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Report: Social Workers Failed to Ensure Proper Care for Distressed Veteran

Shoddy record-keeping, incomplete phone records cited in investigation into veteran's death

Social workers at the Department of Veterans Affairs hospital in Palo Alto made "no attempt" to ensure a mentally ill Iraq war veteran was admitted to the hospital in the days before he killed himself by stepping in front of a train May 2010, according to a report released Wednesday by the VA's Office of the Inspector General in Washington, D.C.

The investigation into the death of William Hamilton, 26, came after The Bay Citizen reported that the 26-year-old was refused entry into the Department of Veterans Affairs hospital psychiatric ward in Palo Alto four days before he died.

Hamilton, who had previously been admitted to the Palo Alto VA’s psychiatric ward on nine separate occasions, saw demons and regularly talked to a man he had killed in Iraq, according to his medical records. Three days before he died, Hamilton’s father brought him to a local community hospital in Calaveras County which, according to hospital records obtained by The Bay Citizen, tried to transfer him to the three VA hospitals, including the one in Palo Alto.

But at 4:39 p.m., a VA social worker wrote in his notebook that the Palo Alto facility “would not accept a transfer of a veteran for admittance this late in the day.”

Later that night, Hamilton was admitted to David Grant Medical Center at Travis Air Force Base in Fairfield. The Pentagon's inspector general has refused to launch an inquiry into David Grant's role in Hamilton's death.

“No attempt was made to transfer the patient” to the Palo Alto VA “in the days that followed,” according to the report, even though Hamilton had been frequently treated at the facility.

Instead, the report noted that both Hamilton’s social worker and the social worker's supervisor at the Palo Alto VA left for the weekend. The supervisor "assumed that the patient would still be hospitalized the following Monday,” the report stated.

That Sunday, David Grant Medical Center discharged Hamilton. Within hours, he was dead.

VA officials have said they have no record of Hamilton being denied care and that their records don't show any telephone calls between the Calaveras County hospital and the Palo Alto VA.

After a nine-month investigation, the VA’s inspector general was unable to determine whether the VA wrongfully turned Hamilton away, because the agency’s phone records are incomplete.

According to the inspector general’s report, staff at the Palo Alto hospital told investigators “that incoming calls could not be tracked.” The Inspector General then requested records of outgoing calls and found “no outgoing calls were recorded from any VAMC (Veterans Affairs Medical Center) extension to anywhere” on the date Hamilton's family and others said he was turned away.

During the course of the investigation, however, the inspector general identified two other dates in 2010 when VA staff told an outside hospital that Hamilton could not be admitted until 8 a.m. the next morning.

In an interview, Hamilton’s mother, Modesto school teacher Dianne Hamilton, said she was “beside myself, in shock” over the inconclusive nature of the inspector general’s report.

“They have terrible documentation. They don’t keep track of things. You have people who don’t follow through. All I really wanted was for them to admit that they should have taken him that day,” she said.

The inspector general also learned of an additional incident — a year after Hamilton’s death — when the psychiatric doctor on duty refused to accept a veteran for treatment, saying “We don’t accept patients for transfer at night.”

In an emailed response to questions, Dr. Stephen Ezeji-Okoye, deputy chief of staff of the VA Palo Alto Health Care System, said Wednesday that the hospital has always accepted psychiatric patients 24 hours a day, 365 days a year. More than 60 percent of psychiatric patients are admitted on nights and weekends, he said.

“We have taken this opportunity to review our internal communications with outside facilities. Based on this analysis, we have revised our tracking mechanism so we are better able to analyze the disposition of any cases referred to the VA Palo Alto Health Care System,” Ezeji-Okoye said.

Rep. Jerry McNerney (D-Stockton), whose request prompted the inspector general’s investigation, said he hoped the investigation would lead to changes at the Palo Alto VA.

“The good news is that, because of this incident, they have done some things to improve,” he said.

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