Spokane VA Center Miscounted Suicides

CVA: VA Profoundly Underreporting Vet Suicides?


Spokane VA Center Miscounted Suicides
August 10, 2009
Spokesman-Review

The number of Spokane, Wash.-area veterans who killed themselves in a one-year period is far greater than the Spokane Veteran Affairs Medical Center knew at the time, a VA investigation has found.

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.

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.

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.

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Spokane VA Center Miscounted Suicides