Report finds local VA leaders 'lacked awareness' ahead of veteran's suicide

WEST PALM BEACH, Fla. (CBS12) — A recent report from government investigators found leaders at the West Palm Beach Veteran’s Administration Hospital “lacked awareness” about aspects of patient safety, in the wake of a soldier’s suicide in March 2019. Additionally, the report found several lapses in protocol by hospital staff, including security cameras that were out of work “for years.”

In a statement to CBS 12 News, the West Palm Beach VA said that “since the time of the review, the West Palm Beach VA Medical Center has taken action on all of the OIG’s recommendations.”

U.S. Army Sergeant Brieux Dash took his own life inside the West Palm Beach VA Hospital on March 14, 2019. After his death, Sgt. Dash’s family told CBS 12 News they believe he was suffering from PTSD. Sgt. Dash served two tours in Iraq.

An investigation into the hospital by the VA’s Office of the Inspector General (OIG) began five days later, naming an undisclosed patient’s suicide as the purpose of the inquiry. The report was released August 22, 2019.

Investigators found that the unnamed patient received appropriate mental health care, after he was admitted to the hospital under Florida’s Baker Act. Dash was admitted to the VA hospital under the Baker Act in the same time frame as the unnamed patient, after family contacted authorities saying they were concerned for his safety, according to his family.

However, the 48 page report also details that hospital staff lacked appropriate mental health training at the time they were treating Dash. Federal investigators found that less than half of hospital staff who required certain mental health training underwent the training.

"Only 44 percent of employees required to have [Mental Health Environment Care Checklist] training were in compliance," says the report.

Additionally, investigators found that security and patient safety cameras in one of the hospital’s mental health units were not operational. The cameras, intended to monitor all patients, had not worked “for at least three years” due to a network crash in 2016, according to the OIG report.

"Had the cameras been functional and monitored as required by policy, an employee may have seen the patient preparing for the event,"
the report adds.

“You guys are supposed to be taking care of him,” said Sherron Permashwar, Sgt. Dash’s Aunt. “What happened?”

“We appreciate the Office of Inspector General’s (OIG) oversight, which focuses on an event that occurred in March 2019. Any time an unexpected death occurs at a VA facility, a comprehensive review is conducted to see if changes in policies and procedures are warranted. OIG reviews are opportunities to strengthen our processes and the way we deliver care to America’s Veterans,” said a spokesperson for the West Palm Beach VA in a statement to CBS 12 News.

“We encourage any Veteran, family member or friend concerned about a Veteran’s mental health 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 www.veteranscrisisline.net. The lines are available 24 hours a day, 7 days a week a week,” added the VA spokesperson.