Lawmakers call for VA hospital changes following fourth suicide

* From 2011 to 2012, the wait list for mental health treatment skyrocketed from 53 to 397 patients.

* Many of the 4,000 patients referred to outside mental health facilities “fell through the cracks.”

* Hospital staff lost track of a suicidal patient who was supposed to be closely monitored for two hours one afternoon. He died that night of an overdose of drugs he got from another patient.

* A schizophrenic man who was missing for eight hours told nurses “he got lost” on the way back to his room.

* Another patient with a history of substance abuse wandered the building for four hours, during which time he injected himself with testosterone.

* A patient who was referred to an outside facility died of an apparent drug overdose after the facility was unable to connect him with a psychiatrist for nearly a year after his referral.

* Another man was told by hospital staff to take public transportation to the emergency room after a VA psychiatrist was not available to see him. He never went and committed suicide the next day.

In-depth coverage

The Atlanta Journal-Constitution has been closely following mismanagement charges at the Atlanta VA Medical Center in the months since inspectors noted dozens of cases where staff failed to follow procedures. A federal audit has since linked three deaths to lack of oversight at the Decatur facility. Today, another troubling case is being reported.

The head of the U.S. House Committee on Veterans’ Affairs said Friday that top leaders at the Atlanta VA Medical Center clearly had “something to hide” after failing to reveal the suicide of a Georgia veteran at the hospital last fall.

U.S. Rep. Jeff Miller, R-Fla., and four Georgia congressmen toured the 405-bed facility in Decatur on Monday in response to recent federal inspection reports linking the deaths of three veterans to pervasive mismanagement of the hospital’s mental health unit.

When Miller asked hospital officials whether there were any other patient deaths Congress should know about, he said he was told, “No.” But last November, hospital staff discovered Army veteran Joseph Petit, 42, locked in a hospital bathroom dead in his wheelchair, a plastic trash bag tied over his head with a blue cord around his neck, a medical examiner’s report shows.

Petit's suicide was not included in two audits released last month by the Inspector General of the U.S. Department of Veterans Affairs.

“I left confident that the leadership there was committed to making an honest effort to turn the facility around, ” Miller said in a statement. “Today, that confidence is shattered.”

A spokeswoman for the veterans hospital declined to comment on Miller’s statements. But a statement from the hospital said that it is continuing to strengthen suicide prevention efforts to provide veterans with the high quality mental health care they deserve.

“Every veteran suicide is a tragedy,” according to the hospital’s statement. “We offer our condolences and support to the families who lost their loved ones and will continue to reach out to provide counseling and treatment.”

Petit's suicide did not happen during three separate visits by inspectors that resulted in last month's audits, which revealed the deaths of three other veterans tied to the facility, according to the Inspector General's office. The reports showed that many of the more than 4,000 veterans the hospital referred to outside mental health facilities "fell through the cracks."

One man died of an apparent drug overdose after providers failed to connect him to a psychiatrist. In another case, hospital staff told a man who tried to see a VA psychiatrist who wasn’t available to take public transportation to the emergency department. He never went and committed suicide the next day.

Both Miller and U.S. Rep. David Scott, an Atlanta Democrat, called on Secretary of Veterans Affairs Eric Shinseki to take action to deal with serious leadership issues at the Atlanta hospital. Scott also called for the resignations of top hospital officials. Military leaders in Washington and the White House both need to get involved, said Scott, adding that he has contacted the Obama administration about the facility’s problems.

“They lied to us,” said Scott, who also toured the facility earlier this week. “This cannot go unanswered. The credibility of the hospital is at stake here.”

‘Already cold’

Joseph Petit dreamed of being an Army Ranger — the best of the best.

But his ambitions began to quickly unravel just months after enlisting when he injured both knees during a parachute landing training exercise. The McDonough man soon found himself declared physically unfit for military duty.

Petit, who as a brother and son was always the one who took care of others, spent the next two decades battling chronic pain, said his sister, Brandie Petit. He eventually resorted to using a wheelchair and walker.

He later spent years battling mental illness, including hallucinations and major depression, and had attempted suicide once before.

When Petit wheeled himself into the veterans hospital’s emergency department on Nov. 8, 2012, he told doctors he was “hearing voices and was afraid he was going to harm his mother,” who he lived with, according to a DeKalb County medical examiner report obtained by Channel 2 Action News. The report shows Petit had over time been prescribed seven different medications, including powerful anti-psychotics and drugs to treat depression and anxiety.

The ER staff said that Petit was having a “mental health crisis” and sent him to his regular psychiatrist, who discharged him later that afternoon.

Instead of leaving the hospital, Petit locked himself in a staff bathroom on the 8th floor. Employees didn’t discover his body until around 11 a.m. the next day.

“They told my mom they had found him and he was already cold,” Petit’s sister said.

‘Lives on the line’

Petit’s death is the latest in a series of troubling revelations that spurred intense scrutiny of the facility and outcries by lawmakers.

The federal audits show, among other findings, that a suicidal patient died of an overdose of drugs given to him by another patient. In another instance, a patient with schizophrenia was missing for eight hours, later telling nurses he “got lost” on the way to his room.

A separate confidential report by the Joint Commission, a nonprofit that accredits health care providers throughout the country, revealed numerous problems in other areas of the hospital, including fire safety concerns and powerful prescription drugs, such as morphine, left unsecured out in the open.

Scott on Friday made a call for federal action.

“There’s nothing that should be more important than the health and the safety of our veterans … those who have put their lives on the line for us,” he said.

Veterans advocates say the troubles in Atlanta reflect bigger problems in the whole VA system, as thousands of soldiers suffering from post-traumatic stress disorder and other issues come home from war.

Petit’s sister said she doesn’t want her brother’s death to be in vain and wants justice for him and other soldiers who need help.

“He was my brother. He was my best friend,” she said. “He was more than just a statistic.”