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Internal audit highlights shortfalls in mental healthcare access at Phoenix VA

Veterans Affairs Private Care
Posted at 9:50 PM, May 06, 2021
and last updated 2021-05-07 01:53:19-04

PHOENIX — Seven years after the infamous wait time scandal shook the Department of Veterans Affairs and the veteran community to its core, an internal audit is highlighting major problems inside a VA hospital that officials believed led to the death of a veteran suffering from mental illness.

This has concerned veterans' groups calling for accountability and change once again while saying amidst the memory of an old scandal, a new one is looming unless VA Secretary Denis McDonough doesn't act fast.

Joshua Stanwitz who is the Coalitions Director with Concerned Veterans of America tells ABC15 their organization has already started hearing from veterans who have been waiting to get an appointment with a doctor or specialist.

"It's just starting to build back up into another waitlist scandal. Veterans, waiting to get access to care, veterans waiting to get even into the system to receive that care," said Stanwitz.

Mental healthcare was another area in which critics of the Department believed the Phoenix VA was falling short. Many of the concerns were highlighted in a report issued by the Office of Inspector General titled: "Deficiencies in Care and Administrative Processes for a Patient who Died by Suicide, Phoenix VA Healthcare System, Arizona."

The report dated March 23, 2021, highlights the case of an unnamed Phoenix Veteran who was desperately seeking help, only to get the run-around by multiple staff members of the Phoenix VA, until he finally decided to take his own life.

Richard Lyons, an attorney in Phoenix who is familiar with the many issues the VA has faced represents two families who are currently involved in a lawsuit against the federal agency after losing loved ones due to alleged insufficient care by the Phoenix VA. Lyons does not represent the family of the veteran named in the lawsuit, nor does he know who they are.

ABC15 asked Lyons to review the report to see if he was familiar with any of the concerns highlighted by the federal inspectors.

"The biggest problem is the bureaucratic mess that veterans deal with when they try to get mental healthcare," said Lyons.

He described feelings of frustration as he read the report.

"From the day he asked for help, in Jan of 2019 for the next 5 months, he talked to 8 different people at different levels of the VA," said Lyons.

"And he still never got the treatment that he needed," he added.

The veteran, who is not named in the report died before he could get an appointment to see a counselor due to poor documentation, a tedious bureaucratic process, and minimal follow-up by VA staff, according to the report.

Critics of the VA feared this was not a single tragedy, but an indication of history repeating itself.

"Unfortunately, I can't do anything. I cannot change the way the VA operates. Literally, the only thing I can do is sue the VA after these veterans commit suicide, on behalf of the families," said Lyons.

One of those was the family of Joshua Kinnard, a Marine Sniper who served in Iraq after 9/11.

"He was an amazing, amazing person who loved our country, who served our country, and was very well decorated," said Maggie Jones, Kinnard's fiancée.

She added that Kinnard was suffering from serious mental health issues when he was admitted to the VA for treatment and observation, but despite her pleas staff at the VA decided to release Kinnard early, before his observation period ended. Ten days later, Jones said Kinnard suffered a major breakdown, that led to a police-involved shooting that left Kinnard dead.

Jones said she was disturbed to see the latest report by the Office of Inspector General.

"The first page of that report I was in actual shock. My heart was broken for that family," said Jones.

"Most of all I was discouraged because the VA had promised after Joshua's passing away, that they were going to make changes that were vital to the care of our veterans. And it seems after this report that I reviewed that those promises were broken," added Jones.

The report calls for the VA to make seven major changes. These include being timely when it comes to setting appointments for veterans, doing more outreach and following up with veterans who are asking for help, conducting a suicide risk assessment right away instead of relying on age-old reports from years ago, and better record keeping.

The full report can be accessed here: Deficiencies in Care and Administrative Processes for a Patient Who Died by Suicide, Phoenix VA Health Care System, Arizona.

ABC15 reached out to the Phoenix VA to request an interview with administrators. The agency did not grant us an interview but did release a statement indicating all of the recommendations were now complete, or almost complete.

A Phoenix VA spokeswoman goes on to state:

"The Phoenix VA Health Care System is deeply saddened by this tragic incident, and our thoughts and prayers are with this Veteran’s family and friends as they continue to grieve the loss of their loved one.

The VA OIG Report focused on events that occurred in 2019. Since that time and subsequent to the OIG review in June 2020, we began to implement measures to strengthen our continuity of care and to prevent similar occurrences from happening. As a result of the time between the onsite investigation and receipt of the formal written notice of the findings on March 22, most of the action items are either complete or in progress.

The Phoenix VA Health Care System offers same-day mental health care services at our main facility, and each of our Community Based Outpatient Clinics. Additionally, any Veteran, family member or friend concerned about a Veteran’s mental health is urged to contact the Veterans Crisis Line at 1-800-273-8255 and press 1 or text 838255. Trained professionals are also available to chat at The lines are available 24 hours a day, 7 days a week.

There is nothing we take more seriously than the safety of our patients and staff. As an organization, we hold ourselves accountable for providing the highest quality care while protecting the safety of patients, employees, and visitors. We thank the OIG for its oversight and shared commitment to improving Veteran healthcare."