Lyons NJ VA Fails to Check for Psychiatric Patient- Patient found Dead Several Days Later at Lyons VAMC

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The patient, referred to in this report as Mr. B, was a 67-year-old male with prior multiple admissions to the Lyons Campus for  ...Mr. B was ·...May 14, 1998, after ... Beginning May 18, 1998, Mr. B was authorized to leave the ward by himself for 2 hours in the morning. On Saturday, May 30, Mr. B did not return to his ward and was reported missing that evening. Lyons Campus officials began an extended search for Mr. B, but terminated it before he was found. On the morning of Monday, June 1, 1998, Mr. B was found unresponsive, lying in a construction trench near an administrative building in an area of the Campus known as Circle I.

...It is undisputed that the nursing staff neglected to appropriately monitor the where abouts of Mr. B on May 30, 1998, which resulted in a delay in initiating a search. It is also undisputed that the VA police neglected to conduct an adequate search of the premises, which delayed finding Mr. B’s body. We consider the above actions evidence of mismanagement at the supervisory level in the Nursing Service and the Police and Security Section.....VA OIG Investigation into Death at Lyons VA