Veteran Oversight Now

“I don’t want to die.” Veteran Left Alone in VA Emergency Department Dies from Suicide

Veteran Oversight Now

Show Notes

In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses deficiencies in the quality of emergency department care for a veteran who died by suicide at the John Cochran Division of the VA St. Louis Healthcare System in Missouri. This edition also includes highlights of the VA OIG’s work from July 2023. “Approximately 10 minutes later is when the staff person finds the patient unresponsive in the exam room with a ligature around his neck. A code was called, meaning a code blue so that all emergency staff would present to that room, and they tried to resuscitate the patient, but that was unsuccessful, and he was pronounced dead about 10 to 15 minutes later.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director

Related Report Deficiencies in Emergency Department Care for a Patient Who Died by Suicide at the John Cochran Division of the VA St. Louis Health Care System in Missouri

More from Veteran Oversight Now

Sep 17, 2025

Each month, the VA Office of Inspector General publishes highlights of our oversight reports, congressional testimony, and investigative work. In August 2025, the VA OIG published 17 reports that included 72 recommendations to VA.

Aug 14, 2025

The Honorable Cheryl L. Mason was confirmed by the Senate as the inspector general of the VA on July 31, 2025, and shortly after being sworn in, took up her leadership of the VA OIG on August 4. IG Mason previously served as the chairman of the Board of Veterans’ Appeals at VA. For more information on IG Mason, see her bio.

Jul 15, 2025

Each month, the VA Office of Inspector General publishes highlights of our oversight reports, congressional testimony, and investigative work. In June 2025, the VA OIG published nine reports that included 81 recommendations. Report topics varied from an evaluation of VA’s governance of recruitment, relocation, and retention incentives awarded for VHA positions to mental health inspections of the VA Salem Healthcare System in Virginia and the VA Philadelphia Healthcare System in Pennsylvania.

Jun 17, 2025

Each month, the VA Office of Inspector General publishes highlights of our oversight reports, congressional testimony, and investigative work. In May 2025, the VA OIG published 11 reports that included 54 recommendations. Report topics varied from an audit of the VHA’s Pain Management, Opioid Safety, and Prescription Drug Monitoring Program to a healthcare inspection to assess allegations of deficiencies in the emergency department care provided to a patient at the Martinsburg VA Medical Center in West Virginia.

May 22, 2025

This Semiannual Report to Congress summarizes the independent oversight efforts of the VA Office of Inspector General (OIG) from October 1, 2024, through March 31, 2025. Visit the VA OIG's website to read the full report.

See all episodes →