DIGGING DEEP. Breakdowns in the Atlanta VA's mental health system led to a scandal in 2013 when a series of patient deaths were linked to pervasive mismanagement at the hospital. Three patients deaths were linked to inadequate oversight. A fourth death occurred when a veteran committed suicide in hospital bathroom. A new hospital director, Leslie Wiggins, was brought in and changes were implemented to improve the mental health unit. The case of Kisha S. Holmes, a 35-year-old Cobb mother accused last week of killing her three children and then committing suicide, has raised fresh questions about the Atlanta VA's mental health system. Holmes was a veteran being treated at the VA and was identified as a suicide risk by the VA staff. She missed three appointments leading up to her suicide.
Atlanta’s Veterans Affairs Medical Center had identified Kisha Holmes as a suicide risk, but she missed her last three scheduled appointments before killing herself and her three children in Cobb County this week.
Holmes’ fragile state of mind was noted in VA documents. The records, obtained exclusively by Channel 2 Action News, say the 35-year-old war veteran was a “high risk for suicide” and might be prone to “possible self-directed violence.”
Holmes, a former Marine, missed two appointments in December and a third on Tuesday, the same day a maintenance worker discovered her body, along with her three children, ages 10, 4 and 9 months, inside their Austell apartment. The VA documents also reveal that Holmes was pregnant.
It’s unknown whether VA officials followed up with the single mother after she failed to show up for her scheduled mental health assessments.
In a statement released Friday, the Atlanta VA Medical Center said it was “deeply saddened to learn of the recent death of Kisha Holmes and her three children.” Citing privacy concerns, the VA declined to comment on specifics of the case. Hospital director Leslie Wiggins refused an interview request.
“For all outpatient suicides, we initiate a peer review of the care recently provided, and the Suicide Prevention Coordinator also does a detailed, standardized medical record review and report, which is submitted to VA’s national Suicide Prevention Program,” the VA’s statement read. “We immediately contact the Veterans Integrated Service Network and the VA Central Office when instances of this nature occur and remain in constant contact to ensure appropriate follow up and communication.”
The case threatens to renew questions about how the Atlanta VA’s mental health system operates, with some of that scrutiny coming from Congress. The House Committee on Veterans’ Affairs is looking into the case and will ask the Department of Veterans Affairs to provide a detailed history of any interactions it may have had with Holmes.
The deaths of Holmes and her children add to what has become an epidemic of veterans suicides. The latest figures show as many as 22 veterans take their lives each day.
Next week, the U.S. Senate is expected to vote on a veterans suicide prevention bill that passed the House earlier this month. The bipartisan bill would require annual reviews of the VA and Department of Defense suicide prevention programs and require the VA to forge stronger relationships with outside groups to improve suicide prevention efforts. It also calls for hiring more mental health professionals to assist veterans.
Less than two years ago, the Atlanta VA was shaken by scandal involving pervasive mismanagement in its mental health program that linked the deaths of three veterans to inadequate oversight by staff.
In one case, a veteran couldn’t get in to see a psychiatrist and was told by staff to go to an emergency room. A day later, he committed suicide. Another man died of a drug overdose after providers failed to get him treatment with a psychiatrist. In a third case, a patient died of an overdose from drugs provided by another patient.
The death of a fourth veteran later came to light after the audits and added to the scandal. He committed suicide in a VA hospital bathroom. Wiggins was brought in 2013 to fix the problems. The medical center added additional mental health providers and implemented a new patient tracking system.
VA Secretary Robert McDonald has praised Wiggins for the job she has done. In a December visit to Atlanta, he said the local system has no wait times in its mental health unit and suggested that Atlanta had become a model other facilities around the country should emulate.
Meanwhile, the investigation continues into the deaths of the children and Holmes, a New York native. Cobb police haven’t released the cause of death, saying they are still awaiting autopsy results.
Holmes’ oldest child, 10-year-old Justin Carter Medina, will be laid to rest Monday in Virginia, where his father’s family resides.
Jenny Hartley, Justin’s P.E. teacher at Sanders Elementary, remembered the boy’s ever-present smile.
“He had a great sense of humor and was really funny,” Hartley wrote on a memorial page for Justin. “His spirit always shined wherever he was in the school.”
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