Marine died under VA care, report faults Wyoming facility (2024)

ALLISON ALLSOP
Casper StarTribune

A man died despite being under the supervision and care of the Sheridan Veterans Affairs Medical Center for suicidal thoughts and alcohol withdrawal, according to a report by the department's Office of Inspector General.

Dean Heyborne was 40 years old when he committed suicide in June of last year. Heyborne had been in the center's care for four days when he committed suicide.

According to the Inspector General's report on the incident, the center failed to remove potentially dangerous items from Heyborne and his room. Also, staff failed to communicate which led to a decrease in the level of supervision. Center healthcare workers also failed to follow protocols when admitting the Heyborne, such as conducting certain risk evaluations.

The Office of Inspector General initiated the investigation after they received two claims that the center has provided inadequate care for a patient. The claims stated that inadequate care was provided in suicide prevention and alcohol withdrawal treatment. The inspector general substantiated the claim in regard to suicide prevention.

"The OIG did not substantiate that clinical staff provided inadequate care for the patient's alcohol withdrawal," said the report. "The OIG found that nursing staff made one medication error but otherwise followed the CIWA-Ar protocol and dosing, as ordered, to monitor and treat the patient."

Heyborne was born in Cedar City, Utah, where he spent much of his life. According to his Facebook page, he enlisted in the marines in 2000 and served for 12 years.

Heyborne had three children, all of which survived him in death.

He was an avid hiker and had completed the Pacific Crest Trail, which is more than 2,000 miles long.

Heyborne, who was deployed to Afghanistan, struggled with post-traumatic stress disorder following his service in the military. He was also struggling with homelessness and other medical issues, according to the report and Facebook posts.

Timeline of events

Heyborne was brought to the Sheridan VA Medical Center on June 2, 2023, after going to the emergency room of a community hospital.

He was transferred at his own request for treatment of alcohol withdrawal and suicidal thoughts, according to the report.

The report details the state that Heyborne was in when he entered the facility. The report states that he had claimed to not have taken psychiatric medication for 6 months, had previous suicide attempts, was drinking heavily for several consecutive days and that alcohol made him suicidal.

Heyborne told the medical office who admitted him that he had not had alcohol before then since 2019. He said that he relapsed due to pain from a car accident that occurred several months prior.

Upon being admitted, Heyborne was placed on 1:1 supervision and treatment for his alcohol withdrawal.

An admitting nurse then conducted a suicide severity rating test to determine the likelihood that Heyborne might attempt to kill himself.

This test asks patients whether or not they have had any thoughts of or taken action in self-harm or suicidal attempts within certain time frames. Heyborne's answer, although not specified, resulted in a positive test result. A positive test result means that the patient answered yes to at least one of the high-risk questions. The report says that Heyborne answered yes to 6 of the 8 total questions.

A certified nursing assistant completed the inventory of items from Heyborne's things. These checks are in place to remove any potentially dangerous objects from the patient. Heyborne was allowed to keep all of his items, including a necklace made out of paracord.

During this time, the certified nursing assistant also documented that she removed hazardous items from the patient's room. However, the ceiling-mounted chair lift was left in the room.

On the second day, a new medical officer was on duty. This officer noted that Heyborne was still on 1:1 observation and alcohol withdrawal treatment.

Heyborne met with the psychiatrist on the second day of his admittance via telehealth. The psychiatrist noted that Heyborne was not "of imminent harm to self or others" and listed him as a low risk for suicide.

Although the psychiatrist made these notes, he did not sign the note for 25 hours and other healthcare workers on Heyborne's case could not see the note until it was signed.

By day three, the medical officer on duty, who was the same as day two, made note that Heyborne was denying suicidal thoughts. Later in the evening, the psychiatrist finally signed his notes and discontinued the 1:1 observation.

From this point on, Heyborne was placed on 15-minute checkins.

At 2:45 a.m. on June 5, Heyborne was found in his room and pronounced dead. He had hung himself from the chair lift with his paracord necklace. The medical officer on duty from day three pronounced him dead at 3:21 a.m.

An autopsy was performed by the Sheridan County coroner later that day.

What should have happened

The investigators found that there were several steps and precautions that the center did not take when admitting and treating Heyborne.

Upon Heyborne's admission and after the positive suicide risk evaluation, the facility's standard of practice requires a warm handoff of the patient to a licensed independent practitioner to perform a more comprehensive suicide risk assessment.

This did not occur, and the medical officer on duty on day one was not aware of this policy. The nurse who performed the original assessment was also unaware that the patient should have been handed off to a licensed independent practitioner.

The psychiatrist also admitted to not knowing that the initial evaluation was positive and did not know a more comprehensive assessment was required.

The psychiatrist did not document performing a comprehensive assessment, but told the investigators that he did consider all elements of that assessment.

Facility standard operating procedure requires the healthcare workers to remove and secure patient's belongings when they are on 1:1 care. The nurse who handled Heyborne's admittance did not confiscate his personal items because Heyborne said that they had sentimental value to him.

The standard operating procedure also states that hazardous environmental items should also be removed to the highest degree possible from patient rooms when the patient presents with suicidal ideations.

The report does state that these items would have likely been returned once he was placed on 15-minute check-ins, per facility policy.

However, the room was still not cleared of all environmental hazards.

"Nurse 1 documented that an environmental risk check was completed; however, in an interview with the OIG stated, 'I failed to verify everything.' Although staff may not be able to make rooms on the medical unit completely free of hazardous items given that the rooms are designed for medical care and not psychiatric care, staff should have mitigated the environmental risks to the greatest degree possible, even though 1:1 was ordered," said the report.

In addition to the failures that occurred when Heyborne was admitted, the staff also failed to properly communicate with one another and admitted that this could have resulted in better care.

The medical officer on duty during day two and three said that if they had known the psychiatrist planned on changing the observation status of the patient, they would have stepped in to have a conversation.

"MOD 2 stated that had the consult note been available, a conversation with the psychiatrist would have occurred to convey the opinion that checks every 15 minutes were not adequate for this patient in the medical unit and to suggest moving the patient to an acute psychiatric unit," according to the report. "The psychiatrist told the OIG that knowledge of the MOD's opinion 'would have definitely helped.'"

The aftermath

Immediately following Heyborne's death, the facility conducted a root-cause analysis to determine what can be done in the future.

The report states that a root-cause analysis is team-based and systems-level investigation, according to the Veterans Health Administration.

The inspector general agreed with the findings and recommendations of the analysis.

The report gives four recommendations based on its findings:

■„ The medical center should ensure completion of warm handoffs and comprehensive evaluations within 24 hours.

„■ The medical center should ensure that staff reassess a patient prior to changing a one-to-one observation status order.

■„ The medical center should ensure that inpatient notes are completed and authenticated as soon as possible, but always within 24 hours. „

■ The medical center should ensure staff follow facility policies for removing belongings and environmental risks.

Pam Crowell, the facility director, concurred with these recommendations in a response to the inspector general. Recommendations one to three have target completion dates for the end of 2024. Recommendation five has a target completion date of January 31, 2025.

Despite clear errors in procedure which directly resulted in Heyborne's suicide, Crowell said that there have been no recommendations for any staff removals.

"This incident resulted in the tragic loss of life of a Veteran under our care and we have taken actions based on internal and external reviews to ensure better outcomes moving forward," said Crowell in a written statement.

Over 17% of the suicides in Wyoming were committed by veterans in 2021, according to a report by the Veterans Crisis Line. However, the report did not state where these suicides occur.

The center did not respond to questions about whether or not they still rely on telehealth visits for patients with suicidal ideations or for the reassessment of suicidal patients' observation statuses.

Allison Allsop is the education and health reporter for the Casper star-tribune. she can be reached at 307-266-0544 or allison.allsop@ trib.com. Her twitter account is @ allisonallsop