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Madison’s Veterans Hospital provided deficient care for a mentally ill patient who killed himself a day after being discharged last year, according to a new federal report.

Staff didn’t hold the man for an additional 72 hours, as they could have, and there were problems with discharge planning, follow-up and outpatient pharmacy care, says a report by the VA Office of the Inspector General.

“These deficiencies in care may have set the stage for progressive worsening of this veteran’s (mental health) disorder that ultimately was a factor in his death by suicide,” says the report, released last week after a review requested by U.S. Sens. Tammy Baldwin, a Democrat, and Ron Johnson, a Republican.

Robert Franks-Mess, a 24-year-old Marine veteran from Lake Mills, died by suicide on Feb. 18, 2017, after being treated at the Madison VA for depression, post-traumatic stress disorder and traumatic brain injury, said his sister, Dawn Franks-Mess, of Madison.

The federal report doesn’t name Robert Franks-Mess, but he is the subject of the report, said his mother, Kathleen Franks, of Madison. She and Dawn Franks-Mess said they were interviewed by OIG investigators as part of the review, and the details of his treatment and death match those in the report.

Robert Franks-Mess, who served in the Marines from 2010 to 2013, was diagnosed with mental illness in 2014, his sister and mother said. As his symptoms worsened, he was hospitalized twice at the Madison VA in 2017.

On Feb. 17 of that year, after being in the hospital two days, he was discharged after a psychiatrist told Kathleen Franks to remove guns from their home, which she had already done, Franks told the State Journal. The next day, he used a gun obtained elsewhere to take his life.

“They definitely need to improve their care,” Franks said. “Hopefully we can get the awareness out there, that there needs to be improvements within all of the VA facilities around the country.”

John Rohrer, director of the Madison VA, said in a statement that the hospital has started coordinating more with family members and county crisis services before veterans are discharged.

“Unfortunately, in mental health and in all medicine, no set of policies or process will succeed in preventing every negative outcome,” Rohrer said. “While we do not agree with every aspect of the OIG report, we continue aggressively to seek ways to improve our care.”

The report says a psychiatrist considered holding the veteran involuntarily for 72 hours to protect him from self-harm, but thought he might react negatively and said he agreed to return for clinic visits. The doctor also believed the patient’s main reason for coming to the hospital was “manipulative,” saying he was trying to get a wrist surgery scheduled more quickly.

Franks said her son was withdrawn and feeling helpless, and clearly having a mental health crisis. When a nurse told her he was being discharged, she said she couldn’t believe it.

“I said, ‘Are you kidding me?’ Do you not see what kind of state he’s in?’” Franks said. “I don’t feel like I had a choice to talk with them and convince them that he needed to stay.”

Dawn Franks-Mess said that other than keeping guns out of the home, there was little discussion about what the family could do to keep her brother safe. “I don’t feel like we were given tools to help him,” she said.

During the hospital stay before the suicide, the report said, the patient reported continued suicidal thoughts and didn’t appear to be responding to treatment. “Although in hindsight, it would have been better not to discharge” him, the psychiatrist “had a clear and medically acceptable rationale for doing so,” the report said.

Discharge planning and follow-up care were inadequate, the report said. Psychiatric clinical pharmacists didn’t properly assess the patient’s symptoms, evaluate his response to medication or monitor him for mood disorder and suicidal thoughts in the months before the hospital stay, the report said.

Similar deficiencies among psychiatric clinical pharmacists were found for another patient who died by suicide 13 months earlier, the report said.

The report also said the pharmacists acted outside of the scope of practice in changing diagnoses and providing psychotherapy.

In addition, inspectors cited “ethically questionable enrollment in a research study,” saying the patient participated in a study but may not have been able to consent voluntarily, thinking participation was required as part of treatment.

Dawn Franks-Mess said the study involved taking lithium or a placebo, and the family later learned her brother was on the fake drug.

Robert Franks-Mess, who liked hunting, fishing and working on cars, had been outgoing and fun-loving before becoming withdrawn, his sister and mother said.

Shortly before his death, he started to help Lake Mills renovate its skateboard park, which he used growing up. That is where he was found dead, Kathleen Franks said.

“How many more families need to go through this before changes are truly made?” she said.

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