., reservists being treated by the VA who is in no physical/mental condition to deploy."

The inspectors made numerous other recommendations on how the medical center could better identify and care for veterans at risk of suicide, most of which already had been implemented before the report's release, Helman said.

"Every one of the recommendations was supportable and something we needed to implement," Helman said. "We have aggressively taken action to improve care to veterans."

The Spokeman-Review