The report, released Nov. 9, indicates Huff, 27, told an emergency room nurse that he felt suicidal when he arrived at the VA, dressed in full combat attire, shortly after midnight. But the nurse didn’t document it in the medical record, raising questions about whether the information was passed to later caregivers. When questioned by another nurse, Huff later denied being suicidal.
The emergency room doctor said Huff was suffering from “severe depression and pain issues.” Huff, 27, sustained a back injury in a 2005 roadside bomb blast. After receiving an injection of pain medication, Huff left the hospital, only to return three hours later to kill himself.
VA Medical Director Guy Richardson said the suicide was “unfortunate and tragic ... my heart goes out to the family members.”
Doc was prepared to admit ailing vet
Jesse Huff was in constant pain from a war wound and in a deep depression when he showed up at the Dayton VA Medical Center shortly after midnight on April 16 in full combat uniform.
He was torn between his desire for pain relief and his fear that he could become addicted to pain medication.
He asked to speak to a nurse in private, Huff “expressed having problems with pain and feeling suicidal,” according to a Veterans Affairs inspector general’s report of Huff’s suicide a few hours after his emergency room visit.
The nurse was busy with a critically ill patient and said she instructed a nursing assistant to inform another nurse that Huff was suicidal, but she didn’t enter that information into the medical record, the report said.
Huff later told the second nurse he wasn’t feeling suicidal.
He said he was wearing his combat uniform “to show I’m a combat vet.”
The second nurse checked Huff’s duffel bag, but found no weapons.
Nonetheless, VA officials considered Huff a high-risk patient.
An emergency room doctor, who previously had Huff involuntarily committed to the VA psychiatric unit, evaluated Huff that night and was preparing to have him admitted voluntarily.
“The patient was crying, but he denied suicidal or homicidal ideation,” the report said.
Huff was moved to a bed directly in front of a nursing station and given an injection for his back pain.
About 10 minutes later, according to the report, Huff left the emergency room without the doctor’s knowledge.
“Approximately three hours later, the patient shot himself twice on the grounds of the medical center,” the report said.
Inspectors concluded the Dayton VA emergency room staff made “reasonable efforts” to treat Huff the night of his suicide and made “appropriate efforts to manage the patient’s pain and treat his (mental health) conditions from August 2008 to April 2010.”
But the VA agreed to improve “hand-off” and intra-staff communication upon inspectors’ recommendations.
It also identified clinicians who had not taken mandatory suicide risk management training, which was required under a 2008 directive.
In a prepared statement to questions by the Dayton Daily News, VA Medical Director Guy Richardson said “all required training for both recommendations is near completion, with the exception of a few individuals due to planned and unplanned leave.”
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