Investigation finds mismanaged healthcare at Tuscaloosa VA hospital after patient died by suicide
TUSCALOOSA, Ala (WIAT) – An investigation by the U.S. Department of Veterans Office of Inspector General found that a patient received mismanaged healthcare in the months and days leading up to his death. That patient was Shannon McDaniel's son.
Shannon McDaniel requested the O.I.G. perform the investigation after her son died by suicide on Nov. 13, 2022.
Hunter Whitley was a United States Marine Corp veteran. His mother provided CBS 42 with his VA medical records that show he was deployed to warzones in Afghanistan, Kuwait, Saudi Arabia, Kabul, and others.
During those tours, records show he was exposed to "IED, RPG, land mines, and grenade explosions."
Whitley was in Afghanistan during the "Fall of Kabul", a time when the Taliban took back over the city. Records show Whitley was stationed at Hamid Karzai International Airport "when a suicide bombing occurred less than 600 feet away from him and his troop."
Whitley returned home to Brookwood in 2022. Shortly after coming home, he went to the Veteran's Affairs Hospital in Tuscaloosa to receive mental health treatment.
Medical records show he screened positive for post-traumatic stress disorder (PTSD), Traumatic Brain Injury (TBI) and depression.
Months after his first appointment at the VA, Whitley died by suiced at the age of 22.
"I guess a year ago,I was just still trying to come to terms with the fact that maybe Hunter just wanted to die, and he couldn't live with his experiences and things he had to do," McDaniel said.
McDaniel requested his medical records from the VA after her son passed, but it took almost a year for them to arrive.
"Something just didn't seem right, so I went online and started looking around," McDaniel said.
After spending weeks browsing the internet, she found the O.I.G, and on April 6, 2023, she requested they look into her son's care at the VA.
Three months later, McDaniel said she received a call from Tony Davis at the Tuscaloosa VA.
"He told me they had found mistakes in Hunter's care, but he really didn't tell me to what extent," McDaniel said.
McDaniel still didn't understand why her son would take his own life, and why it would take a year for the VA to reach out.
Months after that phone call, a letter from the VA came in the mail. It read in part:
"Dear Ms. Shannon McDaniel,
We would like to express our condolences on the death of Hunter Chase Whitley[...] The Tuscaloosa VA Medical Center is providing you with information to file a tort claim if you so chose."
"It's called an institutional disclosure," McDaniel said. "They have to let you know when they've done something wrong."
Despite the phone call, and a letter – McDaniel was still left with unanswered questions.
It was not until the O.I.G finished the investigation that she understood more about what was going on before her soon took his life.
"What I saw was a lot more done wrong than I could have ever imagined," McDaniel said.
This is a brief overview of the O.I.G's findings :
Failure to discuss medication risks
Inadequate assessment of suicide risks
Failure to monitor the patient's medication response
Scheduling Delays
Inadequate Suicide Risks Assessment and Lethal Means Safety Counseling
Failure to submit TBI consult
Insufficient administrative actions following the patient's death
"I would have no idea of any of this if I didn't request the records," McDaniel said.
The report and medical records show that Whitley was prescribed the antidepressant drug Mirtazapine. Side effects include suicidal thoughts and behaviors.
Prior to being prescribed Mirtazapine, Whitley did not report thoughts of suicide according to O.I.G's report and his VA medical record, and such adverse effects were not communicated with Whitley.
"The MHNP noted that 'patient education sheets will be provided with dispensed medications. "[the provider] did not discuss Mirtazapine's boxed warning of increased risks of suicidal ideation or behavior for young adults," the O.I.G reported.
"How many people has this happened to?" McDaniel questioned.
Lack of medication education was just one of many protocols that was not followed during Whitley's care.
"The OIG found that MSA staff did not initiate scheduling of the patient's follow-up appointment within two business days as required by the Veterans Health Administration," the report found.
Instead, Whitley's consultation was scheduled two months later – not two days.
"We need the people that are taking care of them, and if they can't, then they need to be relived of their duties," McDaniel said.
McDaniel has been trying to understand why her son would take his life. Now, she can't help but wonder if things would have been different.
"I'm convinced now he didn't necessarily want to die. He might have taken his life that night, but I don't think he wanted to die," McDaniel said.
The Tuscaloosa VA provided CBS 42 with this statement from Press Secretary Terrence Hayes:
We are deeply saddened and heartbroken by the loss of this Veteran and extend our heartfelt condolences to their family. We are committed to ensuring that all Veterans who seek care at our facility are met with the best care available from compassionate and well-trained staff.
At the Tuscaloosa VA Medical Center (VAMC), we are dedicated to providing exceptional care to our Veterans. In response to the Office of the Inspector General (OIG)'s report, we are implementing significant measures to improve our suicide prevention efforts and overall care standards.
We appreciate the OIG's review and concur with its recommendations. In response to the OIG report, we are taking the following actions:
The Tuscaloosa Director is reviewing patient care provided by clinical staff, evaluating outpatient mental health clinic scheduling, supervising oversight in the PTSD clinic, and assessing care quality to determine if an institutional disclosure is necessary. The Director will consult with Human Resources, General Counsel, and the patient's prescriber when needed and will take appropriate action.
The Tuscaloosa Director is strengthening processes to ensure providers deliver patient education on psychiatric medication warnings, conducting suicide risk assessments, performing lethal means assessments, and following traumatic brain injury screening and consult requirements, while monitoring compliance.
The Tuscaloose Director is ensuring PTSD clinic consults and documentation procedures meet Veterans Health Administration (VHA) standards, reviewing clinic processes for managing worsening mental health symptoms, and monitoring compliance.
The Tuscaloosa Director is evaluating and improving the root cause analysis and peer review committee processes to address system and ensure compliance with Veterans Health Administration (VHA) standards.
The Under Secretary for Health (USH) is establishing written guidelines for the Behavioral Health Autopsy Program's family interview process, including when to consult suicide prevention staff, ensuring decisions are in the family's best interest, and ensuring compliance with the Behavioral Health Autopsy Program, including completing the Family Interview Tool-Contact Form.
Suicide prevention remains our top clinical priority, and we are committed to continuous improvement and accountability. Our goal is to ensure that every Veteran receives compassionate, timely, and high-quality care.
"We all have to work together, and make sure those changes are actually taking place," McDaniel said.
