The federal watchdog agency for veterans cleared Atlanta officials of wrongdoing in the suicide of a former Marine who killed her three children before hanging herself in January.
Kisha Holmes was flagged as a high risk for suicide 23 days late, and staff at the Atlanta VA Medical Center failed to follow protocol for contacting patients who miss their mental health appointments, according to an internal review by the Department of Veterans Affairs. The agency is facing a national epidemic of veteran suicides, and the hospital was previously accused of lax care for suicidal patients.
Yet the lapses in Holmes’ case probably did not result in the the Gulf War veteran’s January death, the report concluded. She declined voluntary hospitalization, and did not meet legal requirements for an involuntary committal. Staff had legitimate worries about alienating her and forcing her children into foster care.
“[W]hile facility staff did not consistently comply with some requirements, it is unlikely that these deficiencies had a direct impact on the outcome in this case,” said the report, which was released Tuesday.
Friend and fellow veteran Dawn L. Jackson, who used the same housing services, was disappointed that the report did not do more to hold the agency accountable. Nonetheless, she was encouraged by the agency’s public acknowledgement of mistakes. Since Holmes’ death, local staff has checked in on her and other program participants as many as three times a week.
“I myself have seen measurable changes as a result of what happened to Kisha and her children,” Jackson said.
The review, conducted by the Office of the Inspector General, also tried unsuccessfully to identify the person who leaked to reporters that Holmes was at high risk for suicide before her death. The disclosure intensified calls for better mental health treatment for veterans, but the agency called the leak improper and illegal.
U.S. Sen. Johnny Isakson, R-Ga., called the leak “deplorable and unacceptable” and said the agency will act on the report’s findings.
“We will use the lessons from this tragedy and recommendations in the Inspector General’s report to make the Atlanta VA medical center and the Department of Veterans Affairs as a whole better,” Isakson said in a written statement.
Holmes, 35, had gone through a veterans homeless program in late 2013 and had moved to an apartment in Austell on a veterans voucher program. Friends, family and others who knew her considered her a loving mother and were shocked by her final act. Justin, 10; Kai, 4; and Faith, 10 months, were found suffocated. Holmes was also pregnant.
The report, which does not mention Holmes by name, shows that the divorced mom repeatedly insisted she was not suicidal, even after she was diagnosed with a chronic medical condition during the summer of 2014. The report does not identify the disease, but a friend told The Atlanta Journal-Constitution that she tested positive for HIV.
By early winter, Holmes’s mental state deteriorated. She told her therapist that she viewed suicide as “retiring from the world and being at peace instead of working daily,” the report states.
Her therapist recommended she be designated as high-risk. Holmes repeatedly missed mental-health appointments and became hard to reach. Her phone was disconnected.
But Holmes said things that made her appear to be healing when a social worker finally tracked her down at her home days before she died, the report said. She was engaged with her children, and said her prior therapy was enough.
“I don’t want to harm myself or anyone else,” she told the social worker, according to the report. “I will follow up in the future should I feel the need.”
Days later, Holmes and her children were dead.
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