A Gulf War veteran committed suicide in front of a VA clinic by setting himself on fire following repeated failures on behalf of the clinic’s staff, an investigation has found.

Charles Ingram, 51, killed himself in 2016 after going nearly a year without mental health treatment or medication and multiple appointment cancellations and reschedules. According to the report, he had been diagnosed with obsessive-compulsive disorder and a number of other medical conditions, and had been receiving care at several VA hospitals since 1997.

But in the year preceding his death, following an appointment cancellation to see a provider, Ingram did not receive a follow-up to reschedule. When he walked into the clinic to ask for one, it was scheduled for three months later.

“We found that in addition to the lack of timely appointments, staff failed to follow up on no-shows, clinic cancellations, termination of services, and Non-VA Care Coordination (NVCC) consults as required.” The report states. “This led to a lack of ordered MH therapy and necessary medications for the patient’s OCD, and may have contributed to his distress.”

In March 2016, Ingram appeared in front of the VA clinic in Northfield, N.J., covered himself in gasoline and lit himself on fire. His death spurred an investigation at the request of Senators Cory Booker, Robert Menendez, and Congressman Frank LoBiondo. “Ingram’s death was a tragedy that shook us to the core and reminded us of what’s at stake when it comes to providing care for veterans suffering from mental health issues,” Senator Book said.

The report is a damning condemnation of the particular failures in leadership at the VA clinic in Northfield, but does not come as a surprise for millions of veterans who have been frustrated with the cumbersome VA healthcare system. Despite many pledges to reform the agency by multiple directors of the VA, the department has been wracked by controversies over the years, particularly with regard to wait times for appointments.

Image courtesy of Morgan Phoenix via Wikipedia

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