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    Missteps by Staff at the St. Louis VA Faulted in Veteran’s In-Hospital Suicide

    Missteps by Staff at the St. Louis VA Faulted in Veteran's In-Hospital Suicide

    Inaction by staff at the St. Louis VA Medical Center contributed to the suicide of a 61-year-old veteran in the hospital's emergency room — systemic failures that must be addressed to improve patient care and safety at the facility, the Veterans Affairs Office of Inspector General said Thursday.

    A VA's internal watchdog published an investigation that found the staff did not properly assess the veteran's suicide risk, even though he expressly raised the topic of death, telling the triage nurse that he didn't “want to die” and that he was depressed. He was placed in a room to await evaluation by a physician but was forgotten.

    When staff finally checked on him more than two hours later, the veteran, who was not identified in the VA OIG report but who was identified by St. Louis-area media at the time as Kenneth Hagans, had killed himself when alone in the room.

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    “The OIG determined that deficiencies in the quality of Emergency Department care provided to the patient resulted in a delay of care and may have contributed to the patient's death,” Dr. John Daigh, assistant inspector general for healthcare inspections, wrote in the report.

    Hagans, who had a history of substance use and suicide attempts, post-traumatic stress disorder, depression and an enlarged prostate, went to the St. Louis VA at 5:14 a.m. on…

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